N-terminal Pro-Brain Natriuretic Peptide and Renal Insufficiency as Predictors of Mortality in Pulmonary Hypertension*

Original Research PULMONARY HYPERTENSION N-terminal Pro-Brain Natriuretic Peptide and Renal Insufficiency as Predictors of Mortality in Pulmonary Hypertension* Hanno H. Leuchte, MD; Michal El Nounou, MD; Juergen Christian Tuerpe; Bertram Hartmann, MD; Rainer A. Baumgartner, MD; Michael Vogeser, MD; Olaf Muehling, MD; and Jürgen Behr, MD Background: N-terminal pro-brain natriuretic peptide (NT-proBNP) is a byproduct of the brain natriuretic peptide (BNP) that was shown to be of prognostic value in pulmonary hypertension (PH). The role of NT-proBNP in PH has to be determined, especially under the influence of renal impairment that might lead to an accumulation of the peptide, and may be a sign of increased mortality per se. Methods: We assessed NT-proBNP, BNP, renal function, and hemodynamic parameters (during right-heart catheterization) in 118 consecutive patients with isolated PH, excluding left-heart disease. Depending on the calculated creatinine clearance, patients were classified into different groups of renal function. Correlation analysis was performed on all key parameters. Results were then compared between the levels of renal function. The prognostic value of each parameter was assessed during a mean follow-up period of 10 months. Results: Twenty-two patients (approximately 19%) had significantly impaired renal function (creatinine clearance < 60 ml/min). Although the overall levels of NT-proBNP were correlated with hemodynamics, we observed no correlation in the group with significant renal dysfunction. Moreover, NT-proBNP was related to creatinine clearance. Finally, NT-proBNP and renal insufficiency were independent predictors of death during univariate and multivariate analysis, whereas BNP only predicted mortality in univariate analysis. Conclusions: The diagnostic accuracy of NT-proBNP as a parameter of the hemodynamic status is diminished by renal function. However, NT-proBNP could be superior to BNP as a survival parameter in PH because it integrates hemodynamic impairment and renal insufficiency, which serves as a sign of increased mortality per se. (CHEST 2007; 131:402 409) Key words: pro-brain natriuretic peptide; pulmonary circulation Abbreviations: BNP brain natriuretic peptide; CI cardiac index; CO cardiac output; NT-proBNP N-terminal pro-brain natriuretic peptide; PAH pulmonary arterial hypertension; PAP pulmonary arterial pressure; PH pulmonary hypertension; PVR pulmonary vascular resistance; RAP right atrial pressure; ROC receiver operating characteristic; WHO World Health Organization Pulmonary hypertension (PH) is a cause of morbidity and mortality in a variety of diseases. 1 6 Increased pulmonary vascular resistance (PVR) leads *From the Division of Pulmonary Diseases (Drs. Leuchte, El Nounou, Baumgartner, Muehling, and Behr, and Mr. Tuerpe), Department of Internal Medicine I, Department of Nephrology (Dr. Hartmann), and Department of Clinical Chemistry (Dr. Vogeser), Ludwig Maximilians University, Klinikum Grosshadern, Munich. The authors have no conflicts of interest to disclose. Manuscript received July 18, 2006; revision accepted August 29, 2006. to raised pulmonary artery pressures (PAPs) and an increased right-heart workload. The natriuretic peptide system is activated in this context as a sign of Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Hanno H. Leuchte, MD, Division of Pulmonary Diseases, Department of Internal Medicine I, Ludwig Maximilians University, Klinikum Grosshadern, Munich, Marchioninistr. 15, 81377 Munich, Germany; e-mail: Hanno.Leuchte@ med.uni-muenchen.de DOI: 10.1378/chest.06-1758 402 Original Research

neurohumoral activation in PH of different etiologies. 7,8 Brain natriuretic peptide (BNP) is the biologically active form of a prohormone that is secreted from cardiomyocytes and is of special interest as it is known to correlate with the hemodynamic severity, functional impairment, and prognosis of patients with idiopathic and associated forms of PH 5,9,10 However, BNP has a short half-life in blood samples, making a rapid processing of samples necessary. On the contrary, N-terminal pro-bnp (NT-proBNP) is not metabolized in blood and is eliminated only via the kidneys, resulting in a significant longer halflife. 11,12 This could be an advantage and may favor the measurement of NT-proBNP in clinical routine, and even more since there is evidence that NTproBNP seems to reflect disease severity in idiopathic and associated forms of pulmonary arterial hypertension (PAH). 13 18 Consequently, measurements of NT-proBNP have entered many ongoing clinical treatment trials in PH as an efficacy parameter. However, renal insufficiency could lead to an accumulation and influence the validity of NTproBNP. In addition, the interpretation of NTproBNP values is difficult because there are no data supporting the prognostic role of NT-proBNP in PH, and extrapolating such information from BNP data is not adequate because of the obvious differences in the physiology of BNP and NT-proBNP. Since renal dysfunction may develop in hemodynamically compromised patients or may exist as an independent comorbidity, we aimed to clarify its impact on the diagnostic validity of both natriuretic peptides (BNP and NT-proBNP) as hemodynamic markers. Another aim was to investigate renal insufficiency as a prognostic marker in PH in comparison with NT-proBNP and BNP. Study Design Materials and Methods One hundred eighteen consecutive patients with stable PH and kidney function were classified according to the Venice conference 6 and were evaluated prospectively. Written informed consent was obtained from every patient. All procedures were in accordance to the institutional guidelines. Patients with significant left-heart disease were excluded. In general, left-heart catheterization was performed in patients 40 years of age and if the left heart could not be entirely assessed during echocardiography. Patients 18 years old as well as patients with acute renal failure and/or end-stage renal disease undergoing hemodialysis were excluded. Right-Heart Catheterization Right-heart catheterization was performed as described before. 10 Hemodynamic parameters were obtained in recumbent position and included heart rate, right atrial pressure (RAP), PAP, as well as pulmonary capillary pressure. Cardiac output (CO) was obtained using triplicate measurements with the thermodilution method. Calculated parameters were PVR and cardiac index (CI). Sampling and Assay Blood was drawn from a peripheral vein and analyzed for routine laboratory parameters, NT-proBNP, and BNP. For serum NT-proBNP (Roche Elecsys probnp; Roche Diagnostics; Mannheim, Germany) 12 and plasma BNP (ADVIA Centaur BNP; Bayer HealthCare; Fernwald, Germany) 19 measurements, we used two commercially available assays. The age- and genderadjusted values for NT-proBNP and BNP ranged from 84 to 222 pg/ml and from 18 to 75 pg/ml, respectively. In order to avoid an underestimation and overestimation of the individual values of NT-proBNP and BNP, we calculated a normalized ratio for each patient. This ratio was calculated as follows: measured value (NT-proBNP or BNP) divided by age- and gender-adjusted normal values. Consequently, the increase of an individual level resulted in a ratio 1. 5 Estimation of Creatinine Clearance and Classification of Renal Insufficiency Patients were receiving a stable dose of diuretics during the evaluation of renal impairment. Creatinine clearance was estimated on a simple calculation according to a formula by Rule and colleagues, 20 incorporating serum creatinine, age, and gender. Four stages of renal insufficiency were classified according to Levey et al, 21 and patients were defined as having no to mild renal insufficiency (creatinine clearance 60 ml/min) or moderate to severe renal insufficiency (creatinine clearance 60 ml/min). Survival Estimates Survival was estimated from the day of completion of the NT-proBNP/BNP tests until last patient contact or cardiopulmonary death with a follow-up rate of 100%. All deaths resulted from cardiopulmonary causes. Statistical Analysis Data are reported as mean SEM. Depending on the normal distribution of parameters, correlation analysis and comparison between groups were performed using the Spearman correlation coefficient and Student t test for unpaired samples or Mann- Whitney U test, respectively. The correlation was tested for two-sided significance. Univariate Cox proportional hazards regression analysis was used to test the prognostic value of each variable followed by a stepwise multivariate analysis. The survival rate was derived from Kaplan-Meier curves. A receiver operating characteristic (ROC) curve analysis was performed to compare the predictive potential of all parameters. Results Patient Characteristics and Comparison of PAH vs Non-PAH Patients PAH patients were younger and had more prominent hemodynamic impairment than non-pah patients. All subgroups of PH-comprised patients with www.chestjournal.org CHEST / 131 / 2/ FEBRUARY, 2007 403

renal insufficiency and the usage of diuretics were not different between groups (Table 1). Correlation of NT-proBNP With Clinical and Hemodynamic Parameters: Impact of Renal Function Overall, the normalized NT-proBNP values were significantly correlated with hemodynamics as well as serum creatinine (r 0.52) and were inversely correlated with the calculated creatinine clearance (r 0.33; all p 0.001) [Table 2]. These correlations were observed in all groups irrespective of the etiology of PH (data not shown). Absolute NTproBNP values showed comparable results (data not shown). Overall, the normalized as well as absolute NT-proBNP values correlated with the respective normalized and absolute BNP values (both r 0.76; p 0.001) [Fig 1]. In patients with creatinine clearance 60 ml/ min, correlations of hemodynamics and NT-proBNP were stronger. The normalized NT-proBNP and normalized BNP values were strongly correlated (r 0.8; p 0.0001). In patients with a creatinine clearance 60 ml/ min, however, normalized NT-proBNP levels were only correlated with RAP. All other hemodynamic parameters did not correlate to NT-proBNP. Nevertheless, normalized NT-proBNP and BNP concentrations were correlated (r 0.65; p 0.001). Correlation of BNP With Clinical and Hemodynamic Parameters: Impact of Renal Function Overall, as expected, normalized plasma BNP values showed a significant correlation with hemodynamics (independent of the renal impairment) and serum creatinine (r 0.38; p 0.001) but were not related with creatinine clearance (Table 2). NTproBNP and BNP levels were not correlated with age, weight, height, or body mass index. Table 1 Patient Characteristics: PAH vs Non-PAH Characteristics Study Population (n 118) PAH, Group I (n 66) Non-PAH, Group II-V (n 52) Follow up time, mo 9.82 0.83 9.78 1.1 9.86 1.27 Age, yr 54 51.19 1.88 57.73 1.72 Male/female gender, No. 44/74 20/46 24/28 Mean WHO class 3.04 0.07 2.81 0.1 3.31 0.1 Diagnosis (WHO group) Idiopathic PAH 43 43 Associated PAH 23 23 WHO group III (hypoxemia associated) 25 25 WHO group IV (chronic thromboembolic PH) 21 21 WHO group V (various etiologies) 6 6 Hemodynamic parameters Mean PAP, mm Hg 47.92 1.39 51.33 1.82 43.6 2.02 PVR, dyne s cm 5 796.8 43.2 920.8 59.2 640 55.2 RAP, mm Hg 7.52 0.46 7.53 0.67 7.5 0.6 CO, L/min 4.33 0.12 4.14 0.17 4.57 2.02 CI, L/min m 2 2.52 0.13 2.29 0.91 2.81 0.27 Renal parameters Serum creatinine, mg/dl 1.2 0.05 1.17 0.04 1.23 0.1 Creatinine clearance, ml/min: calculated 80.34 2.21 80.81 2.74 79.73 3.64 Renal insufficiency Stage 1 44 23 21 Stage 2 51 32 19 Stage 3 18 9 9 Stage 4 5 2 3 BNP and NT-proBNP BNP, pg/ml 196.67 24.3 215.17 35.94 173.16 31.06 BNP ratio 3.94 0.53 4.51 0.78 3.22 0.67 NT-proBNP, pg/ml 1,766.2 219.44 1,576.64 227.27 2,006.8 406.32 NT-proBNP ratio 9.83 1.2 9.39 1.4 10.39 2.07 *Data are presented as mean SEM or No. p 0.05. p 0.01. Stages of renal insufficiency: stage 1 (creatinine clearance 90 ml/min), stage 2 (creatinine clearance 60 to 89 ml/min), stage 3 (creatinine clearance 30 to 59 ml/min), and stage 4 (creatinine clearance 30 ml/min). 404 Original Research

Table 2 Correlation Analysis of Hemodynamic Parameters and Natriuretic Peptides Depending on Renal Function* Parameters Normalized NT-proBNP Ratio Normalized BNP Ratio All patients (n 118) Mean PAP, mm Hg 0.52; 0.001 0.54; 0.001 PVR, dyne s cm 5 0.59; 0.001 0.56; 0.001 RAP, mm Hg 0.48; 0.001 0.4; 0.001 CO, L/min 0.48; 0.001 0.44; 0.001 CI, L/min m 2 0.50; 0.001 0.46; 0.001 Creatinine clearance 60 ml/min (n 96) Mean PAP, mm Hg 0.5; 0.001 0.54; 0.001 PVR, dyne s cm 5 0.63; 0.001 0.56; 0.001 RAP, mm Hg 0.4; 0.001 0.4; 0.001 CO, L/min 0.49; 0.001 0.44; 0.001 CI, L/min m 2 0.52; 0.001 0.46; 0.001 Creatinine clearance 60 ml/min (n 22) Mean PAP, mm Hg NS 0.54; 0.001 PVR, dyne s cm 5 NS 0.56; 0.001 RAP, mm Hg 0.54; 0.01 0.4; 0.001 CO, L/min NS 0.44; 0.001 CI, L/min m 2 NS 0.46; 0.001 *Data are presented as R value; p value. NS not significant. Correlation of Hemodynamic Impairment and Renal Insufficiency We observed a slight correlation of serum creatinine with mean PAP (r 0.22; p 0.05), PVR (r 0.24; p 0.01), and RAP (r 0.29; p 0.01), and an inverse correlation with CO (r 0.23; p 0.05) and CI (r 0.3; p 0.01). Moreover, creatinine clearance showed a slight inverse correlation with RAP (r 0.19; p 0.05) and a slight correlation with CO (r 0.2; p 0.05) and CI (r 0.25; p 0.05). Risk Estimates of Mortality Intending to assess different risk factors of death, we performed a univariate analysis as a first step. NT-proBNP and BNP levels that were 2.5-fold above normal (normalized ratio, 2.5) and a creatinine clearance 60 ml/min increased the risk of death significantly (Tables 2 4). Using the multivariate analysis, a stepwise introduction of covariates was performed for these parameters. Again, elevated NT-proBNP levels (2.5-fold above normal) and a creatinine clearance 60 ml/min were significant predictors of mortality in multivariate analysis. Moreover, a normalized NT-proBNP level of 2.5 was still a significant risk factor of death when a normalized BNP ratio was the covariate. But this was not observed vice versa. Table 3 Predictors of Mortality in Univariate Analysis Variables Risk Ratio Estimates 95% Confidence Interval p Value Figure 1. Correlation of NT-proBNP and BNP. NT-proBNP ratio 2.5 10.57 1.38 81.04 0.05 BNP ratio 2.5 3.47 1.09 11.1 0.05 Creatinine clearance 60 ml/min 1.62 1.11 2.37 0.05 www.chestjournal.org CHEST / 131 / 2/ FEBRUARY, 2007 405

Table 4 Predictors of Mortality in Multivariate Analysis* Variables NT-proBNP Ratio 2.5 BNP Ratio 2.5 Creatinine Clearance 60 ml/min NT-proBNP ratio 2.5 10.13 (1.05 97.83) 8.55 (1.1 66.67) BNP ratio 2.5 1.06 (0.29 3.87) 2.85 (0.87 9.85) Creatinine clearance 60 ml/min 3.27 (1.09 9.88) 3.78 (1.22 11.69) *Data are presented as estimated risk ratio (95% confidence interval). p 0.05. Survival Estimates Based on NT-proBNP, BNP, Renal Insufficiency, and Hemodynamic and Clinical Variables The impact of these risk factors on observed survival was assessed by Kaplan-Meier analysis (Fig 2 4). Sixty-six of 118 patients (55.9%) had elevated NT-proBNP levels of at least 2.5 times above normal. Of these patients, 13 patients (19.7%) died within 25.6 3.4 months. In contrast, only 1 of the remaining 52 patients (1.9%) died within 44.28 1.9 months (p 0.01). Regarding BNP, 50 patients (42.4%) had levels of at least 2.5 times above normal. Ten of these patients (20%) died within 22.37 3.11 months. Four of the remaining 68 patients (5.9%) died within 42.58 1.82 months (p 0.05). Twenty-two patients (18.64%) had an impaired creatinine clearance of 60 ml/min. Six of these patients (27.3%) died within 13.58 1.71 months, whereas only 8 of the 96 patients (8.3%) with a creatinine clearance 60 ml/min died within 38.48 3.04 months (p 0.01). Ninety-four patients (79.66%) were in functional World Health Organization (WHO) class 3 or 4. All 14 deaths occurred in this patient group (14.85%), whereas none of the patients in WHO class 1 or 2 died (p 0.05). None of the hemodynamic or remaining clinical parameters were significant predictors of mortality in our study population. Comparison of Different Predictors of Mortality Fourteen of 118 patients (11.9%) died during follow-up. ROC curve analysis was performed to differentiate between various risk factors of death. During this analysis, a normalized NT-proBNP level of 2.5 was the only prognostic parameter that predicted a significant number of these deaths (area under the curve, 74.6%; p 0.001). Discussion PH is a disabling disease with a high mortality. Natriuretic peptide levels serve as noninvasive markers that reflect the severity of PH and significantly Figure 2. Impact of high NT-proBNP ratios on survival in PH patients. Figure 3. Impact of high BNP ratios on survival in PH patients. 406 Original Research

Figure 4. Impact of renal insufficiency on survival in PH patients. aid in the management of these patients. BNP and NT-proBNP concentrations are increasingly used in various treatment trials and daily practice. NTproBNP might be an attractive parameter in this context because of its long half-life in human blood (up to 3 days, room air) and its fully automatic analysis. 12 However, little is known about the impact of renal dysfunction on the diagnostic accuracy of natriuretic peptides in PH. Moreover, at this time, we lack information to support the prognostic value of NT-proBNP and renal insufficiency in this population. In this study, an elevated NT-proBNP 2.5-fold above normal predicted mortality and served as an independent risk factor of death in patients with PH. In addition, a significantly impaired renal function (creatinine clearance 60 ml/min) was another prognostic marker in this population. As expected, mortality was related to increased BNP levels (2.5- fold above normal). However, during multivariate analysis, only NT-proBNP independently predicted mortality, while BNP did not. The superiority of significantly elevated NT-proBNP levels in terms of the prognostic value was confirmed during ROC curve analysis. In left-heart disease and sickle-cell disease, NT-proBNP adds prognostic information beyond conventional risk factors 18,22. Very recently, NT-proBNP was found to be a prognostic parameter in a smaller group of PH patients. 23 However, this present study is the first to directly compare NTproBNP and BNP in a large cohort of patients with isolated PH as prognostic markers. Different mechanisms could be responsible for the superiority of NT-proBNP as a mortality parameter. Although NT-proBNP and BNP are released from cardiomyocytes on an equimolar basis, circulating concentrations of NT-proBNP are higher than those of BNP. 24 The half-life of BNP is significantly shorter than that of NT-proBNP because BNP is cleaved by neutral endopeptidases, is cleared via a specific receptor, 25 and is excreted to a lesser extent via the kidneys. 26 In contrast, NT-proBNP is only excreted renally without prior degradation, making it more resistant against short-term influences. Moreover, in terms of prognostic information, the integration of renal insufficiency could be of advantage, since a marked renal insufficiency (ie, creatinine clearance 60 ml/min) was a mortality parameter itself in our cohort. Since one of our findings confirmed BNP as a prognostic parameter, these assumptions are not contradictory to previous observations in idiopathic PAH. 9 Based on the observation that the magnitude of NT-proBNP elevation depends on renal function in PH, it seems plausible that the correlation of hemodynamic parameters and natriuretic peptides is reduced in renal insufficiency (which we observed in almost 20% of the population!). With regard to NT-proBNP, levels were related to serum creatinine and calculated clearance. Although all important hemodynamic parameters of PH showed a good correlation with the NT-proBNP levels in the study population as a whole, RAP was the only parameter that correlated with NT-proBNP in patients with markedly impaired creatinine clearance. Since BNP concentrations were influenced by renal function to a minor degree, BNP levels showed good correlation with the severity of hemodynamic impairment irrespective of the renal function. Our data are neither in conflict with preceding studies 13,15,16,27 that describe a correlation between NT-proBNP and hemodynamic parameters in patients with PAH (although these studies did not consider the influence of renal insufficiency), nor are they contradictory to the above observation of the predictive values of NTproBNP and BNP. Since survival in PH is not solely correlated to the severity of hemodynamic impairment, 28 integration of renal insufficiency as a risk factor of death seems to be of advantage. However, we did not characterize the development of NTproBNP under the influence of specific therapies for PH and/or renal insufficiency. Nevertheless, since there is a close correlation of BNP and hemodynamic parameters, even in the presence of moderate renal insufficiency and during long-term follow-up, 29 this might underline the role of BNP as a follow-up parameter in PH. Since renal insufficiency is a known significant risk www.chestjournal.org CHEST / 131 / 2/ FEBRUARY, 2007 407

factor for death 30 and seems to develop in a significant number (20%) of patients with PH, it seems to be of crucial relevance to recognize it as a mortality parameter in PH. Renal function was inversely related to the magnitude of the hemodynamic impairment in our trial, suggesting that a diminished renal perfusion is one factor that leads to renal insufficiency in PH patients. However, we cannot conclude on this because we did not definitely exclude other etiologies of renal insufficiency in our study population. Our study had limitations. One is the heterogeneity of the study population because we included patients with a variety of associated forms of PH. However, the main findings of our study were reproducible in all major subgroups. In addition, PH has been shown repeatedly to be a major risk factor of death irrespective of the underlying disease, and natriuretic peptides are not influenced by lung functional impairment. Another limitation is that we estimated renal function on a simple estimation of creatinine clearance and do not provide repetitive data. However, we included only patients with stable renal function and stable doses of diuretics. Despite these limitations, we conclude the following: (1) in PH, NT-proBNP, BNP, and renal insufficiency are risk factors of death; (2) NT-proBNP is superior to BNP as mortality parameter because it integrates renal impairment and is less susceptible to short-term influences; and (3) the diagnostic accuracy of NT-proBNP as a noninvasive follow-up parameter of the hemodynamic variables seems to be inferior to that of BNP in patients with impaired renal function. ACKNOWLEDGMENT: This article contains a significant portion of the doctoral thesis of Mr. Juergen Christian Tuerpe. The excellent assistance of Mr. Tobias Meis and Mrs. Elisabeth Becker and her team is gratefully acknowledged. References 1 Koh ET, Lee P, Gladmann DD, et al. Pulmonary hypertension in systemic sclerosis: an analysis of 17 patients. Rheumatology 1996; 35:989 993 2 King TE Jr, Tooze JA, Schwarz MI, et al. Predicting survival in idiopathic pulmonary fibrosis: scoring system and survival model. Am J Respir Crit Care Med 2001; 164:1171 1181 3 Oswald-Mammosser M, Weitzenblum E, Quoix E, et al. Prognostic factors in COPD patients receiving long-term oxygen therapy: importance of pulmonary artery pressure. Chest 1995; 107:1193 1198 4 Stevens D, Sharma K, Szidon P, et al. Severe pulmonary hypertension associated with COPD. Ann Transplant 2000; 5:8 12 5 Leuchte HH, Baumgartner RA, Nounou ME, et al. Brain natriuretic peptide is a prognostic parameter in chronic lung disease. Am J Respir Crit Care Med 2006; 173:744 750 6 Simonneau G, Galie N, Rubin LJ, et al. Clinical classification of pulmonary hypertension. J Am Coll Cardiol 2004; 43(suppl 1):S5 S12 7 Nootens M, Kaufmann E, Rector T, et al. Neurohormonal activation in patients with right ventricular failure from pulmonary hypertension: relation to hemodynamic variables and endothelin levels. J Am Coll Cardiol 1995; 26:1581 1585 8 Wiedemann R, Ghofrani HA, Weissmann N, et al. Atrial natriuretic peptide in severe primary and nonprimary pulmonary hypertension: response to iloprost inhalation. J Am Coll Cardiol 2001; 38:1130 1136 9 Nagaya N, Nishikimi T, Uematsu M, et al. Plasma brain natriuretic peptide as a prognostic indicator in patients with primary pulmonary hypertension. Circulation 2000; 102:865 870 10 Leuchte HH, Holzapfel M, Baumgartner RA, et al. Clinical significance of brain natriuretic peptide in primary pulmonary hypertension. J Am Coll Cardiol 2004; 43:764 770 11 Hall C. Essential biochemistry and physiology of (NTpro)BNP. Eur J Heart Fail 2004; 6:257 260 12 Yeo KT, Wu AHB, Apple FS, et al. Multicenter evaluation of the Roche NT-proBNP assay and comparison to the Biosite Triage BNP assay. Clin Chim Acta 2003; 338:107 115 13 Souza R, Bogossian HB, Humbert M, et al. N-terminal-probrain natriuretic peptide as a haemodynamic marker in idiopathic pulmonary arterial hypertension. Eur Respir J 2005; 25:509 513 14 Souza R, Jardim C, Julio Cesar Fernandes C, et al. NTproBNP as a tool to stratify disease severity in pulmonary arterial hypertension. Respir Med 2006 (in press) 15 Allanore Y, Borderie D, Cabanes L, et al. N-terminal probrain natriuretic peptide as a diagnostic marker of early pulmonary artery hypertension in patients with systemic sclerosis and effects of calcium-channel blockers. Arthritis Rheum 2003; 3503 3508 16 Mukerjee D, Yap LB, Holmes AM, et al. Significance of plasma N-terminal pro-brain natriuretic peptide in patients with systemic sclerosis-related pulmonary arterial hypertension. Respir Med 2003; 97:1230 1236 17 Williams MH, Handler CE, Akram R, et al. Role of N- terminal brain natriuretic peptide (N-TproBNP) in scleroderma-associated pulmonary arterial hypertension. Eur Heart J 2006; 27:1484 1494 18 Machado RF, Anthi A, Steinberg MH, et al. N-terminal pro-brain natriuretic peptide levels and risk of death in sickle cell disease. JAMA 2006; 296:310 318 19 Wians J, Wilson BA, Grant A, et al. Evaluation of the analytical performance characteristics of the Bayer ACS: 180(R) B-type natriuretic peptide (BNP) assay. Clin Chim Acta 2005; 353:147 155 20 Rule AD, Larson TS, Bergstralh EJ, et al. Using serum creatinine to estimate glomerular filtration rate: accuracy in good health and in chronic kidney disease. Ann Intern Med 2004; 141:929 937 21 Levey AS, Coresh J, Balk E, et al. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Intern Med 2003; 139: 137 147 22 Kragelund C, Groning B, Kober L, et al. N-terminal pro-btype natriuretic peptide and long-term mortality in stable coronary heart disease. N Engl J Med 2005; 352:666 675 23 Fijalkowska A, Kurzyna M, Torbicki A, et al. Serum N- terminal brain natriuretic peptide as a prognostic parameter in patients with pulmonary hypertension. Chest 2006; 129: 1313 1321 24 Mair J, Hammerer-Lercher A, Puschendorf B. The impact of cardiac natriuretic peptide determination on the diagnosis 408 Original Research

and management of heart failure. Clin Chem Lab Med 2001; 39:571 588 25 Charles CJ, Espiner EA, Nicholls MG, et al. Clearance receptors and endopeptidase 24.11: equal role in natriuretic peptide metabolism in conscious sheep. Am J Physiol Regul Integr Comp Physiol 1996; 271:R373 R380 26 Redfield MM, Rodeheffer RJ, Jacobsen SJ, et al. Plasma brain natriuretic peptide concentration: impact of age and gender. J Am Coll Cardiol 2002; 40:976 982 27 Hesselstrand R, Ekman R, Eskilsson J, et al. Screening for pulmonary hypertension in systemic sclerosis: the longitudinal development of tricuspid gradient in 227 consecutive patients, 1992 2001. Rheumatology 2005; 44:366 371 28 Nunes H, Humbert M, Sitbon O, et al. Prognostic factors for survival in human immunodeficiency virus-associated pulmonary arterial hypertension. Am J Respir Crit Care Med 2003; 167:1433 1439 29 Leuchte HH, Holzapfel M, Baumgartner RA, et al. Characterization of brain natriuretic peptide in long-term follow-up of pulmonary arterial hypertension. Chest 2005; 128:2368 2374 30 Go AS, Chertow GM, Fan D, et al. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 2004; 351:1296 1305 www.chestjournal.org CHEST / 131 / 2/ FEBRUARY, 2007 409