Association of Longitudinal B-Type Natriuretic Peptide Monitoring With Kidney Failure in Patients With CKD: A Cohort Study

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).Study Design: Retrospective cohort study.Setting & Participants: A total of 2,998 out-patients with stages 3-5 of nondialyzed CKD referred to the department of nephrology at an academic hospital. Exposure: BNP monitoring.Outcome: KRT, acute kidney injury (AKI), and heart failure hospitalization.Analytical Approach: Marginal structural models, which create a balanced pseudo population at each time point, were applied to account for po-tential time-dependent confounders. Inverse probability weighted pooled logistic regression models were employed to estimate hazard ratios.Results: At baseline, the median age and esti-mated glomerular filtration rate were 66 years and 38.1 mL/min/1.73 m2, 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.Limitations: Residual confounding by measured and unmeasured variables or indications for BNP measurements.Conclusions: 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.