Diagnostic reliability of BNP and NT-proBNP in acute heart failure amidst sepsis and chronic kidney disease
A Ait Khouya, M LazraqAbstract
Introduction
The usefulness of the BNP and N-terminal proBNP (NT-proBNP) in the diagnostic of acute heart failure (AHF), is today clearly established. However, in clinical situations with regard to sepsis or chronic kidney disease (CKD), the diagnostic accuracy is questioned. The purpose of this review is to re-evaluate the clinical utility of these markers and provide an overview of current threshold recommendations.
Purpose
This review aims to : 1.Evaluate the diagnostic performance of BNP and NT-proBNP in acute heart failure (AHF) / 2.Compare threshold values used in Japan, Europe and around the world / 3.Assess the impact of confounding conditions such as sepsis and chronic kidney disease on biomarker reliability/ 4.Analyze the reliability of BNP and NT- proBNP as diagnostic tools across varying clinical settings.
Method
A structured literature review was conducted using PubMed and Embase for articles published up to June 2024. Studies from Japan and Europe were included if they reported sensitivity, specificity, or threshold values for BNP and NT-proBNP in AHF. Special focus was given to studies addressing confounding conditions such as sepsis and CKD.
Results
Across regions, BNP and NT-proBNP demonstrated high sensitivity in diagnosing AHF (BNP: 90-98%; NT-proBNP: 92-99%). However, specificity decreased significantly in the presence of sepsis (BNP: ~77%, NT-proBNP: ~70%) and CKD (NT-proBNP: ~50-60%). European guidelines recommend increasing NT-proBNP thresholds by 35% for eGFR <30 ml/min/1.73 m², while Japanese guidelines suggest considering higher values without giving specific thresholds. European studies confirm neither BNP nor NT-proBNP can reliably diagnose HF in severe sepsis or septic shock. Japanese research demonstrated that critical illness severity, rather than sepsis-induced cardiomyopathy, is the main determinant of BNP elevation in septic patients, and suggest considering 2-3x higher thresholds in septic patients The markers' elevations in sepsis or renal failure highlight their vulnerability to overdiagnosis in non-cardiac contexts.
Conclusion
BNP and NT-proBNP remain valuable tools for the diagnosis of AHF, particularly due to their high sensitivity. However, their specificity is limited in patients with sepsis or CKD, necessitating cautious interpretation. Recent studies suggest evolving threshold strategies tailored to patient age and comorbidities. Further harmonization across international guidelines is needed to optimize diagnostic reliability and reduce false positives in complex clinical presentations. (Fig 1)Future PerspectivesFor image description, please refer to the figure legend and surrounding text.