New Classification for the Combined Assessment of the Fractional Excretion of Urea Nitrogen and Estimated Plasma Volume Status in Acute Heart Failure

Nogi, Kazutaka; Ueda, Tomoya; Nakamura, Takuya; Nogi, Maki; Ishihara, Shoichiro; Nakada, Yasuki; Hashimoto, Yukihiro; Nakagawa, Hitoshi; Nishida, Taku; Seno, Ayako; Onoue, Kenji; Watanabe, Makoto; Saito, Yoshihiko

doi:10.1161/jaha.122.025596

Cited by 4 publications

(5 citation statements)

References 27 publications

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“…This elevation may occur in patients with severe TBI. Urea nitrogen has been used as a predictor in various critical illnesses [25,26], including ischemic stroke [27], acute myocardial infarction [28], and cardiogenic shock [29]. Herein, the BAR further amplifies the predictive value of urea nitrogen and albumin in trauma as well as acute and critical illnesses [30].…”

Section: Discussionmentioning

confidence: 99%

Blood Urea Nitrogen-to-Albumin Ratio May Predict Mortality in Patients with Traumatic Brain Injury from the MIMIC Database: A Retrospective Study

Guo,

Leng,

Gao

2024

Bioengineering

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Traumatic brain injury (TBI), a major global health burden, disrupts the neurological system due to accidents and other incidents. While the Glasgow coma scale (GCS) gauges neurological function, it falls short as the sole predictor of overall mortality in TBI patients. This highlights the need for comprehensive outcome prediction, considering not just neurological but also systemic factors. Existing approaches relying on newly developed biomolecules face challenges in clinical implementation. Therefore, we investigated the potential of readily available clinical indicators, like the blood urea nitrogen-to-albumin ratio (BAR), for improved mortality prediction in TBI. In this study, we investigated the significance of the BAR in predicting all-cause mortality in TBI patients. In terms of research methodologies, we gave preference to machine learning methods due to their exceptional performance in clinical support in recent years. Initially, we obtained data on TBI patients from the Medical Information Mart for Intensive Care database. A total of 2602 patients were included, of whom 2260 survived and 342 died in hospital. Subsequently, we performed data cleaning and utilized machine learning techniques to develop prediction models. We employed a ten-fold cross-validation method to obtain models with enhanced accuracy and area under the curve (AUC) (Light Gradient Boost Classifier accuracy, 0.905 ± 0.016, and AUC, 0.888; Extreme Gradient Boost Classifier accuracy, 0.903 ± 0.016, and AUC, 0.895; Gradient Boost Classifier accuracy, 0.898 ± 0.021, and AUC, 0.872). Simultaneously, we derived the importance ranking of the variable BAR among the included variables (in Light Gradient Boost Classifier, the BAR ranked fourth; in Extreme Gradient Boost Classifier, the BAR ranked sixth; in Gradient Boost Classifier, the BAR ranked fifth). To further evaluate the clinical utility of BAR, we divided patients into three groups based on their BAR values: Group 1 (BAR < 4.9 mg/g), Group 2 (BAR ≥ 4.9 and ≤10.5 mg/g), and Group 3 (BAR ≥ 10.5 mg/g). This stratification revealed significant differences in mortality across all time points: in-hospital mortality (7.61% vs. 15.16% vs. 31.63%), as well as one-month (8.51% vs. 17.46% vs. 36.39%), three-month (9.55% vs. 20.14% vs. 41.84%), and one-year mortality (11.57% vs. 23.76% vs. 46.60%). Building on this observation, we employed the Cox proportional hazards regression model to assess the impact of BAR segmentation on survival. Compared to Group 1, Groups 2 and 3 had significantly higher hazard ratios (95% confidence interval (CI)) for one-month mortality: 1.77 (1.37–2.30) and 3.17 (2.17–4.62), respectively. To further underscore the clinical potential of BAR as a standalone measure, we compared its performance to established clinical scores, like sequential organ failure assessment (SOFA), GCS, and acute physiology score III(APS-III), using receiver operator characteristic curve (ROC) analysis. Notably, the AUC values (95%CI) of the BAR were 0.67 (0.64–0.70), 0.68 (0.65–0.70), and 0.68 (0.65–0.70) for one-month mortality, three-month mortality, and one-year mortality. The AUC value of the SOFA did not significantly differ from that of the BAR. In conclusion, the BAR is a highly influential factor in predicting mortality in TBI patients and should be given careful consideration in future TBI prediction research. The blood urea nitrogen-to-albumin ratio may predict mortality in TBI patients.

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Section: Discussionmentioning

confidence: 99%

Blood Urea Nitrogen-to-Albumin Ratio May Predict Mortality in Patients with Traumatic Brain Injury from the MIMIC Database: A Retrospective Study

Guo,

Leng,

Gao

2024

Bioengineering

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“…Recently, FEUN has emerged as a surrogate marker of volume status in patients with HF. 13 , 14 , 22 In a single‐centre observational study among patients with AHF, those with low FEUN values at discharge showed a higher BUN/creatinine ratio and a lower BNP level than other patients, indicating that a low FEUN value reflects intravascular dehydration. 13 Whereas a high FEUN value may indicate intravascular volume overload.…”

Section: Discussionmentioning

confidence: 99%

Fractional excretion of urea nitrogen can identify true worsening renal function in patients with heart failure

Watanabe,

Kubota,

Nishino

et al. 2024

ESC Heart Failure

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AimsFractional excretion of urea nitrogen (FEUN), used to differentiate the cause of acute kidney injury, has emerged as a useful fluid index in patients with heart failure (HF). We hypothesized that FEUN could be useful in identifying worsening renal function (WRF) associated with poor outcomes in patients with acute HF (AHF).Methods and resultsOverall, 1103 patients with AHF (median age, 78 years; male proportion, 60%) were categorized into six groups according to the presence of WRF and FEUN values (low, ≤32.1%; medium, >32.1% and ≤38.0%; and high, >38.0%) at discharge. WRF was defined as an increase of ≥0.3 mg/dL in the serum creatinine level from admission to discharge. FEUN was calculated by the following formula: (urinary urea × serum creatinine) × 100/(serum urea × urinary creatinine). The cut‐off values for low, medium, and high FEUN were based on a previous study. The primary outcome of this study was HF readmission after hospital discharge. During the 1 year follow‐up, 170 HF readmissions occurred. Kaplan–Meier analysis revealed significantly higher HF readmission rates in patients with WRF than in those without WRF (log‐rank test, P < 0.001). Additionally, among patients with WRF, HF readmission rates were lowest in those with medium FEUN values, followed by those with low FEUN values and those with high FEUN values. On multivariable analysis, the presence of WRF with low or high FEUN values was independently associated with increased HF readmission, as compared with the absence of WRF with medium FEUN values. Notably, no association was noted between WRF with medium FEUN values and HF readmission.ConclusionsThe prognostic impact of WRF was significantly mediated by the FEUN values and was associated with worse outcomes only when the FEUN values were either low or high. Our study suggests that FEUN can identify prognostically relevant WRF in patients with AHF.

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“…In this issue of the Journal of the American Heart Association ( JAHA ), Nogi and colleagues 6 propose a new classification that combines the assessment of renal perfusion and volume status to prognosticate ADHF outcomes. 6 They use the fractional excretion of urea nitrogen (FEUN) and estimated plasma volume status (ePVS) in combination to create 4 categories that can be intuitive for the clinician with regard to risk profiling. The FEUN has long been a clinical tool in the differential diagnosis of acute kidney injury, with a threshold of <35% being used to differentiate prerenal azotemia from intrinsic renal failure.…”

mentioning

confidence: 99%

“…Nogi et al 6 combine the FEUN and the ePVS and define 4 hemodynamic categories in their sizable cohort of 466 patients with ADHF. Predictably, class I with high FEUN and low ePVS has the best prognosis, and class IV with low FEUN and high ePVS has the worst prognosis.…”

mentioning

confidence: 99%

“…The Nohria‐Stevens clinical classification of ADHF is one such example, based on the adequacy of peripheral perfusion (warm versus cold) and the presence of congestion (dry versus wet); “warm and wet” is the most common profile encountered. 23 The current classification proposed by Nogi et al 6 uses simple indexes from routine laboratory testing to parallel this clinical classification and possibly improve on it. They suggest its use as appropriate for predischarge patients in whom we may want to establish a new baseline before ambulatory follow‐up.…”

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confidence: 99%

See 1 more Smart Citation

Bedside Prognostication in Decompensated Heart Failure: No “Easy Button”

Rao

2023

JAHA

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New Classification for the Combined Assessment of the Fractional Excretion of Urea Nitrogen and Estimated Plasma Volume Status in Acute Heart Failure

Cited by 4 publications

References 27 publications

Blood Urea Nitrogen-to-Albumin Ratio May Predict Mortality in Patients with Traumatic Brain Injury from the MIMIC Database: A Retrospective Study

Blood Urea Nitrogen-to-Albumin Ratio May Predict Mortality in Patients with Traumatic Brain Injury from the MIMIC Database: A Retrospective Study

Fractional excretion of urea nitrogen can identify true worsening renal function in patients with heart failure

Bedside Prognostication in Decompensated Heart Failure: No “Easy Button”

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