B-Type Natriuretic Peptide: An Emerging Biomarker in Pediatric Critical Care
In 1988, Sudoh and colleagues described a novel natriuretic peptide in porcine brain [1 ]. Subsequent studies found that brain natriuretic peptide was most abundant in the heart, and thus it was termed B-type natriuretic peptide (BNP). The release of BNP
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B-Type Natriuretic Peptide: An Emerging Biomarker in Pediatric Critical Care P.E. Oishi, J.-H. Hsu, and J.R. Fineman
Introduction In 1988, Sudoh and colleagues described a novel natriuretic peptide in porcine brain [1]. Subsequent studies found that brain natriuretic peptide was most abundant in the heart, and thus it was termed B-type natriuretic peptide (BNP). The release of BNP is triggered in large part by myocyte stretch and BNP levels are easily quantified by several commercially available assays. Thus, over the past decade numerous investigators sought to determine the clinical utility of BNP and together have now firmly established a role for BNP as a biomarker for diagnosis, prognostication, and management of adults with cardiac disease [2]. Unfortunately, far fewer data are available on the role of BNP in the management of critically ill neonates, infants, and children. Potential uses for BNP in pediatric critical care are outlined in Table 1. This chapter will provide a brief review of these data with the goal of helping clinicians make use of BNP in the care of these patients. Table 1. Potential uses for B-type natriuretic peptide (BNP) determinations in pediatric critical care. Diagnoses that may be aided by BNP determinations in pediatric patients Congestive heart failure Persistent pulmonary hypertension of the newborn Hemodynamically significant patent ductus arteriosus Ventricular diastolic dysfunction in the acute phase of Kawasaki syndrome Hemodynamically significant pulmonary-to-systemic blood flow ratio Anthracycline-induced cardiac toxicity Tonic-clonic seizures (vs partial seizures or syncope) Sleep disordered breathing Sepsis Postoperative outcomes that may be associated with elevated BNP levels in neonates, infants, and children after cardiac surgery Duration of mechanical ventilation Level of inotropic support Residual anatomic lesions Inability to separate from extracorporeal life support Low cardiac output syndrome Intensive care unit length of stay Hospital length of stay Death
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P.E. Oishi, J.-H. Hsu, and J.R. Fineman
Natriuretic Hormone System
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Beginning with the observation by de Bold et al. [3] that rats infused with atrial tissue extracts developed natriuresis and diuresis, much has been learned over the past three decades about the role of the natriuretic hormone system in the homeostatic control of fluid balance and vascular tone. The natriuretic hormone system comprises several related peptides that activate specific receptors, particularly in the kidneys, myocardium, and vasculature, which use cyclic guanosine 3’,5’-monophosphate (cGMP) as a secondary messenger [4]. These peptides include atrial natriuretic peptide (ANP), BNP, C-type natriuretic peptide (CNP), dendroaspis natriuretic peptide (DNP), kaliuretic peptide, and urodilantin. The primary stimulus for the release of these peptides is an increase in intravascular or cardiac volume, which causes increased atrial stretch, ventricular wall stress, vascular sheer stress, intravascular volume, and/or intravascul
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