Elevated Blood Urea Nitrogen and Medical Outcome of Psychiatric Inpatients
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Elevated blood urea nitrogen (BUN) is associated with increased severity of illness and mortality, but its predictive value has not been studied in patients admitted to free-standing psychiatric hospitals. To determine the clinical outcome of psychiatric inpatients with elevated BUN on admission and to create a quantitative method of using BUN for predicting deteriorations requiring transfers of psychiatric inpatients to a general hospital we conducted a retrospective cohort study of 939 adults consecutively admitted to a free-standing psychiatric hospital in 2010. Transfer to a general hospital was used as a proxy marker for poor medical outcome. The score Age (years) plus BUN (mg/dL) was used in sensitivity analyses to identify patients with medical deterioration in derivation (N = 523) and validation (N = 414) samples. Fifty-two (5.5 %) patients had admission azotemia (BUN >25 mg/dL). Medical deteriorations requiring emergency transfer to a general hospital occurred in 24 (46.2 %; 95 % confidence interval = 32.6–49.8 %) of azotemic patients and 112 (12.6 %; 95 % confidence interval = 10.4–14.8 %) of those with normal BUN (p < 0.0001). Age + BUN ≥90 identified 51 transferred patients and had positive and negative predictive values of 39.8 and 89.5 %, respectively, in the entire sample. We conclude that psychiatric inpatients with BUN >25 mg/dL or Age + BUN ≥90 are at risk for medical deterioration. Free-standing psychiatric hospitals should develop models of care requiring frequent, scheduled medical follow-up and enhanced monitoring for this vulnerable populations.
KeywordsMedical outcome Psychiatric inpatients Blood urea nitrogen Age Predictive value
Drs. Manu, Al-Dhaher and Khan have nothing to disclose. Dr. Kane has been a consultant to or has received honoraria from Astra-Zeneca, Bristol-Myers Squibb, Cephalon, Eli Lilly, Janssen Pharmaceutica, Johnson and Johnson, Lundbeck, Otsuka, Pfizer Inc, PgXHealth, Proteus, Vanda and Wyeth, has served on the speaker’s bureau of AstraZeneca, Bristol-Myers Squibb/Otsuka and Eli Lilly, and is a share holder of MedAvante. Dr. Correll has been a consultant and/or advisor to or has received honoraria from: Actelion, Alexza; Bristol-Myers Squibb, Cephalon, Eli Lilly, Genentech, Gerson Lehrman Group, IntraCellular Therapies, Lundbeck, Medavante, Medscape, Merck, Janssen/J&J, Otsuka, Pfizer, ProPhase, Roche, Sunovion, Takeda, Teva, and Vanda. He has received grant support from BMS, Janssen/J&J, and Otsuka.
- 1.Kirtane AJ, Leder DM, Waikar SS, Chertow GM, Ray KK, Pinto DS, Karmpaliotis D, Burger AJ, Murphy SA, Cannon CP, Braunwald E, Gibson CM, TIMI Study Group: Serum blood urea nitrogen as an independent marker of subsequent mortality among patients with acute coronary syndromes and normal to mildly reduced glomerular filtration rates. Journal of the American College of Cardiology 45(11):1781–1786, 2005PubMedCrossRefGoogle Scholar
- 2.Fonarow GC, Adams KF Jr, Abraham WT, Yancy CW, Boscardin WJ, Adhere Scientific Advisory Committee, Study Group, and Investigators: Risk stratification for in-hospital mortality in acutely decompensated heart failure: Classification and regression tree analysis. JAMA 293(5):572–580, 2005Google Scholar
- 5.Baggish AL, Lloyd-Jones DM, Blatt J, Richards AM, Lainchbury J, O’Donoghue M, Sakhuja R, Chen AA, Januzzi JL: A clinical and biochemical score for mortality prediction in patients with acute dyspnoea: Derivation, validation and incorporation into a bedside programme. Heart 94(8):1032–1037, 2008PubMedCrossRefGoogle Scholar
- 15.Wu BU, Bakker OJ, Papachristou GI, Besselink MG, Repas K, vanSantvort HC, Muddano V, Singh VK, Whitcomb DC, Gooszen HG, Banks PA: Blood urea nitrogen in the early assessment of acute pancreatitis: An international validation study. Archives of Internal Medicine 171(7):669–676, 2011Google Scholar
- 19.Bailey SH, Bull DA, Harpole DH, Rentz JJ, Neumayer LA, Pappas TN, Daley J, Henderson WG, Krasnicka B, Khuri SF: Outcomes after esophagectomy: A ten-year prospective cohort [discussion 222]. Annals of Thoracic Surgery 75(1):217–22, 2003Google Scholar
- 20.Beier K, Eppanapally S, Bazick HS, Chang D, Mahadevappa K, Gibbons FK, Christopher KB: Elevation of blood urea nitrogen is predictive of long-term mortality in critically ill patients independent of “normal” creatinine. Critical Care Medicine 39(2):305–313, 2011PubMedCentralPubMedCrossRefGoogle Scholar
- 23.Bloom JD, Krishan B, Lockey C: The majority of inpatients psychiatric beds should not be appropriate by the forensic system. Journal of the American Academy of Psychiatry 36:438–442, 2008Google Scholar
- 24.De Hert M, Correll CU, Bobes J, Cetkovich-Bakmas M, Cohen D, Asai I, Detraux J, Gautam S, Möller HJ, Ndetei DM, Newcomer JM, Uwakwe R, Leucht S: Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry 10(1):52–77, 2011Google Scholar
- 28.Gao M, Zhang L, Liu Y, Yang M, Wang N, Wang K, Ou D, Liu M, Chen G, Liu K, Xiao X: Use of blood urea nitrogen, creatinine, interleukin-6, granulocyte-macrophage colony stimulating factor in combination to predict the severity and outcome of abdominal sepsis in rats. Inflammation Research 61(8):889–897, 2012PubMedCrossRefGoogle Scholar
- 29.Ferrucci L, Guralnik JM, Studenski S, Fried LP, Cutler GB Jr, Walston JD: Designing randomized, controlled trials aimed at preventing or delaying functional decline and disability in frail, older persons: a consensus report. Journal of the American Geriatrics Society 52(4):625–34, 2004PubMedCrossRefGoogle Scholar