Psychiatric Quarterly

, Volume 85, Issue 1, pp 111–120 | Cite as

Elevated Blood Urea Nitrogen and Medical Outcome of Psychiatric Inpatients

  • Peter Manu
  • Zainab Al-Dhaher
  • Sameer Khan
  • John M. Kane
  • Christoph U. Correll
Original Paper


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.


Medical 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. 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. 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
  3. 3.
    Cauthen CA, Lipinski MJ, Aggate A, Appleton D, Nusca A, Varma A, Goudreau E, Cowley MJ, Vetrovec GW: Relation of blood urea nitrogen to long-term mortality in patients with heart failure. The American Journal of Cardiology 101(11):1643–1647, 2008PubMedCrossRefGoogle Scholar
  4. 4.
    Rehman SU, Martinez-Rumayor A, Mueller T, Januzzi JL Jr: Independent and incremental prognostic value of multimarker testing in acute dyspnea: Results from the ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) study. Clinica Chimica Acta 392(1–2):41–45, 2008CrossRefGoogle Scholar
  5. 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
  6. 6.
    Fine MJ, Aubie TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE, Coley CM, Marrie TJ, Kapoor WN: A prediction rule to identify low-risk patients with community-acquired pneumonia. The New England Journal of Medicine 336(4):243–250, 1997PubMedCrossRefGoogle Scholar
  7. 7.
    Raz R, Dyachenko P, Levy Y, Flatau E, Reichman N: A predictive model for the management of community-acquired pneumonia. Infection 31(1):3–8, 2003PubMedCrossRefGoogle Scholar
  8. 8.
    Espana PP, Capelastegui A, Gorordo I, Esteban C, Oribe M, Ortega M, Bilbao A, Quintana JM. Development and validation of a clinical prediction rule for severe community-acquired pneumonia. The American Journal of Respiratory and Critical Care Medicine 174(11):1249–1256, 2006CrossRefGoogle Scholar
  9. 9.
    Mackinney-Novelo I, Barahona-Garrido J, Castillo-Albarran F, Santiago-Hernandez JJ, Mendez-Sanchez N, Uribe M, Chavez-Tapia N: Clinical course and management of acute hepatitis A infection in adults. Annals of Hepatology 11(5):652–657, 2012PubMedGoogle Scholar
  10. 10.
    Tandon P, Garcia-Tsao G: Renal dysfunction is the most important independent predictor of mortality in cirrhotic patients with spontaneous bacterial peritonitis. Clinical Gastroenterology and Hepatology 9(3):260–265, 2011PubMedCentralPubMedCrossRefGoogle Scholar
  11. 11.
    Rhoney DH, Parker D Jr, Millis SR, Whittaker P: Kidney dysfunction at the time of intracerebral hemorrhage is associated with increased in-hospital mortality: A retrospective observational cohort study. Neurological Research 34(5):518–521, 2012PubMedCrossRefGoogle Scholar
  12. 12.
    Lee CC, Wu CJ, Chi CH, Lee NY, Chen PL, Lee HC, Chang CM, Ko NY, Ko WC: Prediction of community-onset bacteremia among febrile adults visiting an emergency department: Rigor matters. Diagnostic Microbiology and Infectious Disease 73(2):168–73, 2012PubMedCrossRefGoogle Scholar
  13. 13.
    Kaya E, Dervisoglu A, Polat C: Evaluation of diagnostic findings and scoring systems in outcome prediction in acute pancreatitis. World Journal of Gastroenterology 13(22):3090–3094, 2007PubMedGoogle Scholar
  14. 14.
    Faisst M, Wellner UF, Utzolino S, Hopt UT, Keck T: Elevated blood urea nitrogen is an independent risk factor of prolonged intensive care unit stay due to acute necrotizing pancreatitis. Journal of Critical Care 25(1):105–111, 2010PubMedCrossRefGoogle Scholar
  15. 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
  16. 16.
    Talukdar R, Nechutova H, Clemens M, Vege SS: Could rising BUN predict the future development of infected pancreatic necrosis? Pancreatology 13(4):355–359, 2013PubMedCrossRefGoogle Scholar
  17. 17.
    Chen SC, Tsai SJ, Chen CH, Huang CC, Lin DB, Wang PH, Chen CC, Lee MC: Predictors of mortality in patients with pyogenic liver abscess. Netherlands Journal of Medicine 66(6):196–203, 2008PubMedGoogle Scholar
  18. 18.
    Barra S, Providencia R, Caetano F, Almeida I, Paiva L, Dinis P, Leitao Marques A: BLEED-myocardial infarction score: Predicting mid-term post-discharge bleeding events. World Journal of Cardiology 5(6):196–206, 2013PubMedCentralPubMedCrossRefGoogle Scholar
  19. 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. 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
  21. 21.
    Singh G, Peterson EL, Wells K, Williams LK, Lanfear DE: Comparison of renal predictors for in-hospital and postdischarge mortality after hospitalized heart failure. Journal of Cardiovascular Medicine (Hagerstown) 13(4):246–253, 2012CrossRefGoogle Scholar
  22. 22.
    Pompei P, Charlson ME, Ales K, MacKenzie CR, Norton M: Relating patient characteristics at the time of admission to outcomes of hospitalization. Journal of Clinical Epidemiology 44(10):1063–1069, 1991PubMedCrossRefGoogle Scholar
  23. 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. 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
  25. 25.
    Leung MW, Xiong GL, Leamon MH, McCarron RM, Hales RE: General-medical hospital admissions from a public inpatient psychiatric health facility: A review of medical complications over 30 months. Psychosomatics 51(6):498–502, 2010PubMedCrossRefGoogle Scholar
  26. 26.
    Passov V, Rundell JR: Analysis of transfers from a medical-psychiatry inpatient unit to a medical-surgical unit within 48 hours of admission. Psychosomatics 49(6):535–7, 2008PubMedCrossRefGoogle Scholar
  27. 27.
    Kazory A: Emergence of blood urea nitrogen as a biomarker of neurohormonal activation in heart failure. The American Journal of Cardiology 106(5):694–700, 2010PubMedCrossRefGoogle Scholar
  28. 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. 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
  30. 30.
    Fried LP, Tangen, CM, Walston J, Newman AB, Hirsch C, Gottdiener J, Seeman T, Tracy R, Kop WJ, Burke G, McBurnie MA: Frailty in older adults: Evidence for a phenotype. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 56(3):146–156, 2001CrossRefGoogle Scholar
  31. 31.
    Inouye SK, Studenski S, Tinetti ME,Kuchel GA: Geriatric syndromes: Clinical, research, and policy implications of a core geriatric concept. Journal of the American Geriatrics Society 55(5):780–791, 2007PubMedCentralPubMedCrossRefGoogle Scholar
  32. 32.
    Manu P, Grudnikoff E, Khan S, Kremen NJ, Greenwald BS, Kane JM, Correll CU: Medical outcome of patients with dementia in a free-standing psychiatric hospital. Journal of Geriatric Psychiatry and Neurology 26(1):29–33, 2013PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Peter Manu
    • 1
    • 2
  • Zainab Al-Dhaher
    • 1
  • Sameer Khan
    • 1
  • John M. Kane
    • 1
    • 2
  • Christoph U. Correll
    • 1
    • 2
  1. 1.Zucker Hillside HospitalNorth Shore – Long Island Jewish Health SystemGlen OaksUSA
  2. 2.Hofstra North Shore – Long Island Jewish School of Medicine at Hofstra UniversityHempsteadUSA

Personalised recommendations