Ultrafiltration in Decompensated Heart Failure with Cardiorenal Syndrome

Morehouse School of Medicine, Atlanta (E.O.O.)
New England Journal of Medicine (Impact Factor: 55.87). 11/2012; 367(24). DOI: 10.1056/NEJMoa1210357
Source: PubMed


Ultrafiltration is an alternative strategy to diuretic therapy for the treatment of patients with acute decompensated heart failure. Little is known about the efficacy and safety of ultrafiltration in patients with acute decompensated heart failure complicated by persistent congestion and worsened renal function.

We randomly assigned a total of 188 patients with acute decompensated heart failure, worsened renal function, and persistent congestion to a strategy of stepped pharmacologic therapy (94 patients) or ultrafiltration (94 patients). The primary end point was the bivariate change from baseline in the serum creatinine level and body weight, as assessed 96 hours after random assignment. Patients were followed for 60 days.

Ultrafiltration was inferior to pharmacologic therapy with respect to the bivariate end point of the change in the serum creatinine level and body weight 96 hours after enrollment (P=0.003), owing primarily to an increase in the creatinine level in the ultrafiltration group. At 96 hours, the mean change in the creatinine level was -0.04±0.53 mg per deciliter (-3.5±46.9 μmol per liter) in the pharmacologic-therapy group, as compared with +0.23±0.70 mg per deciliter (20.3±61.9 μmol per liter) in the ultrafiltration group (P=0.003). There was no significant difference in weight loss 96 hours after enrollment between patients in the pharmacologic-therapy group and those in the ultrafiltration group (a loss of 5.5±5.1 kg [12.1±11.3 lb] and 5.7±3.9 kg [12.6±8.5 lb], respectively; P=0.58). A higher percentage of patients in the ultrafiltration group than in the pharmacologic-therapy group had a serious adverse event (72% vs. 57%, P=0.03).

In a randomized trial involving patients hospitalized for acute decompensated heart failure, worsened renal function, and persistent congestion, the use of a stepped pharmacologic-therapy algorithm was superior to a strategy of ultrafiltration for the preservation of renal function at 96 hours, with a similar amount of weight loss with the two approaches. Ultrafiltration was associated with a higher rate of adverse events. (Funded by the National Heart, Lung, and Blood Institute; number, NCT00608491.).

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Available from: Eric J Velazquez, Apr 01, 2014
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    • "These individuals are at high risk for future cardiovascular (CV) events and the presence of other well-established CV risk factors further increases their risk [1]. Muscle strength has been identified as an index of future CV risk and mortality [2] [3] [4] [5]. Studies of the relationship between strength and CV outcomes have mainly been done in non-Hispanic Caucasians from highincome countries [6] and little data are available regarding this relationship in a wider, more heterogeneous sample of people with dysglycemia. "

    Full-text · Article · Apr 2014 · International journal of cardiology
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    • "However, a more recent trial suggested that in hospitalized patients with decompensated heart failure, the use of pharmacotherapy was superior to ultrafiltration for preserving renal function and achieving weight loss with fewer adverse events [15]. A stepped-up pharmacologic care utilized loop and thiazide diuretics as well as inotropes and intravenous vasodilators [15]. Given the limitations of current available therapies, it seemed reasonable to look for additional strategies using medical therapy. "
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    ABSTRACT: Diuretics, including furosemide, metolazone, and spironolactone, have historically been the mainstay of therapy for acute decompensated heart failure patients. The addition of an aquaretic-like vasopressin antagonist may enhance diuresis further. However, clinical experience with this quadruple combination is lacking in the acute setting. We present two hospitalized patients with acute decompensated heart failure due to massive fluid overload treated with a combination strategy of triple diuretics in conjunction with the aquaretic tolvaptan. The first patient lost 72.1 lbs. (32.7 kg) with an average urine output of 3.5 to 7.5 L/day over eight days on combined therapy with furosemide, metolazone, spironolactone, and tolvaptan. The second patient similarly achieved a weight loss of 28.2 lbs. (12.8 kg) over 4 days on the same treatment. Both patients maintained stable serum sodium, potassium, and creatinine over this period and remained out of the hospital for more than 30 days. Thus, patients hospitalized with acute decompensated heart failure due to volume overload can achieve euvolemia rapidly and without electrolytes disturbances using this regimen, while being under the close supervision of a team of cardiologists and nephrologists. Additionally, this therapy can potentially decrease the need for ultrafiltration and the length of hospital stay.
    Full-text · Article · Dec 2013
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    • "First, there was inconsistency in the UF protocol used across the different RCTs; specifically the two most robust studies (Costanzo [4] and Bart [13]) investigated very different patient populations and took different approaches in study design. Costanzo's study [4] involved UF as a primary therapy (i.e. the protocol did not require failure of initial diuretic therapy for entry), while study by Bart [13] randomized patients with ADHF, worsening renal function and persistent volume overload to a strategy of UF versus stepped pharmacological management [22]. Given continued uncertainty about the ideal dosing of UF [23], we were unable to decisively determine whether results might have differed across various UF protocols. "
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    ABSTRACT: Background: A number of small studies suggest that ultrafiltration (UF) can improve outcomes in patients with acute decompensated heart failure (ADHF), but substantial uncertainty remains. We conducted a systematic review and meta-analysis with the primary goal of assessing the impact of UF on all-cause mortality in adults with ADHF; the secondary outcomes included re-hospitalization, emergency outpatient visits, and potentially deleterious effects (worsening renal function). Methods: We searched the Medline (1966–2013), the Embase (1966–2013), the Cochrane Registry, the U.S. Clinical Trials databases (2000–2013) and the abstracts from key scientific meetings to identify studies comparing UF with usual care (diuretic therapy) in adults hospitalized with ADHF. We identified six randomized controlled trials enrolling 523 patients. Studies were not heterogeneous and a fixed effect model was used for all analysis. Results: Unadjusted mortality was 13.3% among all diuretic patients as compared to 13.4% among UF recipients (p = 0.81). When compared to treatment with diuretics alone, UF did not reduce all-cause mortality (HR: 0.99, 95% CI: 0.60 to 1.61; p = 0.65), re-hospitalizations for HF (HR: 0.96, 95% CI: 0.39 to 2.35; p = 0.92), or unscheduled visits for heart failure (HR: 0.94, 95% CI: 0.36 to 2.50; p = 0.84). Furthermore, UF was not associated with increased risk of worsening renal function when compared to diuretic therapy (HR: 1.41, 95% CI: 0.89 to 2.22; p = 0.89). Conclusions: UF does not appear to reduce mortality, re-hospitalization or unscheduled HF visits in adults with ADHF. At the present time data are insufficient to support routine use of UF for acute HF.
    Full-text · Article · Dec 2013 · International Journal of Cardiology
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