Ultrafiltration for patients with acute decompensated heart failure

Abstract

Background: Ultrafiltration plays an indispensable role in relieving congestion and fluid retention in patients with acute decompensated heart failure (ADHF) in recent years. So far, there is no consistent agreement about whether early ultrafiltration (UF) is a first-line treatment for patients with ADHF. We, therefore, conducted a meta-analysis to assess the efficacy and safety of UF. Methods: PubMed, Embase, and Cochrane Library databases were searched for randomized controlled trials (RCTs) that compared UF with diuretics in patients with ADHF and included our interested outcomes. The primary outcomes are heart failure rehospitalization, all-cause rehospitalization, and mortality. The second outcomes are fluid loss, weight loss, and adverse events. RevMan Version 5.4.1 was used to analyze the data of included studies. Results: A total of 12 studies with 1197 patients were included. Our results showed a reduction in heart failure rehospitalization (risk ratio [RR] 0.67, 95% confidence interval [CI]: 0.52–0.87, P = .003) and all-cause rehospitalization (RR 0.62, 95% CI: 0.42–0.92; P = .02), an increase in fluid loss (1.47 L, 95% CI: 0.95–1.99 L, P < .001) and weight loss (1.65 kg, 95% CI: 0.90–2.41 kg; P < .001). There was no difference in mortality (RR 1.09, 95% CI: 0.78–1.51; P = .62). There were inconsistent agreements about which group have more total adverse events. Subgroup analysis showed that UF with larger mean fluid-remove rate (≥200 mL/h) could significantly remove more fluid, lose more weight, and decrease heart failure rehospitalization. Less weight loss for patients with ADHF may correlated to higher percent of ischemic etiology (ischemic etiology ≥50%). Conclusion: Although UF is more effective in removing fluid than diuretics and decrease rehospitalization of heart failure and all causes, there is not enough evidence to prove that UF is superior because of adverse events and mortality in the UF group. The mean fluid-removal rates should be set to ≥200 mL/h. Patient with different etiology may have different effects when treated with UF and it is a weak conclusion. Trial registration: The systematic review was registered with the International Prospective Registry of Systematic Reviews. ( https://www.crd.york.ac.uk/prospero/ , registration number CRD42021245049).

Ultrafiltration versus Diuretics on Prognostic Cardiac and Renal Biomarkers in Acute Decompensated Heart Failure: A Systematic Review and Meta-Analysis

“…Modulating ultrafiltration treatment parameters may further increase the superiority gap. A meta-analysis by Wang et al, 2021 recommends mean fluid removal to be set at ≥ 200 mL/h after their subgroup analysis demonstrated superior fluid removal, weight loss, and rehospitalisation rates [27]. We hypothesize that flow rate, which differs substantially between studies, may play a similar role in affecting cardiac and renal biomarkers.…”

“…Existing systematic reviews have concluded that ultrafiltration has a benign renal profile without including BUN within their outcomes [8,9,[25][26][27]. Although BUN was measured in five studies [3,5,7,10,16], it has not been sufficiently discussed within RCT manuscripts.…”

“…By design, our meta-analysis is focused and limited in scope. We do not re-address ultrafiltration's impact on morbidity, mortality, or decongestive outcomes, as this has been covered extensively in the literature [8,9,[25][26][27].…”

Efficacy and safety of early ultrafiltration in patients with acute decompensated heart failure: a meta-analysis

“…The results showed that patients in the early ultrafiltration group experienced greater weight reduction, a lower rate of re-hospitalization within 90 days, similar relief of dyspnea compared to the routine diuresis group, and a lower incidence of hypokalemia ( 11 ). Previous meta-analyses ( 22 ) have compared ultrafiltration with diuresis in patients with heart failure and have shown that ultrafiltration is more effective in reducing volume load and rehospitalization rate, but it does not reduce the incidence of adverse events and mortality. This study’s innovation lies in the timing of early ultrafiltration, which aims to determine the efficacy and safety of this approach in patients with acute decompensated heart failure.…”

Cardiovascular Consequences of Acute Kidney Injury: Treatment Options

“…Although UF is more effective in fluid removal compared with diuretics and reduces readmissions due to HF, it is not possible to prove that UF is superior to diuretics because of adverse events and mortality in the UF group. Treatment outcomes seem to vary because of the multiple causes and different aetiologies of patients [ 75 ].…”