Ultrafiltration in Acute Heart Failure: Implications of Ejection Fraction and Early Response to Treatment From CARRESS‐HF

Abstract

Background Ultrafiltration is not commonly used because of higher incidence of worsening renal function without improved decongestion. We examined differential outcomes of high versus low fluid removal and preserved versus reduced ejection fraction (EF) in CARRESS‐HF (Cardiorenal Rescue Study in Acute Decompensated Heart Failure). Methods and Results Baseline characteristics in the ultrafiltration arm were compared according to 24‐hour ultrafiltration‐based fluid removal above versus below the median. Patients were stratified by EF (≤40% or >40%). We compared clinical parameters of clinical decongestion during the hospitalization based on initial (≤24 hours) response to ultrafiltration. Cox‐proportional hazards models were used to identify associations between fluid removal <24 hours and composite of death, hospitalization, or unscheduled outpatient/emergency department visit during study follow‐up. The intention‐to‐treat analysis included 93 patients. Within 24 hours, median fluid removal was 1.89 L (Q1, Q3: 1.22, 3.16). The high fluid removal group had a greater urine output (9.08 versus 6.23 L, P =0.027) after 96 hours. Creatinine change from baseline to 96 hours was similar in both groups (0.10 mg/dL increase, P =0.610). The EF >40% group demonstrated larger increases of change in creatinine ( P =0.023) and aldosterone ( P =0.038) from baseline to 96 hours. Among patients with EF >40%, those with above median fluid removal (n=17) when compared with below median (n=17) had an increased rate of the combined end point (87.5% versus 47.1%, P =0.014). Conclusions In patients with acute heart failure, higher initial fluid removal with ultrafiltration had no association with worsening renal function. In patients with EF >40%, ultrafiltration was associated with worsening renal function irrespective of fluid removal rate and higher initial fluid removal was associated with higher rates of adverse clinical outcomes, highlighting variable responses to decongestive therapy.

New Insight in Cardiorenal Syndrome: From Biomarkers to Therapy

“…In the UNLOAD trial, patients with acute HF who underwent ultrafiltration lost more weight than those on diuretic treatment, with lower readmittance rate after 90 days after hospital discharge, even though no improvement of renal function was observed [ 142 ]. Moreover, in patients with acute HF, ultrafiltration treatment was not associated with renal function worsening [ 143 ].…”

New aspects in cardiorenal syndrome and HFpEF

“…In concordance with this study, a substudy of the CARRESS-HF (Cardiorenal Rescue Study in Acute Decompensated Heart Failure) that examined differential outcomes of high versus low fluid removal and preserved versus reduced ejection, demonstrated that in patients with HFpEF, ultrafiltration was associated with worsening renal function irrespective of fluid removal rate and higher initial fluid removal was associated with higher rates of adverse clinical outcomes, highlighting variable responses to decongestive therapy. For that reason, patients with HFpEF and resistance to diuretics and other pharmacological drugs have clinical benefits in terms of decreasing hospitalization rates with PD treatment [ 74 ]. PD is a home-based treatment that allows a gentle removal of the excess water and sodium with minimal haemodynamic changes, with a great capacity to be able to adapt the requirements according to the clinical situation and the lifestyle of the patients.…”

Continuous renal replacement therapy under special conditions like sepsis, burn, cardiac failure, neurotrauma, and liver failure

“…Authors examined differential outcomes of high versus low fluid removal and preserved versus reduced ejection fraction (EF) in CARRESS-HF (Cardiorenal Rescue Study in Acute Decompensated Heart Failure). 66 In their study, they were able to show that in patients with acute HF, higher initial fluid removal with UF had no association with worsening renal function. 66 In patients with EF > 40%, UF was associated with worsening renal function irrespective of fluid removal rate, and higher initial fluid removal was associated with higher rates of adverse clinical outcomes, highlighting variable responses to decongestive therapy.…”

“…66 In their study, they were able to show that in patients with acute HF, higher initial fluid removal with UF had no association with worsening renal function. 66 In patients with EF > 40%, UF was associated with worsening renal function irrespective of fluid removal rate, and higher initial fluid removal was associated with higher rates of adverse clinical outcomes, highlighting variable responses to decongestive therapy. 66 So, clearly, there is no unanimity about the usefulness of UF in HF.…”