Ultrafiltration in Decompensated Heart Failure with Cardiorenal Syndrome

Abstract

BACKGROUND 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. METHODS 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. RESULTS 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). CONCLUSIONS 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.

Decongestive Therapy and Renal Function in Acute Heart Failure

“…2 Common to many previous studies in AHF ( 17 and Continuous Ultrafiltration for cOngestive heaRt failurE [CUORE] 18 trials) has been continuous background therapy with high doses of loop diuretics. This class of therapy has intrinsic properties that predispose to WRF by ≥3 mechanisms: direct neurohormonal stimulation, transient depletion of intravascular volume, and frank…”

In‐hospital worsening heart failure: a clinically relevant endpoint?

“…Even when such concepts have been reflected as part of the inclusion criteria for a clinical trial, all is not as it seems. For example, the inclusion requirements for the Cardiorenal Rescue Study in Acute Decompensated Heart Failure (CARRESS‐HF) required that patients have worsening renal function and persistent oedema, implying that they either had WHF or HF that was failing to respond 25. However, the patients allocated to conventional therapy in the trial subsequently improved, suggesting that they were neither failing to respond nor worsening 25…”

Role of Peritoneal Ultrafiltration in Heart Failure Treatment

“…It has been showed that lowering IAB in HF patients improves renal function (20)(21)(22)(23)(24)(25)(26). On the other hand, unlike CARRESS, which was one of the three major studies comparing diuretic treatment with extracorporeal UF in patients with acute decompensated HF, weight loss was similar in both groups while the rate of deterioration in renal function in the extracorporeal UF group was greater than in the UF group (p=0.003) (78).…”