Extracorporeal Ultrafiltration vs Conventional Diuretic Therapy in Advanced Decompensated Heart Failure

Abstract

Compared with conventional diuretic (CD) therapy, ultrafiltration (UF) is associated with greater weight loss and fewer re‐hospitalizations in patients admitted with decompensated heart failure (HF). Concerns have been raised regarding its safety and efficacy in patients with more advanced heart failure. The authors conducted a single‐center, prospective, randomized controlled trial in patients with advanced HF admitted to an intensive care unit for hemodynamically guided therapy, comparing UF (n=17) with CD (n=19) at admission. The primary end point was the time required for pulmonary capillary wedge pressure (PCWP) to be maintained at a value of ≤18 mm Hg for at least 4 consecutive hours. Secondary end points included levels of cytokines and neurohormones, as well as several clinical outcomes. In our study cohort, the time to achieve the primary end point was lower in the UF group but did not reach statistical significance (P = .08). UF resulted in greater weight reduction, higher total volume removed, and shorter hospital length of stay. There were no differences in kidney function, biomarkers, or adverse events. In patients with advanced HF under hemodynamically tailored therapy, UF can be safely performed to achieve higher average volume removed than CD therapy without leading to adverse outcomes. Congest Heart Fail. 2012;18:54–63. ©2011 Wiley Periodicals, Inc.

Diuretics and Ultrafiltration in Acute Heart Failure Syndrom

“…Study characteristics: The 5 published RCTs 4,7,[9][10][11][12] in our meta-analysis had a total of 494 patients. Patients who were hospitalized with acute decompensated heart failure, 7) or with 2+ peripheral edema, higher jugular venous pressure, or pulmonary edema, or pleural effusion on chest radiography, 4,[9][10][11] or with NYHA class III/IV HF symptoms 12) were eligible for enrollment, and those with acute coronary syndrome, higher serum creatinine, or higher hematocrit, or hemodynamic instability were excluded. 4,7,[9][10][11][12] They compared ultrafi ltration therapy with diuretic therapy.…”

“…The ultrafi ltration rate of most trials was 200 mL/ hour, and the primary endpoint in most trials was weight change (Table II). Methodological quality assessment: All trials randomized the participants, but only 3 4,7,12) reported details of the randomization process used. These were permuted block randomization stratifi ed according to center.…”

“…Patients who were hospitalized with acute decompensated heart failure, 7) or with 2+ peripheral edema, higher jugular venous pressure, or pulmonary edema, or pleural effusion on chest radiography, 4,[9][10][11] or with NYHA class III/IV HF symptoms 12) were eligible for enrollment, and those with acute coronary syndrome, higher serum creatinine, or higher hematocrit, or hemodynamic instability were excluded. 4,7,[9][10][11][12] They compared ultrafi ltration therapy with diuretic therapy. The total number of patients in each study ranged from 30 to 200, and the duration of follow-up varied from 96 hours to 90 days.…”

Efficacy and Safety of Ultrafiltration in Decompensated Heart Failure Patients With Renal Insufficiency

“…UF treatment led to significantly greater fluid loss compared to control (WMD 1.23, 95% CI 0.63 to 1.82, P < 0.0001, I2 = 43%, Figure 2B). Effect of UF on renal function Three studies 21,22,24) reported creatinine values and there was no significant difference in the creatinine levels between the UF and control groups (WMD 0.05, 95% CI -0.23 to 0.33, P = 0.61, I2 = 77%, Figure 2C). Another 3 studies (4 publications) 19,20,23,25) reported that the changes in creatinine values were similar between the UF and control groups (WMD 0.05, 95% CI -0.15 to 0.26, P = 0.61, I2 = 77%, Figure 2D).…”

“…Thirteen articles were excluded (4 articles due to lack of renal function data, 8 articles were not RCTs, and 1 study was with normal renal function), and the remaining 8 articles [18][19][20][21][22][23][24][25] were analyzed. Among the 8 articles, two 19,25) reported the results of the UNLOAD trial by comparing the outcomes between UF and intravenous diuretics 19) and among UF, intravenous continuous or bolus diuretics 25) and the results from these two publications were summarized in this analysis.…”