Efficacy and cardiovascular tolerability of continuous veno-venous hemodiafiltration in acute decompensated heart failure: a randomized comparative study

Diuretics or ultrafiltration in the treatment of acute decompensated heart failure: An updated systematic review and meta-analysis

INTRODUCTION

Hospitalization for decompensated heart failure is a major public health issue.

METHODS

We performed a meta-analysis to summarize and analyze if there is a benefit in using ultrafiltration over diuretics in terms of reducing mortality or hospital readmissions, primarily and identified 10 randomized controlled trials (RCTs) including 941 patients.

RESULTS

Compared to diuretics, treatment with ultrafiltration was associated with a significant reduction in heart failure hospitalizations (risk ratio [RR]: 0.72; 95% confidence interval [CI]: 0.55-0.96, p = 0.02) and significant increase in weight and net fluid loss (mean difference [MD]: -1.55, CI: -2.36 to -0.74, p = 0.0002) and (MD: -2.10, CI: -3.32 to -0.89, p = 0.0007), respectively. There was no significant difference among treatments regarding the duration of hospitalization, the increase in serum creatinine levels, and mortality.

CONCLUSION

Among patients with decompensated heart failure, compared to diuretics, ultrafiltration is associated with reduced rehospitalizations and increased weight/net fluid loss.

The Impact of Continuous Veno-Venous Hemodiafiltration on the Efficacy of Administration of Prophylactic Doses of Enoxaparin: A Prospective Observational Study

BACKGROUND

Critically ill patients frequently require continuous renal replacement therapy (CRRT). During CRRT, particles up to 10 kDa in size, such as enoxaparin, may be removed. The aim of this study was to determine if patients receiving prophylactic doses of enoxaparin and treated with continuous veno-venous hemodiafiltration (CVVHDF) reach prophylactic values of anti-Xa factor activity.

METHODS

In this observational trial, we compared two groups: 20 patients treated with CVVHDF and 20 patients not treated with CVVHDF. All of them received prophylactic doses of 40 mg of enoxaparin subcutaneously. Anti-Xa factor activity was determined on the third day of receiving a prophylactic dose of enoxaparin. The first blood sample was taken just before the administration of enoxaparin, and other samples were taken 3 h, 6 h, and 9 h after the administration of a prophylactic dose of enoxaparin.

RESULTS

At 3 and 6 h after administration of enoxaparin in both groups, we observed a significant increase in anti-Xa factor activity from baseline, with the peak after 3 h of administration. There were no significant differences in the numbers of patients who had anti-Xa factor activity within the prophylactic range between CVVHDF and control groups.

CONCLUSION

CVVHDF has only a mild effect on the enoxaparin prophylactic effect measured by anti-Xa factor activity. Thus, it seems there is no need to increase the dose of enoxaparin for patients requiring CVVHDF.

Efficacy and Renal Tolerability of Ultrafiltration in Acute Decompensated Heart Failure: A Meta-analysis and Systematic Review of 19 Randomized Controlled Trials

Background: Acute decompensated heart failure (ADHF) is a life-threatening and costly disease. Controversy remains regarding the efficacy and renal tolerability of ultrafiltration for treating ADHF. We therefore performed this meta-analysis to evaluate this clinical issue.Methods: A search of PubMed, EMBASE, and the Cochrane database of controlled trials was performed from inception to March 2021 for relevant randomized controlled trials. The quality of the included trials and outcomes was evaluated with the use of the risk of bias assessment tool and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, respectively. The risk ratio and the standardized mean difference (SMD) or weighted mean difference (WMD) were computed and pooled with fixed-effects or random-effects models.Results: This meta-analysis included 19 studies involving 1281 patients. Ultrafiltration was superior to the control treatments for weight loss (WMD 1.24 kg, 95% confidence interval [CI] 0.38‐2.09 kg, P=0.004) and fluid removal (WMD 1.55 L, 95% CI 0.51‐2.59 l, P=0.003) and was associated with a significant increase in serum creatinine level compared with the control treatments (SMD 0.15 mg/dL, 95% CI 0.00‐0.30 mg/dL, P=0.04). However, no significant effects were found for serum N-terminal prohormone of brain natriuretic peptide level, length of hospital stay, all-cause mortality, or all-cause rehospitalization in the ultrafiltration group.Conclusions: The use of ultrafiltration in patients with ADHF is superior to the use of the control treatments for weight loss and fluid removal, but has adverse renal effects and lacks significant effects on long-term prognosis, indicating that this approach to decongestion in ADHF patients is efficient for fluid management but less safe renally.

Outcomes after Acute Peritoneal Dialysis for Critical Cardiorenal Syndrome Type 1

INTRODUCTION

The aim of the study was to demonstrate the outcomes of peritoneal dialysis (PD) in critically ill cardiorenal syndrome type 1 (CRS1).

METHODS

A cohort of 147 patients with CRS1 who received PD from 2011 to 2019 in a referral hospital in Thailand was analyzed. The primary outcome was 30-day in-hospital mortality. Ultrafiltration and net fluid balance among survivors and nonsurvivors in the first 5 PD sessions were compared.

RESULTS

The 30-day mortality rate was 73.4%. Most patients were critically ill CRS1 (all patients had a respiratory failure of which 68% had cardiogenic shock). Blood urea nitrogen and creatinine at the commencement of PD were 60.1 and 4.05 mg/dL. In multivariable analysis, increasing age, unstable hemodynamics, and positive fluid balance in the first 5 PD sessions were associated with the risk of in-hospital mortality. The change of fluid balance per day during the first 5 dialysis days was significantly different among survivor and nonsurvivor groups (-353 vs. 175 mL per day, p = 0.01).

CONCLUSIONS

PD is a viable dialysis option in CRS1, especially in a resource-limited setting. PD can save up to 27% of lives among patients with critically ill CRS1.

Patients with high-dose diuretics should get ultrafiltration in the management of decompensated heart failure: a meta-analysis

The identification of specific patients with decompensated heart failure (DHF) who may benefit from ultrafiltration (UF) is important in clinical practice. We undertook a meta-analysis to compare the effects of ultrafiltration and diuretics on major clinical outcomes. The outcomes included weight change, length of hospital stay, rehospitalization for HF, mortality, change in serum creatinine, dialysis dependence, and adverse outcomes. We identified 14 trials including 975 patients with HF, met the eligibility criteria. There was a reduction in heart failure-related rehospitalization in ultrafiltration group when compared with the diuretic group. Subgroup analyses revealed a trend toward the decreased HF readmissions in ultrafiltration plus diuretic therapy group but did not reach statistical significance compared with ultrafiltration alone therapy. Overall, UF treatment did not produce apparent beneficial effects for weight loss, lengths of hospitalization, total mortality, the change of serum creatinine, and dialysis rate. Subgroup analyses showed increase in the serum creatinine were significantly higher for a higher dose regimen (> 200 mg/day) when compared with lower dose diuretic therapy (< 200 mg/day). As for adverse events, UF patients were associated with an increased risk of hypotension and lower risk of neurologic symptoms. The current results revealed ultrafiltration was associated with significant reduction in the rate of rehospitalization. Increase in the serum creatinine was observed in patients with high-dose diuretic regimen. Patients with high-dose diuretics should get ultrafiltration therapy.

Impact of furosemide on mortality and the requirement for renal replacement therapy in acute kidney injury: a systematic review and meta-analysis of randomised trials

Objective

To examine the impact of furosemide on mortality and the need for renal replacement therapy (RRT) in adult patients with acute kidney injury (AKI) based on current evidence.

Data sources

PubMed (Medline) and Embase were searched from 1998 to October 2018.

Study selection

We retrieved data from randomised controlled trials comparing prevention/treatment with furosemide at any stage of AKI with alternative treatment/standard of care/placebo. The outcome was short-term mortality and the requirement for RRT, when applicable.

Data extraction

Two reviewers independently extracted appropriate data. PRISMA guidelines were followed for data preparation and reporting.

Data synthesis

We identified 20 relevant studies (2608 patients: 1330 in the treatment arm and 1278 in the control arm). Heterogeneity between studies was deemed acceptable, and the publication bias was low. Furosemide had neither an impact on mortality (OR = 1.015; 95% CI 0.825–1.339) nor the need for RRT (OR = 0.947; 95% CI 0.521–1.721). Furosemide had also no effect on the outcomes in strata defined by intervention strategy (prevention/treatment), AKI origin (cardio-renal syndrome, post-cardiopulmonary bypass, critical illness), control arm comparator (RRT, saline/placebo/standard of care) and its dose (< 160/≥ 160 mg) (p > 0.05 for all). Subjects who received furosemide with matched hydration in prevention of contrast-induced nephropathy (CIN) had a less frequent need for RRT (OR = 0.218; 95% CI 0.05–1.04; p = 0.055).

Conclusions

Furosemide administration has neither an impact on mortality nor the requirement for RRT. Patients at risk of CIN may benefit from furosemide administration. Further well-designed RCTs are needed to verify these findings.

Electronic supplementary material

The online version of this article (10.1186/s13613-019-0557-0) contains supplementary material, which is available to authorized users.

Chinese society of cardiology expert consensus statement on the diagnosis and treatment of adult fulminant myocarditis

Fulminant myocarditis is primarily caused by infection with any number of a variety of viruses. It arises quickly, progresses rapidly, and may lead to severe heart failure or circulatory failure presenting as rapid-onset hypotension and cardiogenic shock, with mortality rates as high as 50%–70%. Most importantly, there are no treatment options, guidelines or an expert consensus statement. Here, we provide the first expert consensus, the Chinese Society of Cardiology Expert Consensus Statement on the Diagnosis and Treatment of Fulminant Myocarditis, based on data from our recent clinical trial (NCT03268642). In this statement, we describe the clinical features and diagnostic criteria of fulminant myocarditis, and importantly, for the first time, we describe a new treatment regimen termed life support-based comprehensive treatment regimen. The core content of this treatment regimen includes (i) mechanical life support (applications of mechanical respirators and circulatory support systems, including intraaortic balloon pump and extracorporeal membrane oxygenation, (ii) immunological modulation by using sufficient doses of glucocorticoid, immunoglobulin and (iii) antiviral reagents using neuraminidase inhibitor. The proper application of this treatment regimen may and has helped to save the lives of many patients with fulminant myocarditis.

Ultrafiltration versus intravenous loop diuretics in patients with acute decompensated heart failure: a meta-analysis of clinical trials

Background Intravenous loop diuretics are the first-line therapy for acute decompensated heart failure (ADHF) but many patients are discharged with unresolved congestion resulting in higher re-hospitalization and mortality rates. Ultrafiltration (UF) is a promising intervention for ADHF. However, studies comparing UF to diuretics have been inconsistent in their clinical outcomes. Methods A comprehensive literature search was performed. Trials were included if they met the following criteria: (1) randomization with a control group, (2) comparison of UF with a loop diuretic, and (3) a diagnosis of ADHF. Results When compared to diuretics, UF was associated with a reduced risk of clinical worsening (odds ratio (OR) 0.57, 95% CI: 0.38-0.86, P-value 0.007), increased likelihood for clinical decongestion (OR 2.32, 95% CI: 1.09-4.91, P-value 0.03) with greater weight (0.97 Kg, 95% CI: 0.52-1.42, P-value <0.0001) and volume reduction (1.11 L, 95% CI: 0.68-1.54, P-value <0.0001). The overall risk of re-hospitalization (OR 0.92, 95% CI: 0.62-1.38, P-value 0.70), return to emergency department (OR 0.69, 95% CI: 0.44-1.08, P-value 0.10) and mortality (OR 0.99, 95% CI: 0.60-1.62, P-value 0.97) were not significantly improved by UF treatment. Conclusions UF is associated with significant improvements in clinical decongestion but not in rates of re-hospitalization or mortality.

[Congestive heart failure: Treatment with ultrafiltration]

INTRODUCTION

The prevalence rate of congestive heart failure is approximately 2% in high-income countries. The aim of this study was to assess the overall benefit of ultrafiltration therapy in patients with acute or persistent congestive heart failure.

METHODS

We conducted a health technology assessment following the EUnetHTA guidelines, with systematic literature review from bibliographic medical databases, independent experts and manufacturer interviews.

RESULTS

Thirteen clinical trials and five meta-analyses were examined. In the most recent one, 608 patients were included, of which 304 received ultrafiltration therapy and 304 received intravenous loop diuretics. Ultrafiltration therapy seems to be more beneficial regarding the fluid removal and the body weight reduction, (mean difference respectively 1.44kg, IC95% [0.29; 2.59], P-value=0.01 and 1.28L [0.43; 2.12], P-value=0.003). No difference has been showed in overall mortality, renal function, hospital readmission or safety. Medico-economic studies are incomplete and contradictory.

CONCLUSION

Ultrafiltration therapy seems to be effective, most likely for patients ineligible or resistant to intravenous diuretics. But most topics remain uncertain, mainly impact on overall mortality, safety and cost-effectiveness. Given these knowledge-gaps, the generalization of ultrafiltration therapy should be examined cautiously, and conditional upon a large-scale systematic evaluation.

Focus on renal congestion in heart failure

Hospitalizations due to heart failure are increasing steadily despite advances in medicine. Patients hospitalized for worsening heart failure have high mortality in hospital and within the months following discharge. Kidney dysfunction is associated with adverse outcomes in heart failure patients. Recent evidence suggests that both deterioration in kidney function and renal congestion are important prognostic factors in heart failure. Kidney congestion in heart failure results from low cardiac output (forward failure), tubuloglomerular feedback, increased intra-abdominal pressure or increased venous pressure. Regardless of the cause, renal congestion is associated with increased morbidity and mortality in heart failure. The impact on outcomes of renal decongestion strategies that do not compromise renal function should be explored in heart failure. These studies require novel diagnostic markers that identify early renal damage and renal congestion and allow monitoring of treatment responses in order to avoid severe worsening of renal function. In addition, there is an unmet need regarding evidence-based therapeutic management of renal congestion and worsening renal function. In the present review, we summarize the mechanisms, diagnosis, outcomes, prognostic markers and treatment options of renal congestion in heart failure.

Meta-Analysis of Ultrafiltration versus Diuretics Treatment Option for Overload Volume Reduction in Patients with Acute Decompensated Heart Failure

INTRODUCTION

Although diuretics are mainly used for the treatment of acute decompensated heart failure (ADHF), inadequate responses and complications have led to the use of extracorporeal ultrafiltration (UF) as an alternative strategy for reducing volume overloads in patients with ADHF.

OBJECTIVE

The aim of our study is to perform meta-analysis of the results obtained from studies on extracorporeal venous ultrafiltration and compare them with those of standard diuretic treatment for overload volume reduction in acute decompensated heart failure.

METHODS

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials databases were systematically searched using a pre‑specified criterion. Pooled estimates of outcomes after 48 h (weight change, serum creatinine level, and all-cause mortality) were computed using random effect models. Pooled weighted mean differences were calculated for weight loss and change in creatinine level, whereas a pooled risk ratio was used for the analysis of binary all-cause mortality outcome.

RESULTS

A total of nine studies, involving 613 patients, met the eligibility criteria. The mean weight loss in patients who underwent UF therapy was 1.78 kg [95% Confidence Interval (CI): -2.65 to -0.91 kg; p < 0.001) more than those who received standard diuretic therapy. The post-intervention creatinine level, however, was not significantly different (mean change = -0.25 mg/dL; 95% CI: -0.56 to 0.06 mg/dL; p = 0.112). The risk of all-cause mortality persisted in patients treated with UF compared with patients treated with standard diuretics (Pooled RR = 1.00; 95% CI: 0.64-1.56; p = 0.993).

CONCLUSION

Compared with standard diuretic therapy, UF treatment for overload volume reduction in individuals suffering from ADHF, resulted in significant reduction of body weight within 48 h. However, no significant decrease of serum creatinine level or reduction of all-cause mortality was observed.

Assessing continuous renal replacement therapy as a rescue strategy in cardiorenal syndrome 1

Background

Patients with acute decompensated heart failure (ADHF) and cardiorenal syndrome (CRS) 1 have poor outcomes. Ultrafiltration (UF) is used to mechanically remove salt and water in ADHF patients with diuretic resistance. However, little is known about the outcomes of ADHF patients on inotropes and/or vasopressors who require continuous renal replacement therapy (CRRT) for both UF and solute clearance in severe acute kidney injury.

Methods

We retrospectively analyzed 37 consecutive critically ill patients who were admitted for ADHF from 2005–13 and were on inotropes and/or vasopressors at the time of CRRT initiation. The primary outcome was in-hospital mortality.

Results

In-hospital mortality rate was 62%. Median survival was 15.5 days after CRRT initiation, and 10 months following hospital discharge. When comparing renal and cardiovascular variables for survivors and non-survivors at baseline, admission and CRRT initiation, survivors were less likely to need vasopressors. After controlling for multiple predictors, vasopressor use remained associated with time to death (HR 9.9; 95% CI 2.3–43.3; P = 0.002). Patients with isolated right ventricular dysfunction had an in-hospital mortality of 45% compared with 69% in those with left ventricular dysfunction (P = 0.27). Age of >70 years was associated with 100% in-hospital mortality.

Conclusions

Rescue therapy using CRRT in refractory CRS1 was associated with high in-hospital mortality, especially when vasopressors were used and when patient age exceeded 70 years. Additionally, survivors had a poor long-term prognosis.

Hemodiafiltration: a novel approach for treating severe amitriptyline intoxication

Tricyclic antidepressant overdose is one of the most common cause of serious drug poisonings. Sometimes amitriptyline intoxication can be difficult to treat with standard treatments. At that case hemodiafiltration (HD) can be an eligible choice. We report a successful treatment of severe case using hemodiafiltration in addition to the supportive measures. Management with gastric lavage, activated charcoal, alkalinization and supportive care is the common approach and not enough for patients in deep coma. We satisfied that HD may have a beneficial role in lethal doses of amitriptyline as an additional therapy.