Sustained benefit from ultrafiltration in moderate congestive heart failure

Ultrafiltration is better than diuretic therapy for volume-overloaded acute heart failure patients: a meta-analysis

Studies on the effectiveness of ultrafiltration (UF) in patients hospitalized with acute decompensated heart failure (ADHF) have led to heterogeneous study outcomes. This meta-analysis aimed to assess the impact of UF therapy in ADHF patients. We searched the medical literature to identify well-designed studies comparing UF with the usual diuretic therapy in this setting. Systematic evaluation of 8 randomized controlled trials enrolling 801 participants showed greater fluid removal (difference in means 1372.5 mL, 95% CI 849.6 to 1895.4 mL; p < 0.001), weight loss (difference in means 1.592 kg, 95% CI 1.039 to 2.144 kg; p < 0.001) and lower incidences of worsening heart failure (OR 0.63, 95% CI 0.43 to 0.94, p = 0.022) and rehospitalization for heart failure (OR 0.54, 95% CI 0.36 to 0.82, p = 0.003) without a difference in renal impairment (OR 1.386, 95% CI 0.870 to 2.209; p = 0.169) or all-cause mortality (OR 1.13, 95% CI 0.75 to 1.71, p = 0.546). UF increases fluid removal and weight loss and reduces rehospitalization and the risk of worsening heart failure in congestive patients, suggesting ultrafiltration as a safe and effective treatment option for volume-overloaded heart failure patients.

Readmission rate after ultrafiltration in acute decompensated heart failure: a systematic review and meta-analysis

Significance of ultrafiltration in acute decompensated heart failure remains unclear. We performed meta-analysis to determine its role in reducing readmissions after acute decompensated heart failure. MEDLINE was searched using PUBMED from inception to March 22, 2017 for prospective randomized control trials comparing ultrafiltration to diuretics in acute decompensated heart failure. Five hundred ninety studies were found; nine studies with 820 patients were included. Studies with renal replacement therapy bar ultrafiltration, chronic decompensated heart failure, and non-English language were excluded. RevMan Version 5.3 was used for analysis. The primary outcomes analyzed were cumulative and 90 days readmissions secondary to heart failure and all-cause readmissions. Baseline characteristics were similar. One hundred eighty-eight patients were readmitted with heart failure, 77 vs 111 favoring ultrafiltration; risk ratio (RR) = 0.71 (95% confidence interval (CI), 0.49-1.02, p = 0.07, I ²  = 47%). Ninety days readmissions were 43 vs 67 favoring ultrafiltration; RR = 0.65 (95%CI, 0.47-0.90, p = 0.01, I ²  = 0%). Ultrafiltration showed significantly higher fluid removal and weight loss. Hypotension was common in ultrafiltration (24 vs 13, OR = 2.06, 95%CI = 0.98-4.32, p = 0.06, I ²  = 0%). Ultrafiltration showed reduced 90 days heart failure readmissions and trend towards reduced cumulative hospital readmissions. Renal and cardiovascular outcomes and hospital stay were similar.

Hemofiltration in Heart Failure

In patients with severe congestive heart failure (CHF), removal of edema by hemofiltration is associated with significant clinical and hemodynamic improvement, correction of hyponatremia, restoration of urine output and diuretic responsiveness, and with a striking fall in neurohormonal activation. Through these effects, hemofiltration is able to interrupt the progression of CHF toward refractoriness, and to revert the clinical condition of CHF patients to a lower functional class.

Fluid refilling from the overhydrated interstitium is the major compensatory mechanism in the prevention of hypovolemia during hemofiltration.

Hemofiltration can also be beneficial in patients who have only moderate cardiac insufficiency (NYHA classes II and III) and in whom over-hydration is restricted to the pulmonary district significantly contributing to limiting patients functional capacity. In this setting, hemofiltration, differently from diuretics, is able to remove the increased lung water content and to improve clinical condition, exercise capacity and lung function.

Extracorporeal ultrafiltration for acute heart failure: patient selection and perspectives

Most patients presenting with acute heart failure (AHF) show signs and symptoms of fluid overload, which are closely associated with short-term and long-term outcomes. Ultrafiltration is an extremely appealing strategy for patients with AHF and concomitant overt fluid overload not fully responsive to diuretic therapy. However, although there are several theoretical beneficial effects associated with ultrafiltration, published reports have shown controversial findings. Differences in selection of the study population and in ultrafiltration indications and protocols, and high variability in the pharmacologic therapy used for the control group could explain some of these conflicting results. Here, we aimed to provide an overview on the current medical evidence supporting the use of ultrafiltration in AHF, with a special focus on the identification of potential candidates who may benefit the most from this therapeutic option.

Acute Kidney Injury in Pediatric Heart Failure

Acute kidney injury (AKI) is very common in pediatric medical and surgical cardiac patients. Not only is it an independent risk factor for increased morbidity and mortality in the short run, but repeated episodes of AKI lead to chronic kidney disease (CKD) especially in the most vulnerable hosts with multiple risk factors, such as heart transplant recipients. The cardiorenal syndrome, a term coined to emphasize the bidirectional nature of simultaneous or sequential cardiac-renal dysfunction both in acute and chronic settings, has been recently described in adults but scarcely reported in children. Despite the common occurrence and clinical and financial impact, AKI in pediatric heart failure outside of cardiac surgery populations remains poorly studied and there are no large-scale pediatric specific preventive or therapeutic studies to date. This article will review pediatric aspects of the cardiorenal syndrome in terms of pathophysiology, clinical impact and treatment options.

Decongestive treatment of acute decompensated heart failure: cardiorenal implications of ultrafiltration and diuretics

In patients with acute decompensated heart failure (ADHF), treatment aimed at adequate decongestion of the volume overloaded state is essential. Despite diuretic therapy, many patients remain volume overloaded and symptomatic. In addition, adverse effects related to diuretic treatment are common, including worsening kidney function and electrolyte disturbances. The development of decreased kidney function during treatment affects the response to diuretic therapy and is associated with important clinical outcomes, including mortality. The occurrence of diuretic resistance and the morbidity and mortality associated with diuretic therapy has stimulated interest to develop effective and safe treatment strategies that maximize decongestion and minimize decreased kidney function. During the last few decades, extracorporeal ultrafiltration has been used to remove fluid from diuretic-refractory hypervolemic patients. Recent clinical studies using user-friendly machines have suggested that ultrafiltration may be highly effective for decongesting patients with ADHF. Many questions remain regarding the comparative impact of diuretics and ultrafiltration on important clinical outcomes and adverse effects, including decreased kidney function. This article serves as a summary of key clinical studies addressing these points. The overall goal is to assist practicing clinicians who are contemplating the use of ultrafiltration for a patient with ADHF.

Ultrafiltration for acute decompensated heart failure: cost, reimbursement, and financial impact

In addition to the proposed pathophysiologic mechanisms whereby ultrafiltration (UF) can be advantageous over diuretics in the treatment of heart failure, there can also be financial and resource-utilization reasons for pursuing this extracorporeal strategy. In those cases in which the clinical outcomes would be equivalent, however, the decision whether to pursue UF will depend greatly on the anticipated hospitalization length of stay (LOS), the patient population's pay or mix, the needs and costs for high-acuity (eg, intensive care unit) care, and widely varying expenses for the equipment and disposable supplies. From a fiscal perspective, the financial viability of UF programs revolves around how improvements in LOS, resource utilization, and readmissions relate to the typical diagnosis-driven (eg, diagnosis-related group) reimbursement. We analyzed the impact of these various factors so as to better understand how the intensity (and expense) of pharmaceutical and extracorporeal therapies impacts a single admission, as well as to serve as the basis for developing strategies for optimizing long-term care.

Urea kinetics and intermittent dialysis prescription in small animals

Hemodialysis improves survival for animals with acute kidney injury beyond what would be expected with conventional management of the same animals. Clinical evidence and experience in human patients suggest a role for earlier intervention with renal replacement to avoid the morbidity of uremia and to promote better metabolic stability and recovery. For a large population of animal patients, it is the advanced standard for the management of acute and chronic uremia, life-threatening poisoning, and fluid overload for which there is no alternative therapy.

Effects of ULTRAfiltration vs. DIureticS on clinical, biohumoral and haemodynamic variables in patients with deCOmpensated heart failure: the ULTRADISCO study

AIMS

To evaluate the clinical, biohumoral, and haemodynamic effects of ultrafiltration vs. intravenous diuretics in patients with decompensated heart failure (HF). Signs and symptoms of volume overload are often present in these patients and standard therapy consists primarily of intravenous diuretics. Increasing evidence suggests that ultrafiltration can be an effective alternative treatment.

METHODS AND RESULTS

Thirty patients with decompensated HF were randomly assigned to diuretics or ultrafiltration. Haemodynamic variables, including several novel parameters indicating the overall performance of the cardiovascular system, were continuously assessed with the Pressure Recording Analytical Method before, during, at the end of treatment (EoT) and 36 h after completing treatment. Aldosterone and N-terminal pro-B-type natriuretic peptide (NT-proBNP) plasma levels were also measured. Patients treated with ultrafiltration had a more pronounced reduction in signs and symptoms of HF at EoT compared with baseline, and a significant decrease in plasma aldosterone (0.24 ± 0.25 vs. 0.86 ± 1.04 nmol/L; P < 0.001) and NT-proBNP levels (2823 ± 2474 vs. 5063 ± 3811 ng/L; P < 0.001) compared with the diuretic group. The ultrafiltration group showed a significant improvement (% of baseline) in a number of haemodynamic parameters, including stroke volume index (114.0 ± 11.7%; P < 0.001), cardiac index (123.0 ± 20.8%; P < 0.001), cardiac power output (114.0 ± 13.8%; P < 0.001), dP/dt(max) (129.5 ± 19.9%; P < 0.001), and cardiac cycle efficiency (0.24 ± 0.54 vs. -0.14 ± 0.50 units; P < 0.05), and a significant reduction in systemic vascular resistance 36 h after the treatment (88.0 ± 10.9%; P < 0.001), which was not observed in the diuretic group.

CONCLUSIONS

In patients with advanced HF, ultrafiltration facilitates a greater clinical improvement compared with diuretic infusion by ameliorating haemodynamics (assessed using a minimally invasive methodology) without a marked increase in aldosterone or NT-proBNP levels.

Need for a unified decision-making tool for ultrafiltration therapy in heart failure; call for action

Although ultrafiltration portends several theoretical advantages over the standard therapy for acute decompensated heart failure, it might not be the optimal treatment for all patients presenting with an episode of decompensation. It is not yet clear how to prospectively identify the subset of patients that would benefit from this therapeutic modality. Based on the pathophysiologic mechanisms underlying acute decompensated heart failure, early ultrafiltration therapy can be an appropriate initial management strategy for those patients with diuretic resistance whose associated renal dysfunction is related to hemodynamic changes rather than a structural abnormality. In the absence of widely accepted consensus guidelines, ultrafiltration use is currently subject to considerable variations among physicians. A clinical tool (eg, a scoring system) that is based on the individual patient's characteristics is therefore needed to prospectively identify the appropriate candidates for this therapy. Using this system is likely to portend better outcomes while helping to avoid unnecessary exposure to potential risks of extracorporeal therapies.

Novel therapeutic option for refractory heart failure in elderly patients with chronic kidney disease by incremental peritoneal dialysis

BACKGROUND

Heart failure (HF) often accompanies chronic kidney disease (CKD) in the elderly. This clinical condition is a critical socio-medical issue, because high-dose diuretic therapy stimulates the renin-angiotensin-aldosterone axis and sympathetic nervous system outflow, and may thus result in vicious cycles of cardio-renal deterioration, leading to excess hospitalization and death. Peritoneal dialysis (PD) is a renal replacement therapy used for maintenance dialysis, and is characterized by the continuous removal of fluid. The present study examined the clinical feasibility and effects of a novel style of PD for elderly CKD patients with refractory HF.

METHODS

Twelve elderly CKD patients (stages 3-5) with refractory HF [New York Heart Association (NYHA) class III, n=9; IV, n=3; mean age, 81+/-6 years] received PD treatment. Patients had episodes of >3 hospitalizations in the previous year, and were initially treated with < or =19 sessions of sequential hemofiltration, followed by incremental PD, with 3 PD sessions/week (8h each) at the start, increasing in frequency and dwelling time as clinically indicated.

RESULTS

During follow-up (median, 26.5 months), PD was well tolerated by all patients, and no patients required hospitalization for HF. Three patients died due to non-HF-related events. All patients showed improvements in NYHA functional class (class I, n=9; class II, n=3) and significant decreases in the dose of diuretics prescribed (P<0.05). Kidney function stabilized, while significant improvements in end-diastolic left ventricular diameter (-5%, P<0.05) and hemoglobin count (+15%, P<0.05) were achieved. Brain natriuretic peptide (-46%) and aldosterone (-13%) levels tended to decrease.

CONCLUSIONS

Incremental PD could represent a novel therapeutic option for elderly patients with refractory HF. In addition to fluid removal by PD, correction of renal anemia, preservation of kidney function, and avoidance of high-dose diuretic therapy may play a role in maximizing clinical benefits.

Does the bronchial circulation contribute to congestion in heart failure?

Pulmonary congestion is a hallmark feature of heart failure and is a major reason for hospital admissions in this patient population. Heart failure patients often demonstrate restrictive and obstructive pulmonary function abnormalities; however, the mechanisms of these changes remain controversial. It has been suggested that the bronchial circulation may play an important role in the development of these pulmonary abnormalities and in the symptoms associated with pulmonary congestion. Congestion may occur in the bronchial circulation from either a marked increase in flow or an increase in blood volume but with a reduction in flow due to high cardiac filling pressures and high pulmonary vascular pressures (a stasis like condition). Either may lead to thickened bronchial mucosal and submucosal tissues and reduced airway compliance resulting in airway obstruction and restriction and a lack of airway distensibility. These structural changes may contribute to "cardiac asthma" and dyspnea, characteristic features common in HF patients. Thus the bronchial circulation may be a potential target for therapeutic interventions. The aim of this paper is to review factors governing the control of the bronchial circulation, how bronchial vascular conductance may change with HF and to pose arguments, both supporting and in opposition to the bronchial circulation contributing to congestion and altered pulmonary function in HF. We ultimately hypothesize that the engorgement of the bronchial circulatory bed may play a role in pulmonary function abnormalities that occur in HF patients and contribute to symptoms such as orthopnea and exertional dyspnea.

Optimal use of diuretics in patients with heart failure

Currently, the use of diuretics in heart failure (HF) remains more of an art than a science. Diuretics are the principle means for relieving congestion in patients with decompensated HF. Unfortunately, they persist as the only major therapy in HF that has not been subjected to a large randomized clinical trial, precisely because no comparable therapy exists that can so easily, efficiently, and inexpensively treat fluid overload. Nonetheless, diuretics have many potential drawbacks, including electrolyte abnormalities, neurohormonal activation, hypovolemia, renal dysfunction, and direct myocardial effects. Until definitive answers about mortality are settled, the lowest dose of a diuretic that can produce euvolemia should be employed and these agents should be discontinued when possible. Many outpatients with HF can be managed quite well without diuretics once adequate neurohormonal blockade with angiotensin-converting enzyme inhibitors and beta blockers has been achieved.

Ultrafiltration in decompensated heart failure

Fluid congestion is the hallmark of decompensated heart failure. As heart failure progresses, reduced response to diuretics is common. In these patients, ultrafiltration has been found to alleviate excess volume and improve diuretic sensitivity. Compared with diuretics, ultrafiltration provides a more predictable and safer way to achieve euvolemia with minimal electrolyte abnormalities and neurohormonal activation. The emerging familiarity and ease of use of ultrafiltration suggests that in the future this will be an important therapy for the treatment of acute and chronic volume overload associated with decompensated heart failure.

Reviews: The Current State of Nonuremic Applications for Extracorporeal Blood Purification

Despite the commonly accepted indications for hemodialysis and extracorporeal depuritive techniques, some clinicians have come to rely on blood purification for clinical states where the targeted substance for removal differs from uremic waste products. Over the last decade, a number of studies have emerged to help define the application of extracorporeal blood purification (ECBP) to these "nonuremic" indications. This review describes the application of extracorporeal blood purification in clinical states including sepsis, rhabdomyolysis, congestive heart failure, hepatic failure, tumor lysis syndrome, adult respiratory distress syndrome, intravenous contrast exposure, and lactic acidosis. Additional comments are provided to review existing literature on thermoregulation and osmoregulation, including acute brain injury.

Intermittent outpatient ultrafiltration for the treatment of severe refractory congestive heart failure

BACKGROUND

Patients with severe congestive heart failure (CHF) become refractory to conventional medical therapy, leading to recurrent rehospitalizations. We examined the impact of intermittent outpatient ultrafiltration (UF), using either peritoneal dialysis or hemofiltration, on long-term clinical outcomes in patients with refractory CHF.

METHODS AND RESULTS

We analyzed clinical and hemodynamic data in 19 consecutive patients with refractory CHF who received intermittent outpatient UF for at least 1 year between July 1998 and November 2002. The mean left ventricular ejection fraction of all 19 patients was 30.2 +/- 19.0%. All patients (100.0%) were New York Heart Association (NYHA) class IV. Only 5 patients (26.3%) received peritoneal dialysis; the remaining 14 (73.7%) received hemofiltration. There were 6 patients with a normal left ventricular ejection fraction (45%). After UF was started, the number of patients that were considered inotrope-dependent was reduced from 86.4% to 36.8% (P < .005). Compared with the year before UF was initiated, the number of CHF hospitalizations during follow-up was reduced from 2.6 to 0.3 (P < .005), and the NYHA class was improved from 4 to 3.1 (P < .005). Among all patients, 2 deaths were related to complications of UF, and cumulative 1-year survival was 63.2%.

CONCLUSION

Our study suggests that UF is a safe, feasible therapy, but it needs further evaluation in carefully designed, prospective, randomized clinical trials. UF has the potential for offering another important therapeutic option for patients with severe and refractory CHF.

Cardiorenal syndrome in decompensated heart failure: Prognostic and therapeutic implications

Various lines of evidence implicate impaired renal function as an important prognostic indicator in patients with congestive heart failure (CHF). Conventional diuretics may aggravate renal dysfunction and can result in neurohumoral activation. Evolving new therapeutic strategies that enhance renal function include administration of B-type natriuretic peptide, adenosine and vasopressin antagonists, and ultrafiltration methods. Prospective studies are needed to evaluate whether these new renal-enhancing strategies will improve patient outcome in CHF.

Artificial in vivo biofiltration: slow continuous intravenous plasmafiltration (SCIP) and artificial organ support

An intravenous plasmafiltration (SCIP) catheter has been developed and is proposed for clinical investigation into the alleviation of acute fluid overload by SCUF of the extracted plasma. The system utilizes a unique backflushing technique, high intravenous shear flow rates and biocompatible polymers to minimize protein and platelet aggregation along the filter surfaces. The absence of platelets from the extracted plasma promotes the longevity of ultrafiltration cartridges, thus theoretically minimizing attendant labor associated with continuous renal replacement therapies. Clinical studies are currently being planned for the near future. Plasma SCUF is envisioned as a predecessor technology to future applications in therapeutic apheresis, tissue engineering, therapeutic sorbent technologies. Further, with improved longevity profiles, intravenous SCUF or dialysis and implantable or wearable artificial organs based upon artificial in vivo biofiltration are possible.

Nonpharmacologic care of heart failure: counseling, dietary restriction, rehabilitation, treatment of sleep apnea, and ultrafiltration

The prognosis of patients with chronic congestive heart failure (CHF) depends not only on pharmacologic therapy but also on nonpharmacologic aspects. A complete and ongoing education program for treating CHF includes an understanding of the causes of CHF, symptoms, diet, salt and fluid restriction, drug regimen, compliance, physical and work activities, lifestyle changes, and measures of self-control. Moreover, the nonpharmacologic treatment (dietary modifications, lifestyle, physical exercise, and health care education) must be inserted in a multidisciplinary program organized by the physician in conjunction with the health system, the nurses, and, especially, the patients themselves, who must understand their disease and the many therapeutic options. Cardiologists should treat patients in a clear and comprehensible way, and other specialists (dietitians, physiotherapists, psychologists, nurses, and social workers), together with the patient's family, should strive for the best living conditions for the patient. In this way, the treatment of CHF can improve the quantity and quality of life and save a significant amount in health care costs.

Techniques for assessing and achieving fluid balance in acute renal failure

Fluid therapy, together with attention to oxygen supply, is the cornerstone of resuscitation in all critically ill patients. Hypovolemia results in inadequate blood flow to meet the metabolic requirements of the tissues and must be treated urgently to avoid the complication of progressive organ failure, including acute renal failure. The kidney plays a critical role in body fluid homeostasis. Renal dysfunction disturbs this homeostasis and requires special attention to issues of fluid balance and fluid overload. In addition, fluid therapy is the only treatment that has been shown to be effective in the prevention of acute renal failure. Special attention to volume status is therefore required in patients at risk for acute renal failure. Hypovolemia is also a major causal factor of morbidity during hemodialysis and may contribute to further renal insults. Although the importance of fluid management is generally recognized, the choice of fluid, the amount, and assessment of fluid status are controversial. As the choice of fluids becomes wider and monitoring devices become more sophisticated, the controversy increases. This article provides an overview of the concept of fluid management in the critically ill patient with acute renal failure.