In Practice
Decongestive Treatment of Acute Decompensated Heart Failure: Cardiorenal Implications of Ultrafiltration and Diuretics

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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.

Section snippets

Case Presentation

A 62-year-old white man with chronic kidney disease (CKD) stage 3 and ischemic cardiomyopathy with ejection fraction of 25% is admitted with 1 week of progressive dyspnea and weight gain. Several days prior, his furosemide dosage was increased from 80 to 160 mg 3 times daily and 5 mg of metolazone was added. At admission, blood pressure and heart rate were 118/70 mm Hg and 82 beats/min, respectively. Jugular venous pressure was 12 cm H20. He had a 2/6 systolic murmur at the left sternal border,

Importance of Decongestive Treatment

In patients with implantable hemodynamic monitoring, significant increases in right ventricular systolic pressure and pulmonary artery diastolic pressure have been documented several days before admission for ADHF,36 suggesting that subclinical volume overload presages clinical congestion. Using ultrafiltration or a variety of diuretic-based approaches for decongestive treatment, multiple studies have shown improvements in patient symptoms,31, 37 cardiac and pulmonary function,38, 39 myocardial

Efficacy of Diuretics

Diuretics remain the standard of care for treatment of congestion in patients with ADHF.3, 43, 44, 45 Heart failure practice guidelines consider diuretics a class I intervention with minimal evidence, given the paucity of randomized clinical trial data.2, 44, 46 Used appropriately, loop diuretics can be very effective in decreasing extracellular fluid volume overload.6 Two recent randomized controlled studies comparing ultrafiltration and diuretic-based decongestive treatment reported fluid

Diuretic Resistance

Although there is no consensus definition of diuretic resistance, most experts agree that patients unable to meet their clinically required decongestive targets despite large doses of loop diuretics are diuretic resistant (Box 1).58, 59, 60, 61 Contemporary data suggest that up to 22% of patients hospitalized with ADHF were discharged with no weight loss.5 It is unclear how much of this is due to true diuretic resistance or suboptimal use of diuretics. It is difficult to predict which patients

Cardiorenal Dysfunction

The presence of cardiorenal dysfunction (Box 1) is associated with persistent congestion, diuretic resistance, and poor outcomes.15, 64, 65, 66, 67 The term cardiorenal syndrome (Box 1) has been used as a broader description of various acute and chronic states linked to worsening function of both the kidney and heart.68 A recent review suggests that cardiorenal dysfunction occurs in 20%-30% of patients with ADHF,61 with 39% of patients with ADHF in one study developing an increase in creatinine

Pathophysiology of Cardiorenal Dysfunction

The cause of cardiorenal dysfunction is multifactorial and incompletely understood (Fig 1).64 Direct hemodynamic factors, such as decreased intravascular volume, poor forward flow, and decreased renal perfusion, do not completely explain the pathophysiologic process of cardiorenal dysfunction.67, 72, 73, 74 Most patients developing cardiorenal dysfunction have sufficient cardiac output and increased filling pressures,75 and many patients have preserved systolic function.14 Worsening kidney

Clinical Studies of Ultrafiltration

Multiple reports have been published using ultrafiltration for the treatment of ADHF (Table 1), utilizing both conventional hemodialysis-based machines and newer portable ultrafiltration devices using variable ultrafiltration rates and duration of treatment (Table 2).

Early studies of patients with chronic heart failure used modified hemofiltration technology (ie, Amicon diafilter) to investigate the impact of ultrafiltration on cardiopulmonary performance. These studies reported that

What Do the Available Studies Tell Us?

Ultrafiltration can be used safely and effectively in patients with ADHF. Most studies included patients with some degree of decreased kidney function, but excluded patients with more severe decreased kidney function, hemodynamic instability, or lack of response to an aggressive diuretic regimen. The theoretical advantages and disadvantages of diuretic and ultrafiltration treatment in heart failure are listed in Table 3.

Peritoneal Dialysis for ADHF

Early studies of patients with diuretic-refractory ADHF showed that acute peritoneal dialysis could be performed safely and successfully to relieve congestion.107 There now are at least 20 studies of more than 200 patients with ADHF treated by peritoneal dialysis. Most of these patients had CKD stage 3 or greater and few had ESRD.108 These case series suggest that most patients treated with 1-4 exchanges daily had improvement in congestive symptoms, decreases in numbers and durations of

What Do the Guidelines Say?

The Heart Failure Society of America suggests that ultrafiltration be considered after sodium and fluid restriction and optimization of diuretic dosing have failed to relieve congestion.110 The European Society of Cardiology Task Force for the Diagnosis and Treatment of Congestive Heart Failure comments that in patients refractory to loop and thiazide diuretics, ultrafiltration could be considered in patients with coexisting kidney failure or hyponatremia.110 The American College of

Future Directions: the CARRESS Study

At the present time, there remain more questions than answers in the pursuit of optimal decongestive strategies for individuals with ADHF. The CARRESS (Cardiorenal Rescue Study in Acute Decompensated Heart Failure) is an ongoing randomized multicenter active control trial sponsored by the National Heart, Lung, and Blood Institute (ClinicalTrials.gov identifier NCT00608491). This 60-day randomized nonblinded phase 3 trial will enroll 200 patients with decompensated heart failure and cardiorenal

Conclusions

The available studies suggest that ultrafiltration and diuretic therapy are highly effective across a broad range of patients with ADHF and cardiorenal dysfunction. Some patients may benefit from ultrafiltration when either diuretics are used suboptimally or the patient is truly diuretic resistant, whereas it is unclear if one therapy should be used preferentially in patients who are not truly diuretic resistant. Several studies suggest that ultrafiltration may be linked to a greater short-term

Case Review

A hemodialysis catheter was placed in the right internal jugular vein and the patient was started on ultrafiltration using the System 100. Blood flow rate was 40 mL/min and ultrafiltration rate was 200 mL/h. Diuretic therapy was discontinued and blood pressure remained stable during the next several hours. The ultrafiltration rate then was increased to 400 mL/h and 8 hours of ultrafiltration were completed with 2,600 mL removed. The next day, serum creatinine level increased to 2.5 mg/dL (221

Acknowledgements

Support: None.

Financial Disclosure: The authors declare that they have no relevant financial interests.

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    Originally published online October 19, 2011.

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