In PracticeDecongestive Treatment of Acute Decompensated Heart Failure: Cardiorenal Implications of Ultrafiltration and Diuretics
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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Edema and the Clinical Use of Diuretics
2017, National Kidney Foundation's Primer on Kidney DiseasesClinical and prognostic role of ammonia in advanced decompensated heart failure. the cardio-abdominal syndrome?
2015, International Journal of CardiologyCitation Excerpt :Diuretic refractoriness is associated with worse prognosis [44] while the persistence of clinical signs of congestion at discharge is a well established predictor of rehospitalization for HF [45]. Little is known about diuretic resistance and only few and very nonspecific indicators have been suggested as risk factors for diuretic resistance (hypotension, decreased kidney function, severe symptoms of ADHF, hyponatremia, significant cardiac dysfunction) [46,47]. In our study, at multivariate analysis high BUN, high estimated RAP and abdominal damage predicted RRT.
Diuretic therapy in acute decompensated heart failure - Bolus or continuous?
2014, Indian Heart JournalLoop diuretic strategies in patients with acute decompensated heart failure: A meta-analysis of randomized controlled trials
2014, Journal of Critical CareCitation Excerpt :Administration of loop diuretics to patients with heart failure may result in a significantly decreased glomerular filtration rate, presumably because of activation of the renin-angiotensin-aldosterone system and the sympathetic nervous system [3]. Developing effective and safe diuretic treatment strategies that would provide symptom relief is important [4]. Loop diuretics inhibit the reabsorption of sodium and water and increase the urinary excretion of chloride, calcium, and magnesium; these characteristics result in a prompt diuretic effect that peaks at 1.5 hours after administration [5].
Diuretics or ultrafiltration for acute decompensated heart failure and cardiorenal syndrome?
2013, American Journal of Kidney DiseasesEdema and the clinical use of diuretics
2013, National Kidney Foundation's Primer on Kidney Diseases, Sixth Edition
Originally published online October 19, 2011.