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Role of Aquapheresis vs. Diuretics in Heart Failure
Study Questions:
What is the impact of aquapharesis/ultrafiltration on hospitalizations for heart failure (HF)?
Methods:
The AVOID-HF (Aquapheresis versus Intravenous Diuretics and Hospitalization for Heart Failure) trial, was designed as a multicenter, 1-to-1 randomized study of 810 hospitalized HF patients. The patients were randomized to ultrafiltration or adjustable intravenous loop diuretics. It was terminated unilaterally and prematurely by the study sponsor (that manufactured the device for ultrafiltration) after enrollment of 224 patients (27.5%) because of slower than projected enrollment in the study. The termination of the trial was in no way related to signals of futility or safety concerns. Following discharge, patients were evaluated at 30, 60, and 90 days. The Clinical Events Committee, blinded to the randomized treatment, adjudicated whether 90-day events were due to HF.
Results:
The study cohort included 110 patients randomized to ultrafiltration and 114 to intravenous loop diuretic therapy; baseline characteristics were similar in both groups. During the index hospitalization, the patients received ultrafiltration at an average rate of 138 ± 47 ml/h (range 50-300 ml/h) for an average of 80 ± 53 hours (media,n 70 hours; range, 12-283 hours). The average number of ultrafiltration filters/patient was 1.67 ± 0.93. The loop diuretic patients received an average daily dose of furosemide-equivalent intravenous loop diuretic of 271.26 ± 263.06 mg (range, 36.00-1446.67 mg) for an average of 100 ± 78 hours (median, 70 hours; range, 70-472 hours). The study investigators found that the estimated days to first HF event for the ultrafiltration and loop diuretic group were, respectively, 62 and 34 (p = 0.106). At 30 days, the ultrafiltration group (when compared with the intravenous loop diuretic group) had fewer HF and cardiovascular events. Renal function changes were similar. More ultrafiltration patients experienced an adverse effect of special interest (p = 0.018) and a serious study product-related adverse event (p = 0.026). The 90-day mortality was similar.
Conclusions:
The study authors concluded that when compared with the intravenous loop diuretics, ultrafiltration trended toward a longer time to first HF event within 90 days and fewer HF and cardiovascular events. They also concluded that further studies are needed given the premature termination of the study.
Perspective:
This study suggests that ultrafiltration is an important therapeutic option in achieving dry weight in HF patients. As the study authors point out, further studies are needed to determine clear indications for initiating ultrafiltration and the cost-effectiveness of this promising therapeutic option.
Keywords: Cardiac Surgical Procedures, Diuretics, Furosemide, Geriatrics, Heart Failure, Sodium Potassium Chloride Symporter Inhibitors, Ultrafiltration
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