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Ultrafiltration in Decompensated Heart Failure With Cardiorenal Syndrome
Study Questions:
Is ultrafiltration (Uf) safe and effective in patients with heart failure (HF) complicated by cardiorenal syndrome?
Methods:
The CARRESS-HF (Cardiorenal Rescue Study in Acute Decompensated Heart Failure) was a multicenter randomized trial of venovenous Uf therapy versus diuretic escalation in inpatients with HF (systolic or diastolic), worsening renal function (creatinine increase >0.3 mg/dl), and evidence of volume overload. In the Uf group, diuretics were discontinued and fluid was removed at a rate of 200 ml/hr. In the diuretic group, intravenous diuretics were titrated to achieve a urine output of 3-5 liters daily. The primary outcome of interest was the change in serum creatinine and body weight 96 hours after randomization.
Results:
There were 94 patients enrolled in each study arm, with a median age of 68 years and median ejection fraction of 33%. In the pharmacologic group, mean serum creatinine decreased by 0.04 ± 0.53 mg/dl by 96 hours compared with an increase of 0.23 ± 70 mg/dl in the Uf group (p = 0.003 between groups). By day 7 and at the 30-day assessment, serum creatinines were no longer different. There was no difference in weight loss after 96 hours in the pharmacologic (12.1 ± 11.3 lbs.) versus Uf (12.6 ± 8.5 lbs.) groups. Likewise, there was no difference between treatments in dyspnea scores or global well-being measurements at 96 hours or 7 days after therapy. In the Uf group, serious adverse events (e.g., renal failure, bleeding complications) were higher at 60 days post-randomization, and there was a trend toward increased mortality (17% vs. 13%).
Conclusions:
The authors concluded that the institution of Uf in patients with congestion and renal dysfunction led to worse outcomes.
Perspective:
A primary aim of HF therapy is to improve congestion without seriously impacting renal function and electrolytes. In this analysis, Uf and diuresis led to similar weight and volume loss over a similar period of time. However, Uf did not protect renal function, had a higher cumulative incidence of adverse events, and showed a trend toward increased mortality. These results, and the fact that Uf therapy is expensive and requires an invasive line, makes Uf therapy in standard HF management of questionable value. The study does not answer if there is a population of HF patients who may still benefit from Uf. Patients requiring inotropes or intravenous vasodilators and those with a creatinine >3.1 mg/dl on admission were excluded. Cardiopulmonary hemodynamics were not measured. Thus, it is unknown if Uf may play a role in those more apt to be diuretic resistant, namely those with low output or high right atrial pressures.
Keywords: Kidney Function Tests, Cardio-Renal Syndrome, Weight Loss, Diuretics, Body Weight, Diuresis, Dyspnea, Vasodilator Agents, Hemodynamics, Heart Diseases, Renal Insufficiency, Hemofiltration, Atrial Pressure, Heart Failure
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