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Ultrafiltration in the Management of Heart Failure
unscheduled visits (14 of 65 [21%] versus 29 of 66 [44%]; p=0.009). Changes hospitalization may exceed those of intravenous diuretics, total cost over time
in serum creatinine were similar in the two groups throughout the study. The may be lower due to decreased resource utilization for heart failure.
percentage of patients with rises in serum creatinine levels >0.3mg/dl was
similar in the ultrafiltration and standard care group at 24 hours (3/90 [14.4%] Conclusion
versus 7/91 [7.7%]; p=0.528), at 48 hours (18/68 [26.5%] versus 15/74 [20.3 Of the ultrafiltration approaches described, the most practical are
%]; p=0.430), and at discharge (19/84 [22.6%] versus 17/86 [19.8%]; veno–venous ultrafiltration techniques in which isotonic plasma is propelled
p=0.709). There was no correlation between net fluid removed and changes through the filter by an extracorporeal pump. These approaches avoid an
in serum creatinine in the ultrafiltration (r=-0.050; p=0.695) or in the arterial puncture, remove a predictable amount of fluid, are not associated
intravenous diuretics group (r=0.028; p=0.820). No clinically significant with significant hemodynamic instability, and, in the case of peripheral
changes in serum blood urea nitrogen, sodium, chloride, or bicarbonate veno–venous ultrafiltration, do not require specialized dialysis personnel.
occurred in either group. Serum potassium <3.5mEq/l occurred in 1/77 Ultrafiltration has been used in patients with decompensated HF and volume
patients (1%) in the ultrafiltration and in 9/75 patients (12%)in the diuretics overload refractory to diuretics. These patients generally have pre-existing
group (p=0.018). Episodes of hypotension during 48 hours after renal insufficiency and, despite daily oral diuretic doses, develop signs of
randomization were similar (4/100 [4%] versus 3/100 [3%]). Thus, UNLOAD pulmonary and peripheral congestion. Ultrafiltration and diuretic holiday may
demonstrated that in decompensated HF, ultrafiltration safely produces restore diuresis and natriuresis. Some patients with volume overload refractory
greater weight and fluid loss than intravenous diuretics, reduces to all available intravenous vasoactive therapies have experienced significant
90-day resource utilization for HF, and is an effective alternate therapy.
24
improvements of symptoms, hemodynamics, and renal function following
ultrafiltration. A strategy of early ultrafiltration and diuretic holiday can result
It is also important to recognize the limitations of the UNLOAD trial. The in more effective weight reduction and can shorten hospitalization. Patients
treatment targets for both diuretics and ultrafiltration were not pre-specified. should not be considered for ultrafiltration if any of the following apply:
Although treatment was not blinded, it is unlikely that a placebo effect venous access cannot be obtained; there is a hypercoagulable state; systolic
influenced either weight loss or the improved 90-day outcomes associated with blood pressure is <8mmHg or there are signs or symptoms of cardiogenic
ultrafiltration. The possibility that standard care patients were inadequately shock; patients require intravenous pressors to maintain an adequate blood
treated is diminished by the observation that improvements in symptoms of pressure; or there is end-stage renal disease, as documented by a requirement
heart failure, biomarkers, and quality of life were similar in the two treatment for dialysis. Ultrafiltration can be carried out in patients with hematocrit >40%
groups throughout the study. Furthermore, 43% of patients in the standard only if it can be proved that hypovolemia is absent.
care group lost at least 4.5kg during hospitalization, a weight loss greater than
that observed in 75% of patients enrolled in the Acute Decompensated Heart Many questions regarding the use of ultrafiltration in HF patients remain
Failure National Registry.
2
Although the study did not include measurements of unanswered and must be addressed in future studies. These include: optimal
blood volume, plasma refill rate, interstitial salt and water, cardiac performance, fluid removal rates in individual patients; the effects of ultrafiltration on
or hemodynamics, ultrafiltration was not associated with excessive hypotension cardiac remodeling; the influence of a low oncotic pressure occurring in
or renal or electrolyte abnormalities. The economic impact of ultrafiltration as patients with cardiac cachexia on plasma refill rates; and the economic impact
an initial strategy for decompensated heart failure was also not addressed in this of ultrafiltration to determine whether the expense of disposable filters is
trial. While the costs associated with ultrafiltration during the index offset by the cost savings due to reduced re-hospitalization rates. ■
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