[Congestive heart failure: Treatment with ultrafiltration]

INTRODUCTION

The prevalence rate of congestive heart failure is approximately 2% in high-income countries. The aim of this study was to assess the overall benefit of ultrafiltration therapy in patients with acute or persistent congestive heart failure.

METHODS

We conducted a health technology assessment following the EUnetHTA guidelines, with systematic literature review from bibliographic medical databases, independent experts and manufacturer interviews.

RESULTS

Thirteen clinical trials and five meta-analyses were examined. In the most recent one, 608 patients were included, of which 304 received ultrafiltration therapy and 304 received intravenous loop diuretics. Ultrafiltration therapy seems to be more beneficial regarding the fluid removal and the body weight reduction, (mean difference respectively 1.44kg, IC95% [0.29; 2.59], P-value=0.01 and 1.28L [0.43; 2.12], P-value=0.003). No difference has been showed in overall mortality, renal function, hospital readmission or safety. Medico-economic studies are incomplete and contradictory.

CONCLUSION

Ultrafiltration therapy seems to be effective, most likely for patients ineligible or resistant to intravenous diuretics. But most topics remain uncertain, mainly impact on overall mortality, safety and cost-effectiveness. Given these knowledge-gaps, the generalization of ultrafiltration therapy should be examined cautiously, and conditional upon a large-scale systematic evaluation.

Cardiac involvement in small and medium-sized vessel vasculitides

The heart can be involved in vasculitides but the frequency of its involvement and the manifestations vary according to the vasculitis. Cardiovascular manifestations include cardiomyopathy (specific or resulting from myocardial infarctions), coronary arteritis (with risk of aneurysms, stenoses and thrombosis formation or rupture), pericarditis, valvulitis, conduction-tissue involvement (with heart blocks), arrhythmias (mainly supraventricular) and/or dissection of the aorta (and/or its proximal branches). As many of these manifestations are clinically silent, at least during their early stages, heart function should be systematically assessed in vasculitis patients, with at least ECG and echocardiography, and more invasive exploratory procedures when the former reveal abnormalities or symptoms become manifest. Specific cardiomyopathy has been identified as a factor of poor outcome in small and medium-sized vessel vasculitides (five-factor score). Therefore, in addition to symptomatic treatments, prescription of corticosteroids and immunosuppressants (mainly cyclophosphamide) is considered mandatory. This regimen has dramatically improved the overall prognosis of affected patients.

Adjunctive plasma exchanges to treat neuropsychiatric lupus: a retrospective study on 10 patients

Neuropsychiatric manifestations of systemic lupus erythematosus (NPSLE) are among the main causes of morbidity and mortality attributed to lupus activity. Conventional NPSLE treatment combines CS and immunosuppressants, but some symptoms do not respond. We retrospectively evaluated the adjunction of plasma exchanges (PE) to treat 13 NPSLE flares occurring in 10 patients (mean age, 30 years) between 1989 and 2002. NP manifestations were the first SLE symptoms for seven patients, with a mean of 3.2 NP manifestations/flare. All patients received CS and cyclophosphamide pulses. A mean of 15 PE/flare were performed. All patients improved within a mean of 3 (median: 2.5; range: 1.5—8) weeks thereafter. Complete remissions of 7/13 flares were obtained within a mean of 7 (median: 4; range: 2—22) weeks. Partial remissions were achieved for the remaining six flares, characterized by new NP manifestations during three and insufficient control of the others. Other SLE manifestations regressed for all patients with the mean European consensus lupus activity measurement score declining from pretreatment 6.9 to 1.2. A regimen combining CS, cyclophosphamide and PE is effective against severe NPSLE, with acceptable toxicity. Lupus (2007) 16, 817—822.

Interleukin-1 receptor antagonist for refractory anti-MDA5 clinically amyopathic dermatomyopathy

Autoantibodies targeting the melanoma-differentiation-associated gene-5 (MDA5)-encoded ribonucleic acid helicase are associated with clinically amyopathic dermatomyopathy (CADM). Marked systemic inflammation, skin ulcers and severe interstitial lung disease seem frequent. DM treatment consists of immunosuppressants and/or intravenous immunoglobulins, but evidence-based knowledge is lacking. Anakinra (an interleukin-1 receptor antagonist (IL-1RA)) use in this setting has never been reported. Herein, we report on a case of anakinra dramatic and rapid efficacy against general and extramuscular (e.g. calcinosis, arthritis, skin ulcers) in a patient with severe and refractory CADM. Unfortunately, short-term follow-up prevented efficacy evaluation against interstitial lung disease. IL-1RA could be a promising treatment for refractory CADM.