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Tay KLY, Osman AR, Yeoh EEX, Luangboriboon J, Lau JF, Chan JJA, Yousif M, Tse BYH, Horgan G, Gamble DT, Myint PK. Ultrafiltration versus Diuretics on Prognostic Cardiac and Renal Biomarkers in Acute Decompensated Heart Failure: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:jcm12082793. [PMID: 37109130 PMCID: PMC10141346 DOI: 10.3390/jcm12082793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 03/19/2023] [Accepted: 03/29/2023] [Indexed: 04/29/2023] Open
Abstract
Existing systematic reviews have insufficiently delineated the differing cardiac and renal profile of ultrafiltration compared to diuretics as a method of decongestion in acute decompensated heart failure. This meta-analysis will investigate the impact of ultrafiltration compared to diuretics on prognostic cardiac and renal biomarkers. We searched PubMed Central, Ovid MEDLINE®, Ovid Embase, all EBM reviews, and Web of Science Core Collection for randomised controlled trials published before 21 July 2022. Our main outcome measures were cardiac (brain natriuretic peptide and N-terminal pro-brain natriuretic peptide) and renal biomarkers (serum creatinine, serum sodium, and blood urea nitrogen). A total of 10 randomised trials were included in our analysis after screening. An inverse-variance random effects meta-analysis of the pooled results demonstrated no significant difference between ultrafiltration and diuretics for brain natriuretic peptide, N-terminal pro-brain natriuretic peptide, creatinine, sodium and long-term blood urea nitrogen. However, ultrafiltration produced statistically greater increases in blood urea nitrogen in the short-term (mean difference, 3.88; 95% confidence interval 0.59-7.17 mg/dL). Overall, ultrafiltration produces a similar impact on prognostic cardiac and renal biomarkers when compared to diuretic therapy. We highlight ultrafiltration's significant impact on short-term BUN and recommend further research to investigate more optimal protocols of ultrafiltration administration.
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Affiliation(s)
- Kirsty Luo-Yng Tay
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK
| | - Abdel Rahman Osman
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK
| | - Esyn Ee Xin Yeoh
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK
| | - Jasmine Luangboriboon
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK
| | - Jie Fei Lau
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK
| | - Joanne Jia An Chan
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK
| | - Majed Yousif
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK
| | - Benjamin Yi Hong Tse
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK
| | - Graham Horgan
- Biomathematics & Statistics Scotland, Aberdeen AB25 2ZD, UK
| | - David T Gamble
- Ageing Clinical & Experimental Research (ACER) Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen AB25 2ZD, UK
- Aberdeen Cardiovascular & Diabetes Centre (ACDC), Institute of Medical Sciences, University of Aberdeen, Aberdeen AB25 2ZD, UK
| | - Phyo Kyaw Myint
- Ageing Clinical & Experimental Research (ACER) Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen AB25 2ZD, UK
- Aberdeen Cardiovascular & Diabetes Centre (ACDC), Institute of Medical Sciences, University of Aberdeen, Aberdeen AB25 2ZD, UK
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Ullah W, Sana MK, Mustafa HU, Sandhyavenu H, Hajduczok A, Mir T, Fischman DL, Shah M, Brailovsky Y, Rajapreyar IN. Safety and efficacy of ultrafiltration versus diuretics in patients with decompensated heart failure: A systematic review and meta-analysis. Eur J Intern Med 2022; 104:41-48. [PMID: 35644712 DOI: 10.1016/j.ejim.2022.05.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 05/04/2022] [Accepted: 05/11/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Ultrafiltration (UF) is used for fluid removal patients with acute decompensated heart failure with reduced ejection fraction (HFrEF) refractory to diuretics. However, data on the relative merits of UF and diuretics are limited. METHODS Online databases were queried to identify clinical trials on the comparison of UF and diuretics. The major adverse cardiovascular (MACE) and its components (mortality and re-hospitalizations) were compared using the random-effects model to calculate the unadjusted odds ratio (OR) with its 95% confidence interval (CI). RESULTS A total of 10 clinical trials comprising 838 patients (413 UF, 425 diuretics) were included in the analysis. At a median follow-up of 90 days, there was no significant difference in the odds of MACE (OR 0.71, 95% CI 0.47-1.07) and all-cause mortality (OR 1.08, 95% CI 0.77-1.52) between patients undergoing UF compared with those receiving diuretics therapy. The need for emergency department visits (OR 1.05, 95% CI 0.38-2.90), all-cause admissions (OR 0.97, 95% CI 0.72-1.30) and heart failure-related re-hospitalization (OR 0.47, 95% CI 0.21-1.02) was also similar between the two groups. The in-hospital risk for hypotension (OR 0.49, 0.23-1.04) and post-therapy creatinine rise>0.3 mg/dL (OR 1.18, 95% CI 0.74-1.89) was also not significantly different between the UF and diuretics arms. A sensitivity analysis of MACE and mortality did not show any deviation from the pooled outcomes. CONCLUSIONS In patients with HFrEF, UF appears to be safe but might not provide significant benefits in terms of reducing the risk of mortality or readmission rates compared with those treated with diuretics.
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Affiliation(s)
- Waqas Ullah
- Department of Cardiovascular Medicine, Thomas Jefferson University Hospitals, Philadelphia, PA, USA.
| | | | - Hamza Usman Mustafa
- Department of Cardiovascular Medicine, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | | | - Alexander Hajduczok
- Department of Cardiovascular Medicine, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | | | - David L Fischman
- Department of Cardiovascular Medicine, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Mahek Shah
- Department of Cardiovascular Medicine, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Yevgeniy Brailovsky
- Department of Cardiovascular Medicine, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Indranee N Rajapreyar
- Department of Cardiovascular Medicine, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
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Dokoupil J, Hrečko J, Čermáková E, Adamcová M, Pudil R. Characteristics and outcomes of patients admitted for acute heart failure in a single-centre study. ESC Heart Fail 2022; 9:2249-2258. [PMID: 35388622 PMCID: PMC9288775 DOI: 10.1002/ehf2.13759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 11/07/2021] [Accepted: 12/01/2021] [Indexed: 11/12/2022] Open
Abstract
Aims Acute heart failure represents a medical condition with very high mortality. Accurate risk stratification can help physicians to improve the health care about these patients. The aim of our study was to characterize real‐life patients admitted for acute heart failure in a specific region with one tertiary medical centre and to describe risk factors of short‐term and long‐term mortality. Methods and results We performed a retrospective analysis of patients admitted from January 2017 to December 2017 to Department of cardiology of the tertiary medical centre University Hospital in Hradec Kralove. We identified 385 patients admitted for acute heart failure to the standard care and intensive care unit. The median of age was 74 years (IQR 67.5–80) and 34% of patients were female. Hospital admission was due to de novo heart failure in 222 (57.7%) patients. The most common comorbidities were arterial hypertension (77.7%), dyslipidaemia (67.3%) and coronary artery disease (63.1%). Coronary artery disease (52.7% of cases) and valve disease (28.1% of cases) were the most common aetiologies of heart failure. The all‐cause in‐hospital mortality was 12.7%, 30‐day mortality was 14.6% and 1 year mortality was 34%. Among risk factors of in‐hospital mortality, the most significant factors were haemodialysis during the hospitalization [odds ratio (OR) 15.82, 95% confidence interval (CI) 2.96–84.57, P = 0.0008], chronic heart failure (OR 4.27, 95% CI 1.66–11.03, P = 0.001) and STEMI as a precipitating factor of heart failure (OR 4.19, 95% CI 1.23–14.25, P = 0.023). Haemodialysis during the hospitalization (OR 4.28, 95% CI 1.17–15.61, P = 0.025) and the comorbidity depression and anxiety (OR 3.49, 95% CI 1.45–8.39, P = 0.005) were the most significant risk factors of long‐term mortality. Conclusions Our study confirms very high mortality rates among patients with acute heart failure underlying poor prognosis of these patients. Comorbidities (peripheral artery disease, atrial fibrillation, chronic heart failure and depression and anxiety), precipitating factors of heart failure (myocardial infarction with ST segment elevation), complications occurring during the hospitalization (acute kidney injury, pulmonary ventilation for respiratory failure and haemodialysis) and the age of patients should be included in the risk stratification of in‐hospital, 30 day and 1 year mortality.
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Affiliation(s)
- Jiří Dokoupil
- 1st Department of Medicine-Cardioangiology, Charles University, Faculty of Medicine and University Hospital in Hradec Králové, Sokolská 581, Hradec Králové, Czech Republic
| | - Juraj Hrečko
- 1st Department of Medicine-Cardioangiology, Charles University, Faculty of Medicine and University Hospital in Hradec Králové, Sokolská 581, Hradec Králové, Czech Republic
| | - Eva Čermáková
- Department of Medical Biophysics, Faculty of Medicine in Hradec Kralove, Charles University, Prague, Czech Republic
| | - Michaela Adamcová
- Department of Physiology, Faculty of Medicine in Hradec Kralove, Charles University, Prague, Czech Republic
| | - Radek Pudil
- 1st Department of Medicine-Cardioangiology, Charles University, Faculty of Medicine and University Hospital in Hradec Králové, Sokolská 581, Hradec Králové, Czech Republic
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Abstract
BACKGROUND Pharmacotherapies such as loop diuretics are the cornerstone treatment for acute heart failure (AHF), but resistance and poor response can occur. Ultrafiltration (UF) is an alternative therapy to reduce congestion, however its benefits, efficacy and safety are unclear. OBJECTIVES To assess the effects of UF compared to diuretic therapy on clinical outcomes such as mortality and rehospitalisation rates. SEARCH METHODS We undertook a systematic search in June 2021 of the following databases: CENTRAL, MEDLINE, Embase, Web of Science CPCI-S and ClinicalTrials.gov. We also searched the WHO ICTRP platform in October 2020. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared UF to diuretics in adults with AHF. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data. We contacted study authors for any further information, and language interpreters to translate texts. We assessed risk of bias in included studies using Risk of Bias 2 (RoB2) tool and assessed the certainty of the evidence using GRADE. MAIN RESULTS We included 14 trials involving 1190 people. We included people who had clinical signs of acute hypervolaemia. We excluded critically unwell people such as those with ischaemia or haemodynamic instability. Mean age ranged from 57.5 to 75 years, and the setting was a mix of single and multi-centre. Two trials researched UF as a complimentary therapy to diuretics, while the remaining trials withheld diuretic use during UF. There was high risk of bias in some studies, particularly with deviations from the intended protocols from high cross-overs as well as missing outcome data for long-term follow-up. We are uncertain about the effect of UF on all-cause mortality at 30 days or less (risk ratio (RR) 0.61, 95% confidence interval (CI) 0.13 to 2.85; 3 studies, 286 participants; very low-certainty evidence). UF may have little to no effect on all-cause mortality at the longest available follow-up (RR 1.00, 95% CI 0.73 to 1.36; 9 studies, 987 participants; low-certainty evidence). UF may reduce all-cause rehospitalisation at 30 days or less (RR 0.76, 95% CI 0.53 to 1.09; 3 studies, 337 participants; low-certainty evidence). UF may slightly reduce all-cause rehospitalisation at longest available follow-up (RR 0.91, 95% CI 0.79 to 1.05; 6 studies, 612 participants; low-certainty evidence). UF may reduce heart failure-related rehospitalisation at 30 days or less (RR 0.62, 95% CI 0.37 to 1.04; 2 studies, 395 participants; low-certainty evidence). UF probably reduces heart failure-related rehospitalisation at longest available follow-up, with a number needed to treat for an additional beneficial effect (NNTB) of 10 (RR 0.69, 95% CI 0.53 to 0.90; 4 studies, 636 participants; moderate-certainty evidence). No studies measured need for mechanical ventilation. UF may have little or no effect on serum creatinine change at 30 days since discharge (mean difference (MD) 14%, 95% CI -12% to 40%; 1 study, 221 participants; low-certainty evidence). UF may increase the risk of new initiation of renal replacement therapy at longest available follow-up (RR 1.42, 95% CI 0.42 to 4.75; 4 studies, 332 participants; low-certainty evidence). There is an uncertain effect of UF on the risk of complications from central line insertion in hospital (RR 4.16, 95% CI 1.30 to 13.30; 6 studies, 779 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS: This review summarises the latest evidence on UF in AHF. Moderate-certainty evidence shows UF probably reduces heart failure-related rehospitalisation in the long term, with an NNTB of 10. UF may reduce all-cause rehospitalisation at 30 days or less and at longest available follow-up. The effect of UF on all-cause mortality at 30 days or less is unclear, and it may have little effect on all-cause mortality in the long-term. While UF may have little or no effect on serum creatinine change at 30 days, it may increase the risk of new initiation of renal replacement therapy in the long term. The effect on complications from central line insertion is unclear. There is insufficient evidence to determine the true impact of UF on AHF. Future research should evaluate UF as an adjunct therapy, focusing on outcomes such as heart failure-related rehospitalisation, cardiac mortality and renal outcomes at medium- to long-term follow-up.
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Affiliation(s)
- Mehul Srivastava
- Institute of Health Informatics Research, University College London, London, UK
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Australia
| | - Nicholas Harrison
- Department of Emergency Medicine, Division of Research, Indiana University School of Medicine, Indianapolis, MI-Michigan, USA
| | | | - Audrey R Tan
- Institute of Health Informatics Research, University College London, London, UK
| | - Mandy Law
- Department of Nephrology, Royal Melbourne Hospital, Parkville, Australia
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Mohiuddin N, Frinak S, Yee J. Sodium-based osmotherapy for hyponatremia in acute decompensated heart failure. Heart Fail Rev 2021; 27:379-391. [PMID: 34767112 DOI: 10.1007/s10741-021-10124-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/25/2021] [Indexed: 10/19/2022]
Abstract
Acute decompensated heart failure (ADHF) accounts for more than 1 million hospital admissions annually and is associated with high morbidity and mortality. Decongestion with removal of increased total body sodium and total body water are goals of treatment. Acute kidney injury (AKI) or chronic kidney disease (CKD) is present in two-thirds of patients with ADHF. The pathophysiology of ADHF and AKI is bidirectional and synergistic. AKI and CKD complicate the management of ADHF by decreasing diuretic efficiency and excretion of sodium and water. Among patients hospitalized with ADHF, hyponatremia is the most common electrolyte abnormality and is classically encountered with volume overload. ADHF represents an additional therapeutic challenge particularly when oligoanuria is present. Predilution continuous venovenous hemofiltration with sodium-based osmotherapy can safely increase plasma sodium concentration without deleteriously increasing total body sodium. We present a detailed methodology that addresses the issue of hypervolemic hyponatremia in patients with ADHF and AKI.
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Affiliation(s)
- Naushaba Mohiuddin
- Division of Nephrology and Hypertension, 2799 West Grand Blvd, CFP-510, Detroit, MI, 48202, USA
| | - Stanley Frinak
- Division of Nephrology and Hypertension, 2799 West Grand Blvd, CFP-510, Detroit, MI, 48202, USA
| | - Jerry Yee
- Division of Nephrology and Hypertension, 2799 West Grand Blvd, CFP-514, Detroit, MI, 48202, USA.
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Xie Y, Chen J, Xu J, Shen B, Liao J, Teng J, Wang Q, Ding X. Early Goal-Directed Renal Replacement Therapy in Acute Decompensated Heart Failure Patients with Cardiorenal Syndrome. Blood Purif 2021; 51:251-259. [PMID: 34130280 DOI: 10.1159/000515826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 03/11/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The aim of this study was to clarify the efficacy of early goal-directed renal replacement therapy (GDRRT) for treatment of cardiorenal syndrome (CRS) patients after acute decompensated heart failure (ADHF). METHODS In the retrospective, observational study, we enrolled 54 patients in the early GDRRT group and 63 patients in the late GDRRT group. Baseline characteristics, clinical data at initiation renal replacement therapy time, and the clinical outcome were collected and several parameters were compared and analyzed between 2 groups. RESULTS The urine volume at GDRRT initiation time in the early group was higher than that in the late GDRRT group (1,060.3 ± 332.1 vs. 300.5 ± 148.3 mL, p < 0.001). Hemodynamic parameters such as mean artery pressure were higher (70.06 ± 32.99 vs. 54.34 ± 40.88 mm Hg, p = 0.012), the heart rate was slower (80.17 ± 15.26 vs. 99.21 ± 25.45 bpm, p = 0.002), and the diameter of inferior vena cava was narrower (22.00 ± 1.91 vs. 25.77 ± 5.5 mm, p = 0.04) in early GDRRT. Primary end point was inhospital all-cause mortality and cardiovascular mortality, which was obviously lower in the early GDRRT group (respectively 24.1 vs. 60.3%, p = 0.002 and 20.3 vs. 50.8%, p = 0.005). The second end point of kidney recovery in the early GDRRT group was much better than that in the latter GDRRT group (p = 0.018). Moreover, urine volume after GDRRT of the early group was more significant than that of the late group (1,432 ± 172 vs. 702 ± 183 mL, p = 0.005). CONCLUSION This study clarified the effectiveness of the early GDRRT strategy in ADHF patients suffered from CRS, which reduced inhospital mortality and improved the urine output and clinical kidney recovery outcome.
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Affiliation(s)
- Yeqing Xie
- Division of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jiahui Chen
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jiarui Xu
- Division of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Bo Shen
- Division of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jianquan Liao
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jie Teng
- Division of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qibing Wang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaoqiang Ding
- Division of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China
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Jentzer JC, Bihorac A, Brusca SB, Del Rio-Pertuz G, Kashani K, Kazory A, Kellum JA, Mao M, Moriyama B, Morrow DA, Patel HN, Rali AS, van Diepen S, Solomon MA. Contemporary Management of Severe Acute Kidney Injury and Refractory Cardiorenal Syndrome: JACC Council Perspectives. J Am Coll Cardiol 2020; 76:1084-1101. [PMID: 32854844 PMCID: PMC11032174 DOI: 10.1016/j.jacc.2020.06.070] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/29/2020] [Accepted: 06/01/2020] [Indexed: 12/14/2022]
Abstract
Acute kidney injury (AKI) and cardiorenal syndrome (CRS) are increasingly prevalent in hospitalized patients with cardiovascular disease and remain associated with poor short- and long-term outcomes. There are no specific therapies to reduce mortality related to either AKI or CRS, apart from supportive care and volume status management. Acute renal replacement therapies (RRTs), including ultrafiltration, intermittent hemodialysis, and continuous RRT are used to manage complications of medically refractory AKI and CRS and may restore normal electrolyte, acid-base, and fluid balance before renal recovery. Patients who require acute RRT have a significant risk of mortality and long-term dialysis dependence, emphasizing the importance of appropriate patient selection. Despite the growing use of RRT in the cardiac intensive care unit, there are few resources for the cardiovascular specialist that integrate the epidemiology, diagnostic workup, and medical management of AKI and CRS with an overview of indications, multidisciplinary team management, and transition off of RRT.
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Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Azra Bihorac
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, Gainesville, Florida
| | - Samuel B Brusca
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Gaspar Del Rio-Pertuz
- Department of Critical Care Medicine and Center for Critical Care Nephrology, The CRISMA Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kianoush Kashani
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Amir Kazory
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, Gainesville, Florida
| | - John A Kellum
- Department of Critical Care Medicine and Center for Critical Care Nephrology, The CRISMA Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michael Mao
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, Florida
| | - Brad Moriyama
- Department of Critical Care Medicine, Special Volunteer, National Institutes of Health, Bethesda, Maryland
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Hena N Patel
- Division of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Aniket S Rali
- Division of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, Texas
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Michael A Solomon
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland; Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
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Shi X, Bao J, Zhang H, Wang H, Li L, Zhang Y. Patients with high-dose diuretics should get ultrafiltration in the management of decompensated heart failure: a meta-analysis. Heart Fail Rev 2020; 24:927-940. [PMID: 31209772 PMCID: PMC6834743 DOI: 10.1007/s10741-019-09812-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The identification of specific patients with decompensated heart failure (DHF) who may benefit from ultrafiltration (UF) is important in clinical practice. We undertook a meta-analysis to compare the effects of ultrafiltration and diuretics on major clinical outcomes. The outcomes included weight change, length of hospital stay, rehospitalization for HF, mortality, change in serum creatinine, dialysis dependence, and adverse outcomes. We identified 14 trials including 975 patients with HF, met the eligibility criteria. There was a reduction in heart failure-related rehospitalization in ultrafiltration group when compared with the diuretic group. Subgroup analyses revealed a trend toward the decreased HF readmissions in ultrafiltration plus diuretic therapy group but did not reach statistical significance compared with ultrafiltration alone therapy. Overall, UF treatment did not produce apparent beneficial effects for weight loss, lengths of hospitalization, total mortality, the change of serum creatinine, and dialysis rate. Subgroup analyses showed increase in the serum creatinine were significantly higher for a higher dose regimen (> 200 mg/day) when compared with lower dose diuretic therapy (< 200 mg/day). As for adverse events, UF patients were associated with an increased risk of hypotension and lower risk of neurologic symptoms. The current results revealed ultrafiltration was associated with significant reduction in the rate of rehospitalization. Increase in the serum creatinine was observed in patients with high-dose diuretic regimen. Patients with high-dose diuretics should get ultrafiltration therapy.
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Affiliation(s)
- Xiaofeng Shi
- Emergency department, Tianjin First Center Hospital, Tianjin, China
| | - Jiating Bao
- Intensive Care Unit, Tianjin First Center Hospital, Tianjin, China
| | - Haili Zhang
- General Surgery Department, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Hao Wang
- Emergency department, Tianjin First Center Hospital, Tianjin, China
| | - Lei Li
- Department of Vascular Surgery, The Second Hospital of Dalian Medical University, Dalin, China.
| | - Yue Zhang
- Institute of Urology, The second Hospital of Tianjin Medical University, Tianjin, China.
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9
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Gologorsky RC, Roy S. Ultrafiltration for management of fluid overload in patients with heart failure. Artif Organs 2019; 44:129-139. [DOI: 10.1111/aor.13549] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 06/13/2019] [Accepted: 07/23/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Rebecca C. Gologorsky
- Department of Surgery University of California, San Francisco‐East Bay Oakland California
- Department of Bioengineering and Therapeutic Sciences University of California San Francisco California
| | - Shuvo Roy
- Department of Bioengineering and Therapeutic Sciences University of California San Francisco California
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10
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Pavo N, Yarragudi R, Puttinger H, Arfsten H, Strunk G, Bojic A, Hülsmann M, Vychytil A. Parameters associated with therapeutic response using peritoneal dialysis for therapy refractory heart failure and congestive right ventricular dysfunction. PLoS One 2018; 13:e0206830. [PMID: 30452453 PMCID: PMC6242305 DOI: 10.1371/journal.pone.0206830] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 10/19/2018] [Indexed: 02/01/2023] Open
Abstract
Background In patients with refractory heart failure (HF) peritoneal dialysis (PD) is associated with improved functional status and decrease in hospitalization. However, previous studies did not focus on right ventricular dysfunction as an important pathophysiologic component of cardiorenal syndrome. Methods In a prospective cohort study PD was started in 40 patients with refractory right HF (with/without left HF). Refractoriness to conservative therapy was defined as persistent right heart congestion/ascites with intensified diuretic treatment and/or ≥2 hospitalizations within 6 months because of cardiac decompensation despite optimal medical treatment, and/or acute renal failure during intensified conservative treatment of cardiac decompensations. Results Patient survival was 55.0% at 1 year, 35.0% at 2 years and 27.5% at 3 years. The number of hospitalization days declined after initiation of PD for both cardiac [13 (IQR 1–53) days before vs. 1 (IQR 0–12) days after start of PD, p<0.001] and unplanned reasons [12 (IQR 3–44) days before vs. 1 (IQR 0–33) days after start of PD, p = 0.007]. Using a combined endpoint including survival time of ≥1 year and either improvement in quality of life or decline in hospitalizations we found that patients with extended ascites, higher systolic pulmonary artery pressure, more marked impairment of right ventricular function and tricuspid valve insufficiency, higher residual renal function as well as those who could perform PD without assistance have benefited most from this therapy. Conclusions Patients with more pronounced backward failure, less marked residual renal functional impairment and those not depending on assistance for therapy are likely to profit most from PD.
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Affiliation(s)
- Noemi Pavo
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Rajashri Yarragudi
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Heidi Puttinger
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Henrike Arfsten
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Guido Strunk
- Complexity Research, Vienna, Austria
- FH Campus Vienna, Vienna, Austria
- Technical University Dortmund, Dortmund, Germany
| | - Andja Bojic
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Martin Hülsmann
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Andreas Vychytil
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
- * E-mail:
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11
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Siddiqui WJ, Kohut AR, Hasni SF, Goldman JM, Silverman B, Kelepouris E, Eisen HJ, Aggarwal S. Readmission rate after ultrafiltration in acute decompensated heart failure: a systematic review and meta-analysis. Heart Fail Rev 2018; 22:685-698. [PMID: 28900774 DOI: 10.1007/s10741-017-9650-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Significance of ultrafiltration in acute decompensated heart failure remains unclear. We performed meta-analysis to determine its role in reducing readmissions after acute decompensated heart failure. MEDLINE was searched using PUBMED from inception to March 22, 2017 for prospective randomized control trials comparing ultrafiltration to diuretics in acute decompensated heart failure. Five hundred ninety studies were found; nine studies with 820 patients were included. Studies with renal replacement therapy bar ultrafiltration, chronic decompensated heart failure, and non-English language were excluded. RevMan Version 5.3 was used for analysis. The primary outcomes analyzed were cumulative and 90 days readmissions secondary to heart failure and all-cause readmissions. Baseline characteristics were similar. One hundred eighty-eight patients were readmitted with heart failure, 77 vs 111 favoring ultrafiltration; risk ratio (RR) = 0.71 (95% confidence interval (CI), 0.49-1.02, p = 0.07, I 2 = 47%). Ninety days readmissions were 43 vs 67 favoring ultrafiltration; RR = 0.65 (95%CI, 0.47-0.90, p = 0.01, I 2 = 0%). Ultrafiltration showed significantly higher fluid removal and weight loss. Hypotension was common in ultrafiltration (24 vs 13, OR = 2.06, 95%CI = 0.98-4.32, p = 0.06, I 2 = 0%). Ultrafiltration showed reduced 90 days heart failure readmissions and trend towards reduced cumulative hospital readmissions. Renal and cardiovascular outcomes and hospital stay were similar.
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Affiliation(s)
- Waqas Javed Siddiqui
- Department of Medicine, Division of Nephrology and Hypertension, Drexel University College of Medicine, Philadelphia, PA, 19102, USA. .,Hahnemann University Hospital, 230 N Broad St, Philadelphia, PA, 19102, USA.
| | - Andrew R Kohut
- Department of Medicine, Division of Cardiology, Drexel University College of Medicine, Philadelphia, PA, 19129, USA.,Hahnemann University Hospital, 230 N Broad St, Philadelphia, PA, 19102, USA
| | - Syed F Hasni
- Department of Medicine, Division of Cardiology, Drexel University College of Medicine, Philadelphia, PA, 19129, USA.,Hahnemann University Hospital, 230 N Broad St, Philadelphia, PA, 19102, USA
| | - Jesse M Goldman
- Department of Medicine, Division of Nephrology and Hypertension, Drexel University College of Medicine, Philadelphia, PA, 19102, USA.,Hahnemann University Hospital, 230 N Broad St, Philadelphia, PA, 19102, USA
| | - Benjamin Silverman
- Department of Medicine, Division of Cardiology, Drexel University College of Medicine, Philadelphia, PA, 19129, USA.,Hahnemann University Hospital, 230 N Broad St, Philadelphia, PA, 19102, USA
| | - Ellie Kelepouris
- Department of Medicine, Division of Nephrology and Hypertension, Drexel University College of Medicine, Philadelphia, PA, 19102, USA.,Hahnemann University Hospital, 230 N Broad St, Philadelphia, PA, 19102, USA
| | - Howard J Eisen
- Department of Medicine, Division of Cardiology, Drexel University College of Medicine, Philadelphia, PA, 19129, USA.,Hahnemann University Hospital, 230 N Broad St, Philadelphia, PA, 19102, USA
| | - Sandeep Aggarwal
- Department of Medicine, Division of Nephrology and Hypertension, Drexel University College of Medicine, Philadelphia, PA, 19102, USA.,Hahnemann University Hospital, 230 N Broad St, Philadelphia, PA, 19102, USA
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12
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Milazzo V, Cosentino N, Marenzi G. Extracorporeal ultrafiltration for acute heart failure: patient selection and perspectives. Vasc Health Risk Manag 2017; 13:449-456. [PMID: 29270016 PMCID: PMC5730184 DOI: 10.2147/vhrm.s128608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Most patients presenting with acute heart failure (AHF) show signs and symptoms of fluid overload, which are closely associated with short-term and long-term outcomes. Ultrafiltration is an extremely appealing strategy for patients with AHF and concomitant overt fluid overload not fully responsive to diuretic therapy. However, although there are several theoretical beneficial effects associated with ultrafiltration, published reports have shown controversial findings. Differences in selection of the study population and in ultrafiltration indications and protocols, and high variability in the pharmacologic therapy used for the control group could explain some of these conflicting results. Here, we aimed to provide an overview on the current medical evidence supporting the use of ultrafiltration in AHF, with a special focus on the identification of potential candidates who may benefit the most from this therapeutic option.
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Affiliation(s)
- Valentina Milazzo
- Intensive Cardiac Care Unit, Centro Cardiologico Monzino, I.R.C.C.S., Milan, Italy
| | - Nicola Cosentino
- Intensive Cardiac Care Unit, Centro Cardiologico Monzino, I.R.C.C.S., Milan, Italy
| | - Giancarlo Marenzi
- Intensive Cardiac Care Unit, Centro Cardiologico Monzino, I.R.C.C.S., Milan, Italy
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13
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Salleck D, John S. [Cardiorenal syndrome]. Med Klin Intensivmed Notfmed 2017; 114:439-443. [PMID: 28905081 DOI: 10.1007/s00063-017-0346-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 07/11/2017] [Accepted: 07/29/2017] [Indexed: 11/29/2022]
Abstract
Patients in the intensive care unit often suffer from cardiorenal syndrome, which can have an important influence on the patient's outcome. The heart and kidney influence each other via organ crosstalk. We screened and evaluated current publications on cardiorenal syndromes and their therapy. A key role in the management of cardiorenal syndromes is renal decongestion via loop diuretics.
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Affiliation(s)
- D Salleck
- Interdisziplinäre Intensivmedizin, Universitätsklinik Medizinische Klinik 8 - Kardiologie, Paracelsus Medizinische Privatuniversität, Klinikum Nürnberg Süd, Breslauer Straße 201, 90471, Nürnberg, Deutschland
| | - S John
- Interdisziplinäre Intensivmedizin, Universitätsklinik Medizinische Klinik 8 - Kardiologie, Paracelsus Medizinische Privatuniversität, Klinikum Nürnberg Süd, Breslauer Straße 201, 90471, Nürnberg, Deutschland.
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14
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Koratala A, Jain A, Kazory A. Ultrafiltration does provide more efficient decongestion compared to conventional treatment for acute heart failure. Int J Cardiol 2017; 234:108. [PMID: 28043675 DOI: 10.1016/j.ijcard.2016.12.155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Accepted: 12/22/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Abhilash Koratala
- Department of Medicine, University of Florida, Gainesville, Florida, USA.
| | - Ankur Jain
- Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Amir Kazory
- Department of Medicine, University of Florida, Gainesville, Florida, USA
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15
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Response to Koratala et al. Int J Cardiol 2017; 234:109-110. [PMID: 28062135 DOI: 10.1016/j.ijcard.2016.12.162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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