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Ultrafiltration for Acute Decompensated HF?

Results with a new, less invasive ultrafiltration system were not definitive.

Diuretics are a central component of therapy for acute decompensated heart failure (HF). However, diuretics sometimes cause neurohormonal activation and renal insufficiency, and some patients are unresponsive to them. Ultrafiltration (UF), an alternative fluid-removal method, is cumbersome and invasive. In two manufacturer-sponsored studies, researchers tested a new, smaller, portable UF device (System 100) that is less invasive and requires less intensive monitoring.

In the RAPID-CHF trial, 40 patients hospitalized with a primary diagnosis of HF, at least moderate lower-extremity edema, and at least one other physical sign of volume overload were randomized to receive usual care alone or UF for 8 hours plus usual care. Diuretics were withheld during UF but could be used subsequently. An especially sensitive statistical analysis did not detect a significant difference between the groups in the primary endpoint of mean weight loss at 24 hours (UF, –2.5 kg; usual care, –1.8 kg; P=0.24). However, mean fluid removal at 24 hours was significantly greater with UF than with usual care (4650 mL vs. 2838 mL). UF was not associated with changes in hemodynamics or electrolytes, but hemoglobin levels declined significantly in the UF group, and one UF recipient developed a catheter-site infection that required 4 weeks of antibiotic therapy.

In an uncontrolled study, 20 patients hospitalized with decompensated HF, clinical evidence of fluid overload, and either renal insufficiency or diuretic resistance (to >80 mg furosemide or equivalent) were treated with UF until symptoms resolved. Mean fluid removal during UF was 8654 mL, and mean length of stay was 3.7 days. UF also significantly reduced body weight, reduced BNP levels, and improved quality of life. Most improvements persisted at 90 days, but diuretic use also increased after discharge. There were no line-related complications, and mean hemoglobin levels did not decline.

Comment: Effective treatments for acute decompensated HF are clearly welcome, but these studies of a new ultrafiltration device are only preliminary. In the controlled trial, UF did not achieve positive results in the primary endpoint and was associated with clinically important adverse events; the second study had no control group. The editorialists note that before this UF system becomes part of the therapeutic armamentarium, important issues (appropriate patient selection, adverse side effects, duration of benefit, and cost of therapy) require resolution. A pending multicenter randomized trial (UNLOAD) might help in that regard.

— Frederick A. Masoudi, MD, MSPH

Published in Journal Watch Cardiology January 19, 2006

Citation(s):

Bart BA et al. Ultrafiltration versus usual care for hospitalized patients with heart failure: The Relief for Acutely Fluid-Overloaded Patients with Decompensated Congestive Heart Failure (RAPID-CHF) Trial. J Am Coll Cardiol 2005 Dec 6; 46:2043-6.

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• Medline abstract (Free)

Costanzo MR et al. Early ultrafiltration in patients with decompensated heart failure and diuretic resistance. J Am Coll Cardiol 2005 Dec 6; 46:2047-51.

• Original article (Subscription may be required)
• Medline abstract (Free)

Bourge RC and Tallaj JA. Ultrafiltration: A new approach toward mechanical diuresis in heart failure. J Am Coll Cardiol 2005 Dec 6; 46:2052-3.

• Original article (Subscription may be required)
• Medline abstract (Free)