Elsevier

International Journal of Cardiology

Volume 228, 1 February 2017, Pages 122-128
International Journal of Cardiology

Ultrafiltration for acute decompensated cardiac failure: A systematic review and meta-analysis

https://doi.org/10.1016/j.ijcard.2016.11.136Get rights and content

Highlights

  • The role of ultrafiltration in acute decompensated heart failure is unclear.

  • Ultrafiltration is as efficacious as diuretics for fluid loss via weight reduction.

  • Ultrafiltration is not associated with a significant decline in renal function.

  • Ultrafiltration reduces heart failure hospitalization.

  • Routine ultrafiltration in acute decompensated heart failure is not recommended.

Abstract

Background

Ultrafiltration is a method used to achieve diuresis in acute decompensated heart failure (ADHF) when there is diuretic resistance, but its efficacy in other settings is unclear. We therefore conducted a systematic review and meta-analysis to evaluate the use of ultrafiltration in ADHF.

Methods

We searched MEDLINE and EMBASE for studies that evaluated outcomes following filtration compared to diuretic therapy in ADHF. The outcomes of interest were body weight change, change in renal function, length of stay, frequency of rehospitalization, mortality and dependence on dialysis. We performed random effects meta-analyses to pool studies that evaluated the desired outcomes and assessed statistical heterogeneity using the I2 statistic.

Results

A total of 10 trials with 857 participants (mean age 68 years, 71% male) compared filtration to usual diuretic care in ADHF. Nine studies evaluated weight change following filtration and the pooled results suggest a decline in mean body weight − 1.8; 95% CI, − 4.68 to 0.97 kg. Pooled results showed no difference between the filtration and diuretic group in change in creatinine or estimated glomerular filtration rate. The pooled results suggest longer hospital stay with filtration (mean difference, 3.70; 95% CI, − 3.39 to 10.80 days) and a reduction in heart failure hospitalization (RR, 0.71; 95% CI, 0.51–1.00) and all-cause rehospitalization (RR, 0.89; 95% CI, 0.43–1.86) compared to the diuretic group. Filtration was associated with a non-significant greater risk of death compared to diuretic use (RR, 1.08; 95% CI, 0.77–1.52).

Conclusions

There is insufficient evidence supporting routine use of ultrafiltration in acute decompensated heart failure.

Introduction

Acute decompensated heart failure (ADHF) accounts for nearly 1 million hospitalizations worldwide [1]. ADHF is a blanket term covering a heterogeneous group of patients sharing a common clinical presentation of symptoms and signs of congestion or ‘fluid overload.’ Diuretics have been the treatment option of choice for congestion for decades—irrespective of any clinical differences in presentation of ADHF. Diuretic prescriptions are thought to reduce severe congestion slowly and therefore contribute to prolonged hospitalizations in these patients. In addition, their use may also be complicated by electrolyte disturbances and some patients may become refractory to their use.

Ultrafiltration, using either extracorporeal hemodialysis circuits or peritoneal dialysis [2], is a recognized method for mechanical fluid management in patients with renal failure and has also been proposed as a therapeutic intervention to optimise fluid management in patients with decompensated heart failure. Several studies have evaluated the efficacy of extracorporeal ultrafiltration compared to intravenous diuretics among decompensated patients without diuretic resistance and the results are inconsistent [3], [4], [5], [6].

In view of the inconsistent evidence and the emergence of new studies we conducted a systematic review and meta-analysis to determine whether reported trials compared the efficacy of ultrafiltration with diuretics alone and if any patient groups more likely to benefit or be harmed by ultrafiltration compared to diuretics.

Section snippets

Methods

We selected studies that investigated outcomes among patients with ADHF who were treated with either ultrafiltration or intravenous diuretics. There was no restriction on whether patients had diuretic resistance but where available, information about the definition and prevalence of diuretic resistance was collected from each included study. The outcomes of interest were weight change, change in creatinine and/or change in estimated glomerular filtration rate, length of stay, hospitalization,

Results

The process of study selection is shown in Fig. 1. After removal of duplicates, our search yielded 1433 titles and abstracts. After independent screening for study inclusion, the full manuscripts or conference abstracts of 57 studies were reviewed and 10 were retained for final inclusion in the review [3], [4], [5], [6], [8], [9], [10], [11], [12], [13], [14], [15].

The description of the included studies is shown in Table 1. There were 10 randomized trials which took place in USA, Canada,

Discussion

Our analysis suggests that ultrafiltration appears to be as efficacious as diuretics in terms of fluid loss and weight reduction without significant decline in renal function. However, the usual care received in both treatment arms is poorly defined and the timing of the evaluation of outcomes is highly variable. It is unclear if other interventions are the same in the usual care group such as the dose of loop diuretics, other diuretics (e.g. thiazides), implementation of fluid restriction, the

Author statement

All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

Contributors

Kwok CS was responsible for the study design, concept, screening and data extraction, data analysis and text of the manuscript. CWW screened and extracted data in the review. All authors provided critical revision for important intellectual content.

Funding sources

None.

Conflicts of interest disclosures

The authors report no relationships that could be construed as a conflict of interest.

Acknowledgements

None.

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