Ultrafiltration for acute decompensated cardiac failure: A systematic review and meta-analysis☆
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.
References (23)
- et al.
Ultrafiltration versus usual care for hospitalized patients with heart failure
J. Am. Coll. Cardiol.
(2005) - et al.
Ultrafiltration versus intravenous diuretics for patients hospitalized for acute decompensated heart failure
J. Am. Coll. Cardiol.
(2007) - et al.
Aquapheresis versus intravenous diuretics and hospitalizations for heart failure
JACC Heart Fail.
(2016) - et al.
Ultrafiltration is associated with fewer rehospitalizations than continuous diuretic infusion in patients with decompensated heart failure: results from UNLOAD
J. Card. Fail.
(2010) - et al.
Continuous ultrafiltration for congestive heart failure: the CUORE trial
J. Card. Fail.
(2014) - et al.
A randomized, controlled trial of the renal effects of ultrafiltration as compared to furosemide in patients with acute decompensated heart failure
J. Card. Fail.
(2008) - et al.
Effect of ultrafiltration versus intravenous furosemide for decompensated heart failure in cardiorenal syndrome: a systematic review with meta-analysis of randomized controlled trials
Nephron
(2015) - et al.
The impact of ultrafiltration in acute decompensated heart failure: a systematic review and meta-analysis
IJC Metab. Endocr.
(2014) - et al.
Loop diuretics in acute decompensated heart failure
Circ. Heart Fail.
(2009) - et al.
Peritoneal dialysis in patients with refractory congestive heart failure: a systematic review
Cardiorenal Med.
(2015)
Ultrafiltration in decompensated heart failure with cardiorenal syndrome
N. Engl. J. Med.
Cited by (18)
Safety and efficacy of ultrafiltration versus diuretics in patients with decompensated heart failure: A systematic review and meta-analysis
2022, European Journal of Internal MedicineCitation Excerpt :However, the lack of randomized clinical trials comparing PD head-to-head with hemodialysis precluded its inclusion in our quantitative analysis. On review, we found 8 meta-analyses on the topic that included 6–9 trials with disputed results [19–26]. Most of these studies were released before the publication of contemporary trials.
Contemporary Management of Severe Acute Kidney Injury and Refractory Cardiorenal Syndrome: JACC Council Perspectives
2020, Journal of the American College of CardiologyCitation Excerpt :Reversal of renal venous congestion using ultrafiltration can improve diuretic responsiveness, particularly in patients with significant right-sided heart failure (59,60). Ultrafiltration is a safe alternative to diuretic therapy in patients with heart failure or CRS who are not medically refractory, and studies have generally shown greater decongestion and lower rates of subsequent rehospitalization with ultrafiltration, but no improvement in renal function or mortality (55,56,61,62). In the CARRESS-HF (Cardiorenal Rescue Study in Acute Decompensated Heart Failure), ultrafiltration was associated with a greater rise in serum creatinine without improved fluid removal or clinical outcomes in CRS patients compared with a stepped diuretic algorithm that involved escalating doses of furosemide infusion ± metolazone (Table 1) (62).
Ultrafiltration does provide more efficient decongestion compared to conventional treatment for acute heart failure
2017, International Journal of CardiologyResponse to Koratala et al.
2017, International Journal of Cardiology
- ☆
The authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.