Blog entry by Meguid El Nahas
Anyone in the world
THE WINNING RAMADAN BLOG BY Dr MOHAMED ESSAM:
AVOID HF(1), a study designed to compare Aquapheresis (ultrafiltration) to IV diuretics with FU 90 days of discharge from the hospital to determine which patients had fewer Heart Failure (HF) events, was recently terminated due to problems with participant allocation. Ultrafiltration (UF) emerged as a recent strategy in the management of ADHF due to several limitations of IV diuretics. UF has many theoretical advantages compared to diuretics including; more sodium removal (isotonic ultrafiltrate compared to hypotonic urine), absence of neurohormonal activation (with adjustment of UF rate to be equal to plasma refill rate using hematocrit monitoring), no resistance to its action, restoration of diuretic sensitivity and low risk of electrolyte imbalance (hyponatremia and hypokalemia with loop diuretic). However, Performance of UF in clinical trials resulted in conflicting data. RAPID-CHF(2) was a proof of concept trial conducted on 40 patients only with ADHF, no significant difference in weight loss “1ry endpoint” between both groups, however, Dyspnea and HF symptoms at 48 h improved significantly in the UF group. The UNLOAD trial(3) studied UF as primary therapy in 200 patients with ADHF as compared to IV diuretics, Weight and fluid loss were greater in the UF group with fewer patients rehospitalisation for HF events at 90 day follow up. The study was criticized by the suboptimal dose of diuretics used and the exclusion of patients with systolic BP of > 90 mmHg or requiring IV vasopressors which favoured the UF group. CARESS-HF(4) compared UF versus stepped pharmacological therapy in 188 ADHF patients with worsened renal functions and persistent congestion despite standard therapy. UF didn’t show greater weight loss than stepped medical therapy with higher rate of serious adverse events in the UF group. The study was also criticized for prohibiting inotropic agents in the UF group and allowing it in the diuretic group if failed to reach target UOP, also for fixing the UF rate (not taking into account many factors for example the plasma refill rate). Still UF has also many theoretical limitations including the cost, vascular access (although a peripheral access may be used) and the absence of long term outcome data. However, a recent meta-analysis(5) concluded that UF is a safe and effective strategy for fluid removal and weight loss without affecting renal functions, mortality or rehospitalisation in patients with ADHF. Our current practice - to start with pharmacological therapy then UF in resistant cases – should still be followed till new evidence from RCTs shows up!
1. Study of Heart Failure Hospitalizations After Aquapheresis Therapy Compared to Intravenous (IV) Diuretic Treatment. ClinicalTrials.gov.
2. 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;46(11):2043–6.
3. Costanzo MR et al. Ultrafiltration versus intravenous diuretics for patients hospitalized for acute decompensated heart failure. J. Am. Coll. Cardiol. 2007;49(6):675–83.
4. Bart BA et al. Ultrafiltration in decompensated heart failure with cardiorenal syndrome. N. Engl. J. Med. 2012;367(24):2296–304.
5. Cheng Z, Wang L, Gu Y, Hu S. Efficacy and safety of ultrafiltration in decompensated heart failure patients with renal insufficiency. Int. Heart J. 2015;56(3):319–23.
[ Modified: Thursday, 1 January 1970, 1:00 AM ]