Ultrafiltration, a Promising Alternative for Acute Heart Failure.

Implications:

- 90% of hospitalizations for acutely decompensated heart failure (ADHF) are due to fluid overload.
- Intravenous diuretics and occasionally other agents (e.g. Natrecor) are effective in most patients.
- However, many patients are unresponsive to these other therapies.
- Diuretics and other agents (e.g., Natrecor) may cause renal deterioration and even death.
- Alternative treatments are needed.
- Ultrafiltration appears as safe and effective as diuretics in ADHF.
- Ultrafiltration may even be cost-effective by reducing subsequent rehospitalizations.
- Ultrafiltration offers a promising new alternative to diuretics, but further studies are needed.

Analysis: This study compared ultrafiltration (using the Aquadex System 100, from CHF Solutions of Minneapolis, MN) to standard intravenous (IV) diuretic treatment in 200 patients hospitalized for acutely decompensated heart failure (ADHF) with volume overload. The primary endpoints were change in symptoms and weight loss. After 48 hours, patients on ultrafiltration lost significantly more weight (5.0 vs. 3.1 kg) and more fluids (4.6 vs. 3.1 liters) than those on IV diuretics (both p<0.001). Though symptoms were not different after 48 hours, after 90 days fewer patients treated with ultrafiltration were rehospitalized for HF (18% vs. 32%, p<0.037). There were no significant differences in renal function or number of deaths. The authors conclude that ultrafiltration can safely remove fluids and prevent costly hospital readmissions, and that this offers an alternative approach for patients with ADHF.

It is estimated that there are 1 million hospitalizations annually for HF in the US, and 90% of these are due to ADHF with fluid overload. These patients are almost always treated with IV diuretics and often receive other parenteral agents. Although the majority of these patients respond well with prompt loss of fluids and improvement in symptoms, many are refractory to these treatments. In addition, diuretics may cause renal deterioration, serious electrolyte imbalance, and even death, which the other therapies may also do (e.g., Natrecor). Also, there is no conclusive evidence that they impact outcomes after hospital discharge. Thus, the present results are encouraging as they suggest that ultrafiltration may be a safe and effective alternative to IV diuretics. It is also possible that ultrafiltration may reduce readmissions, the major contributor to healthcare costs in HF. This latter observation, however, requires confirmation by larger clinical trials.