The role of early and sufficient isolated venovenous ultrafiltration in heart failure patients with pulmonary and systemic congestion.
Hypervolemia, present in at least 70% of patients with decompensated heart failure, results in renal dysfunction due to increased renal venous pressure, impaired renal autoregulation, and decreased renal blood flow that are associated with increased morbidity and mortality. Loop diuretics, widely used in congested patients, result in the production of hypotonic urine and neurohormonal activation. In contrast, ultrafiltration (UF) removes isotonic fluid without increasing renin secretion by the macula densa. Simplified devices that permit us to perform UF with peripheral venous access, adjustable blood flows, and small extracorporeal blood volumes make this therapy feasible at most hospitals and in less acute care settings. Conflicting results on the effects of UF in heart failure patients underscore the challenges of patient selection and choice of fluid removal rates. Unfavorable outcomes in patients undergoing UF in the midst of cardiorenal syndrome type 1 are in contrast with the sustained benefits of UF initiated before unsuccessful use of high-dose intravenous (IV) diuretics. UF rates should be based on a precise knowledge of the degree of hypervolemia and careful assessment of blood volume changes, so that extracellular fluid gradually refills the intravascular space and volume depletion is avoided. Poor outcomes are likely to occur if fluid removal rates are not tailored to individual patients' clinical characteristics. A large trial is ongoing to determine if a strategy of early UF, initiated before renal function is worsened by other therapies, is superior to IV diuretics in reducing 90-day heart-failure-related hospitalizations in patients with pulmonary and systemic congestion.
Midwest Heart Specialists-Advocate Medical Group, Naperville, IL.
Maria Rosa
MR
Costanzo
Department of Medicine, Division of Renal Diseases and Hypertension, George Washington University Medical Center, Washington, DC.
L S
LS
Chawla
University of Tennessee College of Medicine, Department of Internal Medicine, Chattanooga, TN.
J A
JA
Tumlin
Department of Medicine, Division of Cardiology, Hennepin County Medical Center, University of Minnesota, Minneapolis, MN.
C A
CA
Herzog
St. John Providence Health System, Warren, MI, Providence Hospitals and Medical Centers, Southfield and Novi, MI.
Peter A
PA
McCullough
Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
J A
JA
Kellum
Department of Nephrology Dialysis & Transplantation, San Bortolo Hospital, Vicenza, Italy.
C
C
Ronco
D061605:Administration, Intravenous; D001810:Blood Volume; D059347:Cardio-Renal Syndrome / Q000503:physiopathology / Q000628:therapy; D004232:Diuretics / Q000008:administration & dosage; D006333:Heart Failure / Q000150:complications / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D006439:Hemodynamics; D006440:Hemofiltration / Q000009:adverse effects; D006801:Humans; D007668:Kidney / Q000503:physiopathology; D018579:Patient Selection; D011654:Pulmonary Edema / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology / Q000628:therapy*; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014883:Water-Electrolyte Imbalance / Q000503:physiopathology / Q000628:therapy
D004232:Diuretics