title: Association of haemodynamic changes measured by serial central venous saturation during ultrafiltration for acutely decompensated heart failure with diuretic resistance and change in renal function.
abstract: BACKGROUND
  Patients with acute decompensated heart failure with diuretic resistance (ADHF-DR) have a poor prognosis. The aim of this study was to assess in patients with ADHF-DR, whether haemodynamic changes during ultrafiltration (UF) are associated with changes in renal function (Δcreatinine) and whether Δcreatinine post UF is associated with mortality.
  
  
  METHODS
  Seventeen patients with ADHF-DR underwent 20 treatments with UF. Serial bloods (4-6 hourly) from the onset of UF treatment were measured for renal function, electrolytes and central venous saturation (CVO2). Univariate and multivariate analysis were performed to assess the relationship between changes in markers of haemodynamics [heart rate (HR), systolic blood pressure (SBP), packed cell volume (PCV) and CVO2] and Δcreatinine. Patients were followed up and mortality recorded. Cox-regression survival analysis was performed to determine covariates associated with mortality.
  
  
  RESULTS
  Renal function worsened after UF in 17 of the 20 UF treatments (baseline vs. post UF creatinine: 164±58 vs. 185±69μmol/l, P<0.01). ΔCVO2 was significantly associated with Δcreatinine [β-coefficient of -1.3 95%CI (-1.8 to -0.7), P<0.001] and remained significantly associated with Δcreatinine after considering changes in SBP, HR and PCV [P<0.001]. Ten (59%) patients died at 1-year and 15(88%) by 2-years. Δcreatinine was independently associated with mortality (adjusted-hazard ratio 1.03 (1.01 to 1.07) per 1μmol/l increase in creatinine; P=0.02).
  
  
  CONCLUSIONS
  Haemodynamic changes during UF as measured by the surrogate of cardiac output was associated with Δcreatinine. Worsening renal function at end of UF treatment occurred in the majority of patients and was associated with mortality.
authors.affiliation: Department of Cardiology, NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom; High Dependency Unit, Royal Brompton Hospital, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom; National Heart & Lung Institute, Imperial College London, United Kingdom. Electronic address: a.vazir@imperial.ac.uk.
authors.forename: Ali
authors.initials: A
authors.lastname: Vazir
authors.affiliation: Department of Cardiology, NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom.
authors.forename: Victoria L
authors.initials: VL
authors.lastname: Simpkin
authors.affiliation: Critical Care, Guys' and St Thomas' NHS Foundation trust, London, United Kingdom.
authors.forename: Philip
authors.initials: P
authors.lastname: Marino
authors.affiliation: Department of Cardiology, NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom.
authors.forename: Andrew
authors.initials: A
authors.lastname: Ludman
authors.affiliation: Department of Statistics, Royal Brompton Hospital, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom.
authors.forename: Winston
authors.initials: W
authors.lastname: Banya
authors.affiliation: Adult Intensive Care Unit, Royal Brompton Hospital, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom; University of Pavia, Foundation Policlinico San Matteo, IRCCS. Piazzale Golgi 2, Pavia, Italy.
authors.forename: Guido
authors.initials: G
authors.lastname: Tavazzi
authors.affiliation: High Dependency Unit, Royal Brompton Hospital, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom.
authors.forename: Anthony J
authors.initials: AJ
authors.lastname: Bastin
authors.affiliation: High Dependency Unit, Royal Brompton Hospital, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom.
authors.forename: Sarah
authors.initials: S
authors.lastname: Trenfield
authors.affiliation: High Dependency Unit, Royal Brompton Hospital, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom.
authors.forename: Arshad
authors.initials: A
authors.lastname: Ghori
authors.affiliation: High Dependency Unit, Royal Brompton Hospital, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom.
authors.forename: Peter D
authors.initials: PD
authors.lastname: Alexander
authors.affiliation: Adult Intensive Care Unit, Royal Brompton Hospital, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom.
authors.forename: Mark
authors.initials: M
authors.lastname: Griffiths
authors.affiliation: Adult Intensive Care Unit, Royal Brompton Hospital, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom.
authors.forename: Susanna
authors.initials: S
authors.lastname: Price
authors.affiliation: Department of Cardiology, NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom; National Heart & Lung Institute, Imperial College London, United Kingdom.
authors.forename: Rakesh
authors.initials: R
authors.lastname: Sharma
authors.affiliation: Department of Cardiology, NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom; National Heart & Lung Institute, Imperial College London, United Kingdom.
authors.forename: Martin R
authors.initials: MR
authors.lastname: Cowie
mesh_terms: D000208:Acute Disease; D000368:Aged; D002405:Catheterization, Central Venous / Q000379:methods; D002496:Central Venous Pressure / Q000502:physiology*; D015331:Cohort Studies; D004232:Diuretics / Q000494:pharmacology / Q000627:therapeutic use*; D004351:Drug Resistance / Q000187:drug effects / Q000502:physiology; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000175:diagnosis* / Q000628:therapy*; D006439:Hemodynamics / Q000502:physiology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012189:Retrospective Studies; D016896:Treatment Outcome; D014462:Ultrafiltration / Q000639:trends
chemical_list: D004232:Diuretics
keywords: Central venous saturation; Heart failure; Ultrafiltration; Worsening renal function