Abstract
Background
Patients with decompensated heart failure frequently present with volume overload, which is conventionally treated with diuretics. These drugs have been associated with several adverse effects, including increased mortality, leading some clinicians to propose ultrafiltration as a safe alternative to remove sodium and water.
Objective
The objective of our study was to compare the safety and efficacy of ultrafiltration and conventional intravenous diuretic therapy for patients with acute heart failure and volume overload.
Data Sources
We searched the following databases through November 2012: Cochrane Library (1993–), PubMed (1988–), OVID (1984–), EBSCO (1984–), CBM (1978–), VIP (1989–), and CNKI (1979–). In addition, we manually searched relevant references and review articles.
Study Selection
Randomized controlled trials comparing the efficacy of ultrafiltration and intravenous diuretics in patients diagnosed with hypervolemic acute heart failure were included. Five trials were found to satisfy all the inclusion criteria.
Study Appraisal and Synthesis Methods
Two reviewers independently determined study eligibility, assessed methodological quality and extracted the data. We analyzed the data and pooled them, when appropriate, using Revman 5.0. We assessed the risk of bias in the included studies using guidelines in the Cochrane Handbook 5.0 for Systematic Reviews of Interventions, taking into account sequence generation, allocation concealment, blinding, incomplete outcome data, and selective outcome reporting.
Results
Data from the initial phase of five trials involving 477 participants were included. Meta-analysis of the pooled data showed that ultrafiltration was significantly better than diuretic drugs based on 48-h weight loss (Z = 3.72; P < 0.001, weighted mean difference [WMD] = 1.25 kg, 95 % CI 0.59–1.91) and based on 48-h fluid removal (Z = 4.23; P < 0.001, WMD = 1.06 L, 95 % CI 0.57–1.56). Adverse events did not differ significantly between the ultrafiltration and intravenous diuretic treatment groups.
Limitations
There are several limitations to our review, including publication bias and selection bias. Our review included only a few studies involving relatively few participants.
Conclusions
The available evidence suggests that early ultrafiltration is safe and effective for patients with hypervolemic acute heart failure. It allows greater fluid removal and weight loss by 48 h than do intravenous diuretics, with no significant increase in adverse effects.
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References
American Heart Association. Heart disease and stroke facts, 2006 update. Dallas: AHA; 2006.
Gu DF, Huang GY. Heart failure epidemiological investigation and its prevalence. Chin J Cardiol. 2003;31:3–6.
Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart disease and stroke statistics—2010 update. A report from the American Heart Association Statistics. Circulation. 2010;121:e46–215
Fang J, Mensah GA, Croft JB, Keenan NL. Heart failure related hospitalization in the U.S., 1979 to 2004. J Am Coll Cardiol. 2008;52(6):428–34.
Adams KF Jr, Fonarow GC, Emerman CL, et al. Characteristics and outcomes of patients hospitalized for heart failure in the United States: rationale, design, and preliminary observations from the first 100,000 cases in the Acute Decompensated Heart Failure National Registry (ADHERE). Am Heart J. 2005;149:209–16.
Jain P, Massie BM, Gattis WA, et al. Current medical treatment for the exacerbation of chronic heart failure resulting in hospitalization. Am Heart J. 2003;145:S3–17.
Cayley WE, Jr. Prognostic importance of elevated jugular venous pressure and a third heart sound in patients with heart failure. N Engl J Med 2001;345:1912 [Author’s reply, p. 1913].
Androne AS, Katz SD, Lund L, et al. Hemodilution is common in patients with advanced heart failure. Circulation. 2003;107:226–9.
Sackner-Bernstein JD. Management of diuretic-refractory, volume-overloaded patients with acutely decompensated heart failure. Curr Cardiol Rep. 2005;7:204–10.
Ellison DH. Diuretic therapy and resistance in congestive heart failure. Cardiology. 2001;96:132–43.
Philbin EF, Cotto M, Rocco TA Jr, et al. Association between diuretic use, clinical response, and death in acute heart failure. Am J Cardiol. 1997;80:519–22.
Butler J, Forman DE, Abraham WT, et al. Relationship between heart failure treatment and development of worsening renal function among hospitalized patients. Am Heart J. 2004;147:331–8.
Francis GS, Benedict C, Johnstone DE, et al. Comparison of neuroendocrine activation in patients with left ventricular dysfunction with and without congestive heart failure: a substudy of the Studies of Left Ventricular Dysfunction (SOLVD). Circulation. 1990;82:1724–9.
Gottlieb SS, Brater DC, Thomas I, et al. BG9719 (CVT-124), an A1 adenosine receptor antagonist, protects against the decline in renal function observed with diuretic therapy. Circulation. 2002;105:1348–53.
Ronco C, Ricci Z, Bellomo R, et al. Extracorporeal ultrafiltration for the treatment of overhydration and congestive heart failure. Cardiology. 2001;96:155–68.
Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009;151(4):264–9, W64.
Bart BA, Boyle A, Bank AJ, 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;46:2043–6.
Costanzo MR, Guglin ME, Saltzberg MT, et al. Ultrafiltration versus intravenous diuretics for patients hospitalized for acute decompensated heart failure. J Am Coll Cardiol. 2007;49:675–83.
Rogers HL, Marshall J, Bock J, 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;14:1–5.
Costanzo MR, Saltzberg MT, Jessup M, 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;16(4):277–84.
Giglioli C, Landi D, Cecchi E, et al. Effects of ULTRAfiltration vs. DIureticS on clinical, biohumoral and haemodynamic variables in patients with deCOmpensated heart failure: the ULTRADISCO study. Eur J Heart Fail. 2011;13(3):337–46.
Bart BA, Goldsmith SR, Lee KL, et al. Ultrafiltration in decompensated heart failure with cardiorenal syndrome. N Engl J Med. 2012;367:2296–304.
Forslund T, Riddervold F, Fauchald P, et al. Hormonal changes in patients with severe chronic congestive heart failure treated by ultrafiltration. Nephrol Dial Transplant. 1992;7(4):306–10.
Agostoni PG, Marenzi GC, Pepi M, et al. Isolated ultrafiltration in moderate congestive heart failure. J Am Coll Cardiol. 1993;21:424–31.
Costanzo MR. The role of ultrafiltration in the management of heart failure. Congest Heart Fail. 2008;14:19–24.
Sica D, Oren RM, Gottwald MD, et al. Natriuretic and neurohormonal responses to nesiritide, furosemide, and combined nesiritide and furosemide in patients with stable systolic dysfunction. Clin Cardiol. 2010;33(6):330–6.
De Maria E, Pignatti F, Patrizi G, et al. Ultrafiltration for the treatment of diuretic-resistant, recurrent, acute decompensated heart failure: experience in a single center. J Cardiovasc Med (Hagerstown). 2010;11(8):599–604.
Testani JM, et al. Potential effects of aggressive decongestion during the treatment of decompensated heart failure on renal function and survival. Circulation. 2010;122(3):265–72.
Fiaccadori E, Regolisti G, Maggiore U, Parenti E, Cremaschi E, Detrenis S, Caiazza A, Cabassi A. Ultrafiltration in heart failure. Am Heart J. 2011;161(3):439–49.
Dickstein K, Cohen-Solal A, Filippatos G, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). Eur J Heart Fail. 2008;29(19):2388–442.
Acknowledgments
The authors thank Bart et al. [22] for providing 48-h data from their trial. No sources of funding were used to support this work. The authors alone were responsible for designing and conducting this study. The authors have no relevant conflicts of interest.
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Y. Zhang and H. Wen contributed equally to this article.
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Wen, H., Zhang, Y., Zhu, J. et al. Ultrafiltration versus Intravenous Diuretic Therapy to Treat Acute Heart Failure: A Systematic Review. Am J Cardiovasc Drugs 13, 365–373 (2013). https://doi.org/10.1007/s40256-013-0034-3
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DOI: https://doi.org/10.1007/s40256-013-0034-3