Skip to main content

Advertisement

SpringerLink
Log in

Isolated Ultrafiltration in Heart Failure Patients

  • Congestive Heart Failure (J Lindenfeld, Section Editor)
  • Published:
Current Cardiology Reports Aims and scope Submit manuscript

Abstract

Most heart failure hospitalizations are due to volume overload, which contributes to disease progression. Heart failure decompensation is typically treated with intravenous diuretics, which are of limited efficacy especially in patients with underlying chronic kidney disease. Since the introduction of hemodialysis, ultrafiltration has been used to remove excess body fluid. Newer, simplified isolated ultrafiltration devices make ultrafiltration feasible at most hospitals and in less acute care settings. Veno-venous ultrafiltration is characterized by transport of solutes and water across a semipermeable membrane in response to a transmembrane pressure gradient generated by a peristaltic pump. Monitoring of ultrafiltration requires a combination of clinical and biomarkers values. Hemodynamic instability due to overaggressive fluid removal must be avoided. Based on recent clinical trials, practice guidelines state that ultrafiltration is reasonable for patients with congestion refractory to medical therapy (Class IIa, Level of Evidence B). Unanswered questions regarding ultrafiltration in heart failure patients include optimal fluid removal rates, effect on long-term survival, and cost.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. • 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–e215. According to this Heart Disease Update from the AHA number of hospitalizations for HF decompensation exceeds 1.2 million per year..

    Article  PubMed  Google Scholar 

  2. Adams KF, 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.

    Article  PubMed  Google Scholar 

  3. Jain P, Massie BM, Gattis WA, et al. Current medical treatment for exacerbation of chronic heart failure resulting in hospitalization. Am Heart J. 2003;145:S3–S17.

    Article  PubMed  Google Scholar 

  4. Drazner MH, Rame JE, Stevenson LW, Dries DL. Prognostic importance of elevated jugular venous pressure and a third heart sound in patients with heart failure. N Engl J Med. 2001;345:574–81.

    Article  PubMed  CAS  Google Scholar 

  5. Androne AS, Katz SD, Lund L, et al. Hemodilution is common in patients with advanced heart failure. Circulation. 2003;107:226–9.

    Article  PubMed  Google Scholar 

  6. Heywood JT, Fonarow GC, Costanzo MR, Mathur VS, Wigneswaran JR, Wynne J. High prevalence of renal dysfunction and its impact on outcome in 118,465 patients hospitalized with acute decompensated heart failure: a report from the ADHERE database. J Card Fail. 2007;13:422–30.

    Article  PubMed  Google Scholar 

  7. Ronco C, Haapio M, House A, Anavekar N, Bellomo R. Cardiorenal syndrome. J Am Coll Cardiol. 2008;52:1527–39.

    Article  PubMed  Google Scholar 

  8. Felker GM, Lee KL, Bull DA, et al. Diuretic strategies evaluation in patients with acute decompensated heart failure. N Engl J Med. 2011;364:797–805.

    Article  PubMed  CAS  Google Scholar 

  9. Silverstein ME, Ford CA, Lysaght MJ, Henderson LW. Treatment of severe fluid overload by ultrafiltration. N Engl J Med. 1974;291:747–51.

    Article  PubMed  CAS  Google Scholar 

  10. Henderson LW, Lilley JJ, Ford CA, Stone RA. Hemodiafiltration. J Dial. 1977;1(3):211–38.

    PubMed  CAS  Google Scholar 

  11. • Nalesso F, Garzotto F, Ronco C. Technical aspects of extracorporeal ultrafiltration: mechanisms, monitoring and dedicated technology. Contrib Nephrol. 2010;164:199–208. This is a comprehensive review of UF methods spanning from isolated UF to extracorporeal fluid removal in the settings of hemodiafiltration and dialysis..

    Article  PubMed  Google Scholar 

  12. Ricci Z, Bonello M, Salvatori G, et al. Continuous renal replacement technology: from adaptive technology and early dedicated machines towards flexible multipurpose machine platforms. Blood Purif. 2004;22(3):269–76.

    Article  PubMed  Google Scholar 

  13. Jaski BE, Ha J, Denys BG, Lamba S, Trupp RJ, Abraham WT. Peripherally inserted veno-venous ultrafiltration for rapid treatment of volume overloaded patients. J Card Fail. 2003;9:227–31.

    Article  PubMed  Google Scholar 

  14. Ronco C, Ricci Z, Bellomo R, Bedogni F. Extracorporeal ultrafiltration for the treatment of overhydration and congestive heart failure. Cardiology. 2001;96:155–68.

    Article  PubMed  CAS  Google Scholar 

  15. Clark WR, Macias WL, Molitoris BA, Wang NH. Plasma protein adsorption to highly permeable hemodialysis membranes. Kidney Int. 1995;48:481–88.

    Article  PubMed  CAS  Google Scholar 

  16. Clark WR, Hamburger RJ, Lysaght MJ. Effect of membrane composition and structure on solute removal and biocompatility in hemodialysis. Kidney Int. 1999;56:2005–15.

    Article  PubMed  CAS  Google Scholar 

  17. Ronco C, Brendolan A, Bellomo R. On-line monitoring in continuous renal replacement therapies. Kidney Int. 1999;56 suppl 72:S8–S14.

    Article  Google Scholar 

  18. Ward RA, Ronco C. Improvements in technology: a path to safer and more effective hemodialysis. Blood Purif. 2009;27:6–10.

    Article  PubMed  Google Scholar 

  19. Schrier RW, Abraham WT. Hormones and hemodynamics in heart failure. N Engl J Med. 1999;341:577–85.

    Article  PubMed  CAS  Google Scholar 

  20. Ellison DH, Velazquez H, Wright FS. Adaptation of the distal convoluted tubule of the rat: structural and functional effects of dietary salt intake and chronic diuretic infusion. J Clin Invest. 1989;83:113–26.

    Article  PubMed  CAS  Google Scholar 

  21. Marenzi GC, Lauri G, Grazi M, Assanelli E, Campodonico J, Agostoni PG. Circulatory response to fluid overload removal by extracorporeal ultrafiltration in refractory congestive heart failure. J Am Coll Cardiol. 2001;38:963–8.

    Article  PubMed  CAS  Google Scholar 

  22. Asaba H, Bergstrom J, Furst P, et al. Treatment of diuretic-resistant fluid retention with ultrafiltration. Acta Med Scand. 1978;204:145–9.

    Article  PubMed  CAS  Google Scholar 

  23. Fauchald P, Forfang K, Amlie J. An evaluation of ultrafiltration as treatment of therapy-resistant cardiac edema. Acta Med Scand. 1986;219:47–52.

    Article  PubMed  CAS  Google Scholar 

  24. Donato L, Biagini, Contini C, et al. Treatment of end-stage congestive heart failure by extracorporeal ultrafiltration. Am J Cardiol. 1987;59:379–80.

    Article  PubMed  CAS  Google Scholar 

  25. Rimondini A, Cipolla CM, Della Bella P, et al. Hemofiltration as short-term treatment for refractory congestive heart failure. Am J Med. 1987;83:43–8.

    Article  PubMed  CAS  Google Scholar 

  26. Di Leo M, Pacitti A, Bergerone S, et al. Ultrafiltration in the treatment of refractory congestive heart failure. Clin Cardiol. 1988;11:449–52.

    Article  Google Scholar 

  27. Simpson IA, Simpson K, Rae AP, et al. Ultrafiltration in diuretic resistant heart failure. Ren Fail. 1987;10:115–9.

    Article  PubMed  CAS  Google Scholar 

  28. Akiba T, Taniguchi K, Marumo F, Matsuda O, et al. Clinical significance of renal hemodynamics in severe congestive heart failure: responsiveness to ultrafiltration therapies. Jpn Circ J. 1989;53:191–6.

    Article  PubMed  CAS  Google Scholar 

  29. Cipolla CM, Grazi S, Rimondini A, et al. Changes in circulating norepinephrine with hemofiltration in advanced heart failure. Am J Cardiol. 1990;66:987–94.

    Article  PubMed  CAS  Google Scholar 

  30. Marenzi G, Grazi S, Giraldi F, et al. Interrelation of humoral factors, hemodynamics, and fluid and salt metabolism in congestive heart failure: effects of extracorporeal ultrafiltration. Am J Med. 1993;94:49–56.

    Article  PubMed  CAS  Google Scholar 

  31. Agostoni PG, Marenzi GC, Lauri GF, et al. Sustained improvement in functional capacity after removal of body fluid with isolated ultrafiltration in chronic cardiac insufficiency: failure of furosemide to provide the same result. Am J Med. 1994;96:191–9.

    Article  PubMed  CAS  Google Scholar 

  32. Costanzo MR, Saltzberg M, O’Sullivan J, Sobotka P. Early ultrafiltration in patients with decompensated heart failure and diuretic resistance. J Am Coll Cardiol. 2005;46:2047–51.

    Article  PubMed  Google Scholar 

  33. Bart BA, Boyle A, Bank AJ, et al. Randomized controlled trial of ultrafiltration versus usual care for hospitalized patients with heart failure: relief for acutely fluid overloaded patients with decompensated congestive heart failure. J Am Coll Cardiol. 2005;46:2043–6.

    Article  PubMed  Google Scholar 

  34. 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.

    Article  PubMed  CAS  Google Scholar 

  35. •• Costanzo MR, Saltzberg MT, Jessup M, et al. Ultrafiltration is associated with fewer re-hospitalizations than continuous diuretic infusion in patients with decompensated heart failure: results from UNLOAD. J Card Fail. 2010;16:277–84. This analysis preformed in the UNLOAD population shows that despite similar fluid loss by UF and IV diuretics administered by continuous infusion, HF events were reduced only in the UF group. This finding suggests that removal of isotonic fluid by UF may be superior to removal of hypotonic urine by IV diuretics..

    Article  PubMed  Google Scholar 

  36. Ali SS, Olinger CC, Sobotka PA, et al. Loop diuretics can cause clinical natriuretic failure: a prescription for volume expansion. Congest Heart Fail. 2009;15:1–4.

    Article  PubMed  CAS  Google Scholar 

  37. Konstam MA, Gheorghiade M, Burnett JC, for the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan (EVEREST) Investigators, et al. Effects of oral tolvaptan in patients hospitalized for worsening heart failure. The EVEREST outcome trial. JAMA. 2007;297:1319–31.

    Article  PubMed  CAS  Google Scholar 

  38. Abdallah JG, Schreier RW, Edelstein C, et al. Loop diuretic infusion increases thiazide-sensitive Na+/Cl—cotransporter abundance: role of aldosterone. J Am Soc Nephrol. 2001;12:1335–41.

    PubMed  CAS  Google Scholar 

  39. •• Mullens W, Abrahams Z, Francis GS, et al. Importance of venous congestion for worsening of renal function in advanced decompensated heart failure. J Am Coll Cardiol. 2009;53:589–96. The findings reported in this manuscript confirm and expand the knowledge that central venous pressure influences renal function more than other hemodynamic values, including blood pressure, pulmonary artery wedge pressure, and cardiac index..

    Article  PubMed  Google Scholar 

  40. •• Jessup M, Costanzo MR. The cardiorenal syndrome: do we need a change of strategy or a change of tactics? J Am Coll Cardiol. 2009;53:597–9. The authors of this editorial provide a possible explanation of the effects of central venous pressure on renal function: increase in central venous pressure is transmitted to the renal veins and eventually to the efferent arteriolar system of the kidney. This results in a decrease in net filtration pressure and glomerular filtration rate..

    Article  PubMed  Google Scholar 

  41. Rogers HL, Marshall J, Bock J, Dowling TC, Feller E, Robinson S, 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.

    Article  PubMed  CAS  Google Scholar 

  42. Bartone C, Saghir S, Menon SG, et al. Comparison of ultrafiltration, nesiritide, and usual care in acute decompensated heart failure. Congest Heart Fail. 2008;14:298–301.

    Article  PubMed  CAS  Google Scholar 

  43. •• Testani JM, Chen J, McCauley BD, Kimmel SE, Shannon RP. Potential effects of aggressive decongestion during the treatment of decompensated heart failure on renal function and survival. Circulation. 2010;122(3):265–72. This very provocative analysis of the ESCAPE trial population shows that patients who develop hemoconcentration have substantially improved survival despite a higher incidence of worsening renal function. These observations suggest that aggressive decongestion of patients with ADHF may improve survival, even when high diuretic doses are required or renal function deteriorates..

    Article  PubMed  Google Scholar 

  44. Jessup M, Abraham WT, Casey DE, et al. 2009 focused update: ACCF/AHA guidelines for the diagnosis and management of heart failure in adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2009;119:1977–2016.

    Article  PubMed  Google Scholar 

  45. Howlett JG, McKelvie RS, Costigan J, et al. The 2010 Canadian Cardiovascular Society guidelines for the diagnosis and management of heart failure update: heart failure in ethnic minority populations, heart failure and pregnancy, disease management, and quality improvement/assurance programs. Can J Cardiol. 2010;26:185–202.

    Article  PubMed  Google Scholar 

  46. 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. Eur Heart J. 2008;29:2388–442.

    Article  PubMed  CAS  Google Scholar 

  47. • Gheorghiade M, Follath F, Ponikowski P, et al. Assessing and grading congestion in acute heart failure: a scientific statement from the acute heart failure committee of the heart failure association of the European Society of Cardiology and endorsed by the European Society of Intensive Care Medicine. Eur J Heart Fail. 2010;12:423–33. This expert consensus manuscript proposes a grading of congestion based on multiple clinical and biomarker values and suggests that a congestion score greater than 12 may warrant treatment with UF..

    Article  PubMed  Google Scholar 

  48. Hook KM, Abrams CS. Treatment options in heparin-induced thrombocytopenia. Curr Opin Hematol. 2010;17:424–31.

    Article  PubMed  Google Scholar 

  49. http://www.accessdata.fda.gov/scripts/cdrh/devicesatfda/index.cfm?db=pmn&id=K040489. Accessed September 21, 2011

  50. Bradley SM, Levy WC, Veenstra DL. Cost-consequences of ultrafiltration in acute heart failure: a decision model analysis. Circ Cardiovasc Qual Outcomes. 2009;2:566–73.

    Article  PubMed  Google Scholar 

  51. Setoguchi S, Stevenson LW. Hospitalizations in patients with heart failure: who and why. J Am Coll Cardiol. 2009;54:1703–5.

    Article  PubMed  Google Scholar 

  52. Ricci Z, Ronco C, D’amico G, et al. Practice patterns in the management of acute renal failure in the critically ill patient: an international survey. Nephrol Dial Transplant. 2006;21(3):690–6.

    Article  PubMed  Google Scholar 

  53. Ronco C, Davenport A, Gura V. The future of the artificial kidney: moving towards wearable and miniaturized devices. Nefrologia. 2011;3:9–16.

    Google Scholar 

  54. Ronco C, Davenport A, Gura V. A wearable artificial kidney: dream or reality? Nat Clin Pract Nephrol. 2008;4:604–5.

    Article  PubMed  Google Scholar 

Download references

Disclosure

Conflicts of interest: M.R. Costanzo: receives consulting and speaking honoraria from Gambro; C. Ronco: receives speaking honoraria from Alere, Abbott, Gambro, GE, and Pfizer.

Author information

Authors and Affiliations

  1. Midwest Heart Foundation, Edward Heart Hospital, 4th Floor, 801 South Washington Street, P.O. Box 3223, Naperville, IL, 60189, USA

    Maria Rosa Costanzo

  2. Department of Nephrology, Dialysis and Transplantation, St. Bortolo Hospital, Vicenza, Italy

    Claudio Ronco

Authors
  1. Maria Rosa Costanzo
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Claudio Ronco
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Maria Rosa Costanzo.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Costanzo, M.R., Ronco, C. Isolated Ultrafiltration in Heart Failure Patients. Curr Cardiol Rep 14, 254–264 (2012). https://doi.org/10.1007/s11886-012-0257-y

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11886-012-0257-y

Keywords

Search

Navigation