November 6th, 2012

Ultrafiltration Fails to Show Benefit in Acute Heart Failure

Although ultrafiltration (UF) in recent years has become increasingly popular as an alternative to intravenous diuretics for patients with acute decompensated heart failure with acute cardiorenal syndrome (type 1), the first clinical trial to test its value shows that it is inferior to standard drug therapy.

The results of CARRESS-HF (Cardiorenal Rescue Study in Acute Decompensated Heart Failure) were presented at the AHA scientific session in Los Angeles by Bradley Bart and published simultaneously in the New England Journal of Medicine. The study compared UF with standard drug care in 188 patients with acute decompensated heart failure, worsening renal function, and persistent congestion.

UF was inferior to standard pharmacologic therapy as assessed by the primary endpoint of the trial, which was the bivariate change in serum creatinine and weight measured at 96 hours. Weight loss was similar between the groups (5.5 kg in the drug treatment group and 5.7 kg in the UF group ((p=0.58), but creatinine was significantly higher in the UF group:

  • -0.04 mg/dL in the drug group versus +0.23 mg/dL in the UF group (p=0.003)

At 60 days, there  was no difference in the rate of death or rehospitalization between the groups, but a serious safety signal emerged as more UF patients had a serious adverse event (57% vs. 72%, p=0.03).

The authors conclude:

Given the high cost and complexity of ultrafiltration, the use of this technique as performed in the current study does not seem justified for patients hospitalized for acute decompensated heart failure, worsened renal function, and persistent congestion.

In an accompanying editorial, W.H. Wilson Tang writes that “it is difficult to argue that ultrafiltration provides ‘diuretic sparing’ benefits in patients with acute cardiorenal syndrome when a well-managed pharmacologic approach provided equivalent clinical outcomes with fewer serious adverse effects.” He left hope that “a slower but steady ultrafiltration rate” might yet prove beneficial. Further, it is possible that aggressive therapy in order to reduce length of stay “may actually result in an increased incidence of the acute cardiorenal syndrome and cause unwanted consequences. Perhaps slow and steady may ultimately win the race after all.”

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2 Responses to “Ultrafiltration Fails to Show Benefit in Acute Heart Failure”

  1. Tariq Ahmad, MD, MPH says:

    Perhaps ultrafiltration for heart failure will go the way of the Southey tubes: I can think of few clinical instances where its use would be justified. Do others disagree?

  2. Dmitri V Vasin, MD says:

    Perhaps we should look instead at something simple and inexpensive for management of decompensated CHF… like Hypertonic Saline and high dose furosemide protocol pioneered by Paterna (SMAC-HF trial).
    No expensive technology or fancy drugs. We already have everything that is needed (3% saline and furosemide, infusion pump). We just lack courage (or may be also contributions from a deep pocket sponsor to “key opinion leaders” – to make them look at it seriously)…
    In any case – here are the results of SMAC-HF:
    Length of stay 3.5 vs. 5.5 days
    Readmissions 19 vs. 34%
    All cause mortality 13 vs 34%
    If anyone interested in adaptation of SMAC-HF protocol to the realities of a very average US hospital – I have one available.