Ultrafiltration vs Diuretics for Heart Failure Patients

Bret Stetka, MD; Ihab M. Wahba, MD


May 10, 2013

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Hello, I'm Bret Stetka, Editorial Director at Medscape. Welcome to the F1000 Practice-Changing Minute, where we report commentaries from the Faculty of 1000 on highly rated studies that may change clinical practice.

Our commentary today covers the study "Ultrafiltration in Decompensated Heart Failure With Cardiorenal Syndrome,"from Drs. Bart and colleagues and published in New England Journal of Medicine.[1] The F1000 commentator has given this study a ranking of "Changes Clinical Practice," with the conclusion that mechanical ultrafiltration should not be used for patients with decompensated heart failure not resistant to diuretics; these patients should receive diuretics as first-line therapy.

The following F1000 commentary on this study was written by Ihab M. Wahba, MD of Good Samaritan Regional Medical Center, Corvallis, Oregon.

In his commentary on this study, Dr. Wahba wrote:

"This is the largest study published to date evaluating whether mechanical ultrafiltration is superior to pharmacologic diuresis in patients with decompensated heart failure and renal dysfunction (cardiorenal syndrome). This was a large randomized trial of mechanical ultrafiltration versus intensive diuresis with furosemide to achieve a urine output of 3-5l per day at 96 hours. The primary endpoints were the change in serum creatinine and the volume of fluid removal. Secondary endpoints included improvement in signs and symptoms of heart failure. The study showed that mechanical ultrafiltration resulted in a higher serum creatinine (despite the fact that ultrafiltration is expected to lower serum creatinine by virtue of increased creatinine clearance) and more complications, including renal failure, bleeding and vascular access-related adverse effects. Both treatments were equivalent in terms of fluid removal and symptoms.

This study refutes the results of prior small studies suggesting the superiority of ultrafiltration over diuretics for heart failure symptoms and outcomes,[2] and suggests that ultrafiltration should be reserved to patients with resistance to diuretics or advanced renal dysfunction. This study is by far the largest and the best currently in the field, and presently there are patients receiving ultrafiltration even if they are responsive to diuretics; this practice should stop since it was shown here to be more risky than beneficial. Until another study proves otherwise, physicians should first practice what is safe."

This concludes today's commentary from Ihab M. Wahba for the F1000 Practice-Changing Minute. I am Bret Stetka. Thank you for listening.