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Cardiologists debate use of ultrafiltration as alternative HF therapy
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LOS ANGELES — Experts offered arguments for and against the use of ultrafiltration as an alternative treatment for HF during a debate held at the American Association of Heart Failure Nurses Annual Conference.
Leslie Miller, MD, FACC from the Pepin Heart Institute in Tampa, Fla, argued that ultrafiltration is an effective therapy for the management of acute decompensated HF, while Tom Heywood, MD, director of the congestive HF program and clinic at Scripps Clinic, La Jolla, Calif., argued that intravenous diuretics remain the best choice for treating this condition.
Ultrafiltration as a viable alternative HF therapy
The high hospital readmission rate of HF patients is a persistent problem, and strategies need to be implemented that will reduce readmission rates, Miller said here. “We have almost nothing now that changes the natural history of advanced heart failure once people are hospitalized,” he added.
According to Miller, intravenous diuretics are used in 88% of patients. However, he said, data from the Acute Decompensated Heart Failure National Registry (ADHERE) database indicated that length of stay, the number of days spent in the ICU and overall mortality were higher when intravenous diuretics were administered.
“Our most common therapy has some very questionable outcomes, and it is clearly not ideal for every patient,” Miller said. He argued that ultrafiltration is a viable alternative for patients with HF who did not respond to intravenous diuretics.
“With ultrafiltration, there is a pressure gradient between intravascular pressure and interstitial pressure, and across this pressure gradient, there is essentially an … ultrafiltration of plasma,” Miller said. “So you don’t change electrolytes like you do with very aggressive diuretics.”
The advantages of ultrafiltration for patients with HF include ambulation, greater and continuous fluid loss, adjustable filtration rate and hematocrit sensor, minimal electrolyte depletion, ease of care and patient comfort, according to Miller.
He also discussed the results of the AVOID trial, a prospective, randomized trial that compared ultrafiltration to intravenous diuretics, with time to readmission as the primary endpoint. While the results from this study have not been published yet, Miller said that he is hopeful that the data will demonstrate that ultrafiltration can be a better treatment option than intravenous diuretics.
Intravenous diuretics as the superior treatment option
Both Heywood and Miller cited results from the UNLOAD trial, which compared the safety and efficacy of ultrafiltration and intravenous diuretics. The primary endpoints of the UNLOAD trial were weight loss and dyspnea relief at 48 hours, but the researchers found that fewer patients were readmitted to the hospital after receiving ultrafiltration.
However, “with any trial, there are problems,” Heywood said, noting that the trial was of a smaller size and also unblinded, which could potentially lead to bias. “Ultrafiltration did take off more weight than diuretics, but there was no change in length of stay. The diuretic dose was 119 mg; was that enough to really diurese [patients]?”
Heywood also outlined results from the DOSE and CARRESS trials, which evaluated the use of either twice-daily or continuous administration of diuretics. These studies found that patients who received higher doses diuresed more than those who received lower amounts.
“Typically, patients receive 80 mg of Lasix twice a day with an infusion of 5 mg per hour,” Heywood said. “But the investigators of CARRESS had a stepwise approach to increasing diuretics so that patients who were diuretic resistant received escalating doses of diuretics [at nearly] 1 g of furosemide … which was much more than has typically been given to patients with congestive HF. This has really changed my practice, and I think it’s one reason that diuretics can be used more effectively, because we know now that higher doses need to be used.”
Heywood closed his argument by emphasizing the high cost of ultrafiltration: An ultrafiltration device costs $15,000 on average, with filters costing $1,000 and catheters $200, in addition to insertion costs. He also noted that ultrafiltration facilities will result in additional staff costs for an ICU.
Heywood concluded that does not belong in the HF treatment regimen, due to largely unproven benefits, expense, detriment to renal function and an increase in adverse events compared with diuretics.
For more information:
Miller, L, Heywood JT. Great debate: Does ultrafiltration have a place in the HF algorithm? Presented at: the American Association of Heart Failure Nurses Annual Conference; June 26-28, 2014; Los Angeles.
Disclosure: Miller reported no relevant financial disclosures. Heywood is a member of the speaker’s bureau for Actelion, Medtronic, St. Jude and Thoratec. He also reports receiving research support from Gambro and Medtronic, and fellowship support from St. Jude.