Ultrafiltration Adds to Options for Hard-to-Treat Heart Failure

Indeed, if it is assumed that conventional supplies are used for ultrafiltration instead, this therapy becomes less expensive than standard care at 90 days, at about $11,300 versus $11,600 (Am. J. Cardiol. 2010;105:1504-5). In other words, he said, "if you use the nephrologists’ devices ... it seems to be cost effective."

A final question is whether non-nephrologists should be trained in the use of ultrafiltration. At present, most of the major cardiovascular professional societies recommend consultation with a nephrologist when undertaking this therapy.

"Ultrafiltration has the potential for greatly impacting our therapeutic approach to patients in heart failure," Dr. Kazory concluded. "A number of questions still exist."

"For now, ultrafiltration should be used with the strict [eligibility] criteria that have been used in the trials so far," he added. "You can use the UNLOAD trial or EUPHORIA trial or others to see what the criteria are; they are fairly narrow."

A related study, reported at the congress by Dr. John N. Nanas of the University of Athens, found ultrafiltration to be superior to inotropes for reducing the risk of hospitalization in patients with decompensated heart failure.

"In advanced heart failure patients with diuretic resistance who are not responding to standard measures and are not candidates for cardiac transplantation or long-term mechanical assistance, fluid removal by ultrafiltration seems a reasonable solution," he commented.

Dr. Nanas and colleagues studied 40 consecutive patients with heart failure and severe decompensation. Half were treated with intermittent inotrope infusion and half were treated with intermittent ultrafiltration.

"All patients in both groups were very symptomatic" at baseline, he noted, with similarly low mean systolic blood pressure (95-98 mm Hg), left ventricular ejection fraction (22%-25%), and cardiac index (1.7-1.8 L/min/m2), and similarly high mean pulmonary capillary wedge pressure (26-29 mm Hg) and levels of B-type natriuretic peptide (1,639-2,237 pg/mL).

But those in the ultrafiltration group had significantly higher mean right atrial pressure (19 vs. 14 mm Hg) and serum creatinine levels (3.1 vs. 1.6 mg/dL), suggesting that they were somewhat sicker.

Study results showed that the two groups did not differ with respect to mortality rates during follow-up, according to Dr. Nanas.

However, the risk of hospitalization was more than tripled in the inotrope group compared with the ultrafiltration group, a highly significant difference (hazard ratio 3.5). Patients treated with inotropes were also three times as likely to make scheduled visits.

"Ultrafiltration might be an important therapeutic option for treating congestion in heart failure patients," Dr. Nanas concluded. "Further evaluation in prospective, randomized clinical studies is mandatory for acute decompensated heart failure, but especially for advanced heart failure."

Dr. Kazory reported having no conflicts of interest related to his presentation. Dr. Nanas reported having no conflicts of interest related to the study.