Ultrafiltration in Decompensated Heart Failure with Cardiorenal Syndrome
Patients with decompensated heart failure and cardiorenal syndrome were randomly assigned to ultrafiltration or diuretic therapy. Ultrafiltration was inferior to diuretics with respect to the primary end point, a bivariate measure of change in creatinine and body weight. The acute cardiorenal syndro...
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Published in | The New England journal of medicine Vol. 367; no. 24; pp. 2296 - 2304 |
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Main Authors | , , , , , , , , , , , , , , , , , , , , , |
Format | Journal Article |
Language | English |
Published |
Waltham, MA
Massachusetts Medical Society
13.12.2012
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Subjects | |
Online Access | Get full text |
ISSN | 0028-4793 1533-4406 1533-4406 |
DOI | 10.1056/NEJMoa1210357 |
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Abstract | Patients with decompensated heart failure and cardiorenal syndrome were randomly assigned to ultrafiltration or diuretic therapy. Ultrafiltration was inferior to diuretics with respect to the primary end point, a bivariate measure of change in creatinine and body weight.
The acute cardiorenal syndrome (type 1) is defined as worsening renal function in patients with acute decompensated heart failure.
1
It occurs in 25 to 33% of patients with acute decompensated heart failure and is associated with poor outcomes.
1
,
2
Multiple processes contribute to the development of the acute cardiorenal syndrome, including extrarenal hemodynamic changes, neurohormonal activation, intrarenal microvascular and cellular dysregulation, and oxidative stress.
1
In some cases, intravenous diuretics, which are often administered in patients with acute decompensated heart failure,
3
may directly contribute to worsening renal function.
1
,
4
,
5
The use of diuretics to treat persistent congestion after the onset . . . |
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AbstractList | Patients with decompensated heart failure and cardiorenal syndrome were randomly assigned to ultrafiltration or diuretic therapy. Ultrafiltration was inferior to diuretics with respect to the primary end point, a bivariate measure of change in creatinine and body weight.
The acute cardiorenal syndrome (type 1) is defined as worsening renal function in patients with acute decompensated heart failure.
1
It occurs in 25 to 33% of patients with acute decompensated heart failure and is associated with poor outcomes.
1
,
2
Multiple processes contribute to the development of the acute cardiorenal syndrome, including extrarenal hemodynamic changes, neurohormonal activation, intrarenal microvascular and cellular dysregulation, and oxidative stress.
1
In some cases, intravenous diuretics, which are often administered in patients with acute decompensated heart failure,
3
may directly contribute to worsening renal function.
1
,
4
,
5
The use of diuretics to treat persistent congestion after the onset . . . Ultrafiltration is an alternative strategy to diuretic therapy for the treatment of patients with acute decompensated heart failure. Little is known about the efficacy and safety of ultrafiltration in patients with acute decompensated heart failure complicated by persistent congestion and worsened renal function. We randomly assigned a total of 188 patients with acute decompensated heart failure, worsened renal function, and persistent congestion to a strategy of stepped pharmacologic therapy (94 patients) or ultrafiltration (94 patients). The primary end point was the bivariate change from baseline in the serum creatinine level and body weight, as assessed 96 hours after random assignment. Patients were followed for 60 days. Ultrafiltration was inferior to pharmacologic therapy with respect to the bivariate end point of the change in the serum creatinine level and body weight 96 hours after enrollment (P=0.003), owing primarily to an increase in the creatinine level in the ultrafiltration group. At 96 hours, the mean change in the creatinine level was -0.04±0.53 mg per deciliter (-3.5±46.9 μmol per liter) in the pharmacologic-therapy group, as compared with +0.23±0.70 mg per deciliter (20.3±61.9 μmol per liter) in the ultrafiltration group (P=0.003). There was no significant difference in weight loss 96 hours after enrollment between patients in the pharmacologic-therapy group and those in the ultrafiltration group (a loss of 5.5±5.1 kg [12.1±11.3 lb] and 5.7±3.9 kg [12.6±8.5 lb], respectively; P=0.58). A higher percentage of patients in the ultrafiltration group than in the pharmacologic-therapy group had a serious adverse event (72% vs. 57%, P=0.03). In a randomized trial involving patients hospitalized for acute decompensated heart failure, worsened renal function, and persistent congestion, the use of a stepped pharmacologic-therapy algorithm was superior to a strategy of ultrafiltration for the preservation of renal function at 96 hours, with a similar amount of weight loss with the two approaches. Ultrafiltration was associated with a higher rate of adverse events. (Funded by the National Heart, Lung, and Blood Institute; ClinicalTrials.gov number, NCT00608491.). Ultrafiltration is an alternative strategy to diuretic therapy for the treatment of patients with acute decompensated heart failure. Little is known about the efficacy and safety of ultrafiltration in patients with acute decompensated heart failure complicated by persistent congestion and worsened renal function.BACKGROUNDUltrafiltration is an alternative strategy to diuretic therapy for the treatment of patients with acute decompensated heart failure. Little is known about the efficacy and safety of ultrafiltration in patients with acute decompensated heart failure complicated by persistent congestion and worsened renal function.We randomly assigned a total of 188 patients with acute decompensated heart failure, worsened renal function, and persistent congestion to a strategy of stepped pharmacologic therapy (94 patients) or ultrafiltration (94 patients). The primary end point was the bivariate change from baseline in the serum creatinine level and body weight, as assessed 96 hours after random assignment. Patients were followed for 60 days.METHODSWe randomly assigned a total of 188 patients with acute decompensated heart failure, worsened renal function, and persistent congestion to a strategy of stepped pharmacologic therapy (94 patients) or ultrafiltration (94 patients). The primary end point was the bivariate change from baseline in the serum creatinine level and body weight, as assessed 96 hours after random assignment. Patients were followed for 60 days.Ultrafiltration was inferior to pharmacologic therapy with respect to the bivariate end point of the change in the serum creatinine level and body weight 96 hours after enrollment (P=0.003), owing primarily to an increase in the creatinine level in the ultrafiltration group. At 96 hours, the mean change in the creatinine level was -0.04±0.53 mg per deciliter (-3.5±46.9 μmol per liter) in the pharmacologic-therapy group, as compared with +0.23±0.70 mg per deciliter (20.3±61.9 μmol per liter) in the ultrafiltration group (P=0.003). There was no significant difference in weight loss 96 hours after enrollment between patients in the pharmacologic-therapy group and those in the ultrafiltration group (a loss of 5.5±5.1 kg [12.1±11.3 lb] and 5.7±3.9 kg [12.6±8.5 lb], respectively; P=0.58). A higher percentage of patients in the ultrafiltration group than in the pharmacologic-therapy group had a serious adverse event (72% vs. 57%, P=0.03).RESULTSUltrafiltration was inferior to pharmacologic therapy with respect to the bivariate end point of the change in the serum creatinine level and body weight 96 hours after enrollment (P=0.003), owing primarily to an increase in the creatinine level in the ultrafiltration group. At 96 hours, the mean change in the creatinine level was -0.04±0.53 mg per deciliter (-3.5±46.9 μmol per liter) in the pharmacologic-therapy group, as compared with +0.23±0.70 mg per deciliter (20.3±61.9 μmol per liter) in the ultrafiltration group (P=0.003). There was no significant difference in weight loss 96 hours after enrollment between patients in the pharmacologic-therapy group and those in the ultrafiltration group (a loss of 5.5±5.1 kg [12.1±11.3 lb] and 5.7±3.9 kg [12.6±8.5 lb], respectively; P=0.58). A higher percentage of patients in the ultrafiltration group than in the pharmacologic-therapy group had a serious adverse event (72% vs. 57%, P=0.03).In a randomized trial involving patients hospitalized for acute decompensated heart failure, worsened renal function, and persistent congestion, the use of a stepped pharmacologic-therapy algorithm was superior to a strategy of ultrafiltration for the preservation of renal function at 96 hours, with a similar amount of weight loss with the two approaches. Ultrafiltration was associated with a higher rate of adverse events. (Funded by the National Heart, Lung, and Blood Institute; ClinicalTrials.gov number, NCT00608491.).CONCLUSIONSIn a randomized trial involving patients hospitalized for acute decompensated heart failure, worsened renal function, and persistent congestion, the use of a stepped pharmacologic-therapy algorithm was superior to a strategy of ultrafiltration for the preservation of renal function at 96 hours, with a similar amount of weight loss with the two approaches. Ultrafiltration was associated with a higher rate of adverse events. (Funded by the National Heart, Lung, and Blood Institute; ClinicalTrials.gov number, NCT00608491.). Background Ultrafiltration is an alternative strategy to diuretic therapy for the treatment of patients with acute decompensated heart failure. Little is known about the efficacy and safety of ultrafiltration in patients with acute decompensated heart failure complicated by persistent congestion and worsened renal function. Methods We randomly assigned a total of 188 patients with acute decompensated heart failure, worsened renal function, and persistent congestion to a strategy of stepped pharmacologic therapy (94 patients) or ultrafiltration (94 patients). The primary end point was the bivariate change from baseline in the serum creatinine level and body weight, as assessed 96 hours after random assignment. Patients were followed for 60 days. Results Ultrafiltration was inferior to pharmacologic therapy with respect to the bivariate end point of the change in the serum creatinine level and body weight 96 hours after enrollment (P=0.003), owing primarily to an increase in the creatinine level in the ultrafiltration group. At 96 hours, the mean change in the creatinine level was -0.04±0.53 mg per deciliter (-3.5±46.9 μmol per liter) in the pharmacologic-therapy group, as compared with +0.23±0.70 mg per deciliter (20.3±61.9 μmol per liter) in the ultrafiltration group (P=0.003). There was no significant difference in weight loss 96 hours after enrollment between patients in the pharmacologic-therapy group and those in the ultrafiltration group (a loss of 5.5±5.1 kg [12.1±11.3 lb] and 5.7±3.9 kg [12.6±8.5 lb], respectively; P=0.58). A higher percentage of patients in the ultrafiltration group than in the pharmacologic-therapy group had a serious adverse event (72% vs. 57%, P=0.03). Conclusions In a randomized trial involving patients hospitalized for acute decompensated heart failure, worsened renal function, and persistent congestion, the use of a stepped pharmacologic-therapy algorithm was superior to a strategy of ultrafiltration for the preservation of renal function at 96 hours, with a similar amount of weight loss with the two approaches. Ultrafiltration was associated with a higher rate of adverse events. (Funded by the National Heart, Lung, and Blood Institute; ClinicalTrials.gov number, NCT00608491.) |
Author | Deswal, Anita Stevenson, Lynne W Ibarra, Jenny C LeWinter, Martin M Bart, Bradley A Chen, Horng H O'Connor, Christopher M Semigran, Marc J Lee, Kerry L Mascette, Alice M Ofili, Elizabeth O Velazquez, Eric J Felker, G. Michael Goldsmith, Steven R Hernandez, Adrian F Anstrom, Kevin J Redfield, Margaret M Givertz, Michael M Rouleau, Jean L McNulty, Steven E Bull, David A Braunwald, Eugene |
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DeBakey VA Medical Center and Baylor College of Medicine, Houston (A.D.); University of Montreal and Montreal Heart Institute, Montreal (J.L.R.); University of Vermont, Burlington (M.M.L.); Morehouse School of Medicine, Atlanta (E.O.O.); and the National Heart, Lung, and Blood Institute, Bethesda, MD (A.M.M.) – sequence: 2 givenname: Steven R surname: Goldsmith fullname: Goldsmith, Steven R organization: From the Hennepin County Medical Center, Minneapolis (B.A.B., S.R.G.) and Mayo Clinic, Rochester (M.M.R., H.H.C.) — both in Minnesota; Duke Clinical Research Institute (K.L.L., A.F.H., K.J.A., S.E.M., E.J.V., J.C.I.) and Duke University Medical Center and Duke Heart Center (C.M.O., G.M.F.) — both in Durham, NC; Brigham and Women's Hospital (M.M.G., L.W.S., E.B.) and Massachusetts General Hospital (M.J.S.) — both in Boston; University of Utah, Salt Lake City (D.A.B.); Michael E. 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DeBakey VA Medical Center and Baylor College of Medicine, Houston (A.D.); University of Montreal and Montreal Heart Institute, Montreal (J.L.R.); University of Vermont, Burlington (M.M.L.); Morehouse School of Medicine, Atlanta (E.O.O.); and the National Heart, Lung, and Blood Institute, Bethesda, MD (A.M.M.) – sequence: 17 givenname: Kevin J surname: Anstrom fullname: Anstrom, Kevin J organization: From the Hennepin County Medical Center, Minneapolis (B.A.B., S.R.G.) and Mayo Clinic, Rochester (M.M.R., H.H.C.) — both in Minnesota; Duke Clinical Research Institute (K.L.L., A.F.H., K.J.A., S.E.M., E.J.V., J.C.I.) and Duke University Medical Center and Duke Heart Center (C.M.O., G.M.F.) — both in Durham, NC; Brigham and Women's Hospital (M.M.G., L.W.S., E.B.) and Massachusetts General Hospital (M.J.S.) — both in Boston; University of Utah, Salt Lake City (D.A.B.); Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston (A.D.); University of Montreal and Montreal Heart Institute, Montreal (J.L.R.); University of Vermont, Burlington (M.M.L.); Morehouse School of Medicine, Atlanta (E.O.O.); and the National Heart, Lung, and Blood Institute, Bethesda, MD (A.M.M.) – sequence: 18 givenname: Steven E surname: McNulty fullname: McNulty, Steven E organization: From the Hennepin County Medical Center, Minneapolis (B.A.B., S.R.G.) and Mayo Clinic, Rochester (M.M.R., H.H.C.) — both in Minnesota; Duke Clinical Research Institute (K.L.L., A.F.H., K.J.A., S.E.M., E.J.V., J.C.I.) and Duke University Medical Center and Duke Heart Center (C.M.O., G.M.F.) — both in Durham, NC; Brigham and Women's Hospital (M.M.G., L.W.S., E.B.) and Massachusetts General Hospital (M.J.S.) — both in Boston; University of Utah, Salt Lake City (D.A.B.); Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston (A.D.); University of Montreal and Montreal Heart Institute, Montreal (J.L.R.); University of Vermont, Burlington (M.M.L.); Morehouse School of Medicine, Atlanta (E.O.O.); and the National Heart, Lung, and Blood Institute, Bethesda, MD (A.M.M.) – sequence: 19 givenname: Eric J surname: Velazquez fullname: Velazquez, Eric J organization: From the Hennepin County Medical Center, Minneapolis (B.A.B., S.R.G.) and Mayo Clinic, Rochester (M.M.R., H.H.C.) — both in Minnesota; Duke Clinical Research Institute (K.L.L., A.F.H., K.J.A., S.E.M., E.J.V., J.C.I.) and Duke University Medical Center and Duke Heart Center (C.M.O., G.M.F.) — both in Durham, NC; Brigham and Women's Hospital (M.M.G., L.W.S., E.B.) and Massachusetts General Hospital (M.J.S.) — both in Boston; University of Utah, Salt Lake City (D.A.B.); Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston (A.D.); University of Montreal and Montreal Heart Institute, Montreal (J.L.R.); University of Vermont, Burlington (M.M.L.); Morehouse School of Medicine, Atlanta (E.O.O.); and the National Heart, Lung, and Blood Institute, Bethesda, MD (A.M.M.) – sequence: 20 givenname: Jenny C surname: Ibarra fullname: Ibarra, Jenny C organization: From the Hennepin County Medical Center, Minneapolis (B.A.B., S.R.G.) and Mayo Clinic, Rochester (M.M.R., H.H.C.) — both in Minnesota; Duke Clinical Research Institute (K.L.L., A.F.H., K.J.A., S.E.M., E.J.V., J.C.I.) and Duke University Medical Center and Duke Heart Center (C.M.O., G.M.F.) — both in Durham, NC; Brigham and Women's Hospital (M.M.G., L.W.S., E.B.) and Massachusetts General Hospital (M.J.S.) — both in Boston; University of Utah, Salt Lake City (D.A.B.); Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston (A.D.); University of Montreal and Montreal Heart Institute, Montreal (J.L.R.); University of Vermont, Burlington (M.M.L.); Morehouse School of Medicine, Atlanta (E.O.O.); and the National Heart, Lung, and Blood Institute, Bethesda, MD (A.M.M.) – sequence: 21 givenname: Alice M surname: Mascette fullname: Mascette, Alice M organization: From the Hennepin County Medical Center, Minneapolis (B.A.B., S.R.G.) and Mayo Clinic, Rochester (M.M.R., H.H.C.) — both in Minnesota; Duke Clinical Research Institute (K.L.L., A.F.H., K.J.A., S.E.M., E.J.V., J.C.I.) and Duke University Medical Center and Duke Heart Center (C.M.O., G.M.F.) — both in Durham, NC; Brigham and Women's Hospital (M.M.G., L.W.S., E.B.) and Massachusetts General Hospital (M.J.S.) — both in Boston; University of Utah, Salt Lake City (D.A.B.); Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston (A.D.); University of Montreal and Montreal Heart Institute, Montreal (J.L.R.); University of Vermont, Burlington (M.M.L.); Morehouse School of Medicine, Atlanta (E.O.O.); and the National Heart, Lung, and Blood Institute, Bethesda, MD (A.M.M.) – sequence: 22 givenname: Eugene surname: Braunwald fullname: Braunwald, Eugene organization: From the Hennepin County Medical Center, Minneapolis (B.A.B., S.R.G.) and Mayo Clinic, Rochester (M.M.R., H.H.C.) — both in Minnesota; Duke Clinical Research Institute (K.L.L., A.F.H., K.J.A., S.E.M., E.J.V., J.C.I.) and Duke University Medical Center and Duke Heart Center (C.M.O., G.M.F.) — both in Durham, NC; Brigham and Women's Hospital (M.M.G., L.W.S., E.B.) and Massachusetts General Hospital (M.J.S.) — both in Boston; University of Utah, Salt Lake City (D.A.B.); Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston (A.D.); University of Montreal and Montreal Heart Institute, Montreal (J.L.R.); University of Vermont, Burlington (M.M.L.); Morehouse School of Medicine, Atlanta (E.O.O.); and the National Heart, Lung, and Blood Institute, Bethesda, MD (A.M.M.) |
BackLink | http://pascal-francis.inist.fr/vibad/index.php?action=getRecordDetail&idt=26727121$$DView record in Pascal Francis https://www.ncbi.nlm.nih.gov/pubmed/23131078$$D View this record in MEDLINE/PubMed |
BookMark | eNp1kc9vFCEYhompsdvq0auZxDTxMpZfMwwXE7O2rk3Vg_ZMGObDsmFghZma_veydldtk3KAAw9vno_3CB2EGAChlwS_JbhpT7-cXXyOmlCCWSOeoAVpGKs5x-0BWmBMu5oLyQ7RUc5rXBbh8hk6pIwwgkW3QKsrPyVt3XafXAyVC9UHMHHcQMh6gqFagU5Tda6dnxNUv9x0XS11GlxMELSvvt2GIcURnqOnVvsML3bnMbo6P_u-XNWXXz9-Wr6_rA0XzVRLTGxDOsF6LgyAlEPRaDnlVouO0r5rLLe9lQYkGLCW06GnLeN6IKYbgLJj9O4udzP3IwwGQjH3apPcqNOtitqp-zfBXasf8UaxVmIutgFvdgEp_pwhT2p02YD3OkCcsyKUSdw0xaqgrx-g6zinMvWeIoJsqVf_G_1V2X9yAU52gM5Ge5t0MC7_41pBRSmwcOyOMynmnMAq46Y_rZRBnFcEq23l6l7l5VX94NU--DF-ZzOOWQVYj49wvwHwlrhz |
CODEN | NEJMAG |
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ContentType | Journal Article |
Contributor | Lee, K Redfield, M Sheppard, R Mackendanz, S Parillo, J Lipinski, P Velazquez, E Bart, B Cai, J Deswal, A Kfoury, A Bull, D Stehlik, J Milbrandt, S Morrissette, J Greenberg, B Tracy, R Bozkurt, B Chadwick, L Virmani, R Desvigne-Nickens, P Mascette, A Abraham, W St Laurent, K Ofili, E Felker, M Rosenberg, R Hegeman, J Scanlon, J Johnson, M Penn, M Anstrom, K Tuinei, J Rose, E Anello, S Cocca-Spofford, D Rouleau, J Ibarra, J Johnson, J Fleurent, J Geyen, K Fleck, D Altmus, D Ducharme, A Hanovich, G Chee, A Ryan, J Cornell, E Brown, H LeWinter, M Agresti, A Sharp, J Collins, I O'Connor, C Barry, M Rowen, M Kennedy, K Berg, J Brinegar, P Humbert, J McNamara, D Steidley, E Gatzke, J Cross, J Vaughan, D Keleti, J Brooks, K Semigran, M Givertz, M Hernandez, A McNulty, S Kaping, B Boyle, R Boddicker, K DeNofrio, D Braunwald, E Adams, P Potash, A Stevenson, L Goldsmith, S Knight, B Lizzul, A Miller, L Rohrback, K Lapointe, N Schuchard, T Meldrum, P Anand, I Estep, J Taff, E Barbagelata, A Slawksy, M |
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Copyright | Copyright © 2012 Massachusetts Medical Society. All rights reserved. 2014 INIST-CNRS Copyright © 2012 Massachusetts Medical Society. 2012 |
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Keywords | Heart failure Medicine Cardiovascular disease Ultrafiltration Heart disease Syndrome |
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Snippet | Patients with decompensated heart failure and cardiorenal syndrome were randomly assigned to ultrafiltration or diuretic therapy. Ultrafiltration was inferior... Ultrafiltration is an alternative strategy to diuretic therapy for the treatment of patients with acute decompensated heart failure. Little is known about the... Background Ultrafiltration is an alternative strategy to diuretic therapy for the treatment of patients with acute decompensated heart failure. Little is known... |
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SubjectTerms | Aged Algorithms Biological and medical sciences Cardio-Renal Syndrome - etiology Cardio-Renal Syndrome - therapy Cardiology. Vascular system Creatinine - blood Diuretics - adverse effects Diuretics - therapeutic use Drug therapy Female General aspects Heart Heart failure Heart Failure - complications Heart Failure - drug therapy Heart Failure - mortality Heart Failure - therapy Heart failure, cardiogenic pulmonary edema, cardiac enlargement Humans Infusions, Intravenous Male Medical sciences Middle Aged Ultrafiltration - adverse effects Weight Loss - drug effects |
Title | Ultrafiltration in Decompensated Heart Failure with Cardiorenal Syndrome |
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