Loop diuretics VS venous ultrafiltration
in cardio-renal syndrome
Radek Debiec
SHO Renal Medicine
LGH Sept 2013
Heart failure
• Multi-factorial, heterogeneous syndrome where
signs and symptoms result from cardiac
dysfunction(1)
• Prevalence of estimated at 1–2% in the western
world; incidence 5–10/1000 *year (2)
• 1 year mortality 1960s =28%; mortality 1990s-28%
(1) Guidelines of the European Society of Cardiology.
(2) Clinical epidemiology of heart failure. Heart. 2007:93:1137-46.
(3) Long term trends in trends in the incidence of and survival with heart failure. N Engl J Med 2002;347:1397-402
Cardio-renal syndrome
• Syndrome where cardiac dysfunction leads to
deterioration of renal function
- present in around 30% of patients
- associated with longer hospital stay
- hospital readmission
- increased mortality
Cardiorenal Rescue Study in Acute Decompensated Heart Failure: Rationale and Design of CARRESS-HF, for the Heart Failure Clinical
Research Network. J. Card. Fail. 2012;18:176-182
CARRESS-HF Study - rationale
•Ultrafiltration is an acceptable option for patients
with congestion resistant to medical treatment
• Ultrafiltration is superior to iv diuretics in treatment
of acute exacerbation of heart failure
• ??? Is ultrafiltration better in a setting of initially
impaired renal function
Cardiorenal Rescue Study in Acute Decompensated Heart Failure: Rationale and Design of CARRESS-HF, for the Heart Failure Clinical
Research Network. J. Card. Fail. 2012;18:176-182
CARRESS-HF Study
•Multicentre, prospective, randomised, control trial
stepped pharmacological approach VS venous
ultrafiltration
•Acute decompensated heart failure and evidence of
renal injury
•Intention to treat principle
Cardiorenal Rescue Study in Acute Decompensated Heart Failure: Rationale and Design of CARRESS-HF, for the Heart Failure Clinical
Research Network. J. Card. Fail. 2012;18:176-18
CARRESS-HF inclusion criteria
• 2+ peripheral oedema
• JVP ≥10cm
• Pulmonary oedema/pleural effusions on
CXR
• Evidence of deterioration of renal function
(increase of 26.5mmol from baseline)
CARRESS-HF – therapeutic
intervention
• 2l fluid restriction and low salt diet
• Continuation of ACE-I, b-blockers, digoxin
Ultrafiltration of 200ml/hr +
discontinuation of iv diuretics
Stepped pharmacological
approach
Management was to be continued until clinical decongestion: JVP≤ 8cm
No more than trace of peripheral oedema and lack of orthopnoea
CARRESS-HF – end points
• Primary end-point: weight and creatinine
change after 96 hours from randomisation
• Secondary end points
-rate of clinical decongestion
-general well being scores
• Patients followed up until 60 days after the
study
CARRESS-HF – results
• 94 patients enrolled to each group
• Median age 68 years
• 75% males
• 85% HTN
• 66% DM
• IHD as a main cause of the heart failure
CARRESS-HF – results
• Study terminated earlier due to lack of
evidence of benefit and excess adverse
events in the ultrafiltration group
CARRESS-HF – results
CARRESS-HF – results
• No difference between time to discharge
• No difference in the rate of clinical decongestion
• No difference in the scores of dyspnoea or well
being
• Higher prevalence of adverse events in ultra
filtration group (72% vs 52%)
• Significantly higher mortality in the ultrafiltration
group at 60 day observation (17% vs 13%)
CARRESS-HF – positives
• Important clinical question
• Well designed
• Open protocol resembles real life clinical
scenario
CARRESS-HF – drawbacks
• ? Heterogeneity between centres
• Heterogeneous group of patients (aetiology;
systolic diastolic function impairment)
• 30% of ultrafiltration patients were treated
with diuretics afterwards, but before 96 hour
assessment
• Clinical vs biochemical outcomes
HF stupid questions
• Most sensitive symptom of HF?
• Most specific symptom of HF?
• Most specific sign of HF?
• 1 year and 5 year mortality in HF?
Management of acute decompensated heart failure CMAJ. 2007 March 13; 176(6): 797–805.
Thank you