Number 9
The management of patients with the acute cardiorenal syndrome (CRS) in patients with acute decompensated heart failure (ADHF) is examined in this paper that I rank the 9th best in 2012.
The management of patients with the acute cardiorenal syndrome (CRS) in patients with acute decompensated heart failure (ADHF) is examined in this paper that I rank the 9th best in 2012.
Bart et al published
the Cardiorenal Rescue Study in Acute Decompensated Heart Failure (CARRESS-HF)online Nov 6, 2012 in NEJM (pubmed link).
Bart et al state: "Potential advantages of ultrafiltration
include greater control over the rate and volume of fluid removal, greater net
loss of sodium, and less neurohormonal activation. Current treatment guidelines
state that ultrafiltration is a reasonable approach in patients with congestion
that is not responding to medical therapy (class IIa, level of evidence B)."
The research question was - is UF better than intensive
diuretic therapy for renal outcomes in patients with ADHF? An open label RCT was performed to examine this question.
First some more background ...
Ronco has divided CRS into 5 subtypes:
- Type 1 ADHF leads to AKI.
- Type 2 CHF causes CKD.
- Type 3 AKI leads to acute cardiac dysfunction such as arrhythmia or heart failure.
- Type 4 Primary CKD causes cardiac dysfunction.
- Type 5 Systemic disease such as sepsis or SLE leads to combined cardiac and renal dysfunction.
Bock and Gottlieb stated it well when they wrote in Circulation "Maintenance of
blood volume, vascular tone, and hemodynamic stability depends on a set of
elegant interactions between the heart and kidney. For some time, physicians
have recognized that severe dysfunction in either of these organs seldom
occurs." in isolation.
CRS type 1 occurs in 25 to 33% of patients with acute
decompensated heart failure and is associated with poor outcomes. It is now
widely recognized that the etiology of CRS is multifactorial, including
extrarenal hemodynamic changes, neurohormonal activation, intrarenal
microvascular and cellular dysregulation, and oxidative stress.
In the Bart study, 88 patients with acute decompensated heart failure,
worsened renal function, and persistent congestion were randomized to a strategy of stepped
pharmacologic therapy (94 patients) or ultrafiltration (94 patients). The median age of the population was 68
years, 75% of the patients were men, 85% had hypertension, and 66% had diabetes
mellitus. The median ejection fraction was 33%.
"Ultrafiltration
was performed [using the CHF solutions device] at a fluid-removal rate of 200 ml per hour. The addition of
intravenous vasodilators or positive inotropic agents after randomization was
prohibited unless they were deemed to be necessary as rescue therapy. For
patients assigned to stepped pharmacologic therapy, intravenous diuretics were
used to manage signs and symptoms of congestion. Investigators were encouraged
to decrease doses, increase doses, or continue current doses of diuretics as
necessary to maintain a urine output of 3 to 5 liters per day."
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.
The
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), because
of 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%,
The main limitations of the study was that it was not blinded - investigator biases could have impacted
on the results, the limited sample size, and the absence of hard endpoints in the outcome measures.
Bottom-line: Intensive intravenous diuretic therapy works just as well and is better tolerated than the bedside CHF solutions bedside ultrafiltration strategy.
