Ultrafiltration

This article appeared in the Summer 2006 issue of Cardiovascular Update.

Ultrafiltration: An Innovative Therapeutic Approach to Heart Failure

BWH provides a novel therapeutic approach for patients hospitalized with advanced heart failure

Brigham and Women’s Hospital (BWH) heart failure specialists are offering ultrafiltration, a novel therapy for patients hospitalized with decompensated heart failure, poor renal function, and volume overload. BWH specialists have the most extensive clinical and research experience in the New England area with this innovative technology.

Ultrafiltration has been available therapeutically for some time, but this new, patient-friendly system uses peripheral access rather than a central line and can be used at the bedside rather than in an ICU setting. The new system can remove up to 500 cc of fluid per hour, and physicians can titrate the rate of fluid removal and the length of treatment, generally over a period of hours to days. Following ultrafiltration therapy, patients can usually be managed with standard oral diuretics.

BWH was a study site for UNLOAD, a prospective, randomized, multicenter trial designed to test the safety and efficacy of the new ultrafiltration system. The goal of UNLOAD was to determine whether ultrafiltration therapy is equivalent to or better than conventional therapy (intravenous diuretics), and the results were reported at the American College of Cardiology Scientific Sessions in March. The study findings confirmed both short- and longterm benefits of ultrafiltration therapy.

• At 48 hours, patients treated with ultrafiltration experienced greater weight and fluid loss as compared with those receiving standard therapy, without any adverse impact on renal function.
• At 90 days after hospital discharge, the ultrafiltration group experienced reductions in numbers of patients requiring rehospitalization for heart failure, total number of rehospitalizations, total days of rehospitalization, and emergency or unscheduled office visits as compared with the standard care group.

UNLOAD demonstrated that ultrafiltration is safe and effective in reducing volume overload and improving outcomes. However, questions as to how best to use this approach remain unanswered. What group of patients will benefit most? What are the optimum rate and duration of fluid removal? What other therapies may be beneficial for patients with decompensated heart failure and volume overload? Does ultrafiltration have value as a prophylactic therapy for non-hospitalized patients with heart failure and chronic kidney disease?

Michael M. Givertz, MD, Co-Director of BWH’s Cardiomyopathy and Heart Failure Program, says “Some of these questions may be answered when the study is published; others may await the completion of future trials. We believe at this time that ultrafiltration should probably not be used as a routine upfront treatment strategy, but rather to benefit patients who have been hospitalized and are not responding well to standard therapy.”

The Advanced Heart Disease Program has applied for designation as one of eight sites in a national heart failure clinical research network. The five-year program provides funding to investigate novel approaches to heart failure. One proposal submitted by the BWH group targets heart failure patients admitted to the hospital with volume overload and evidence of renal dysfunction, and would randomize them to receive one of three different strategies – standard IV diuretics, ultrafiltration, or a new pharmacologic agent.

Dr. Givertz concludes, “Decompensated heart failure is the most common reason for hospitalization among Medicare patients, and inability to achieve optimum fluid control in this setting is an independent predictor of poor outcome. We are confident that ultrafiltration will prove to be a valuable strategy, and we will continue to investigate this and other promising treatments to benefit patients with decompensated heart failure, impaired renal function, and volume overload.”