No benefit to ultrafiltration for treatment of acute cardiorenal syndrome (CARRESS-HF)

Clinical question

Does ultrafiltration therapy result in improved diuresis in hospitalized patients with decompensated heart failure and worsening renal function?

Bottom line

For hospitalized patients with acute decompensated heart failure and worsening renal function, intravenous diuretic therapy is superior to ultrafiltration for preserving renal function while providing similar weight reduction. Moreover, ultrafiltration is a costly and invasive therapy that is associated with more adverse events. LOE = 1b

Reference

Bart BA, Goldsmith SR, Lee KL, et al, for the Heart Failure Clinical Research Network. Ultrafiltration in decompensated heart failure with cardiorenal syndrome. N Engl J Med 2012;367(24):2296-2304.

Study Design

Randomized controlled trial (nonblinded)

Funding Source

Government

Allocation

Concealed

Setting

Inpatient (any location)

Synopsis

In hospitalized patients with acute cardiorenal syndrome (acute heart failure exacerbation and worsening renal function), ultrafiltration is an alternative strategy for fluid removal. These investigators used concealed allocation to randomize 188 of these patients to receive either ultrafiltration therapy or pharmacologic therapy with intravenous diuretics for fluid removal. Patients with severe renal impairment were excluded (creatinine >3.5 mg/dL [> 309.4 umol/L]). In the pharmacologic therapy group, diuretic doses were adjusted as needed to achieve a urine output of 3 liters to 5 liters per day. In the ultrafiltration group, fluid removal was performed at a rate of 200 mL per hour. Both therapies were continued until symptoms and signs of congestion were optimally reduced. Participants had a median age of 68 years and a median ejection fraction of 33%. More than 75% had been hospitalized for heart failure within the previous year. Analysis was by intention to treat. The primary endpoint was change in weight and change in serum creatinine level at 96 hours postrandomization. Although there was no significant difference in weight loss between the 2 groups at 96 hours, there was a significant increase in serum creatinine level in the ultrafiltration group (an increase of 0.23 mg/dL [20.3 umol/L] in ultrafiltration group vs a decrease in creatinine of 0.04 mg/dL [3.5 umol/L] in diuretic group; P = .003). Despite the worsened renal function in the short-term, there were no differences in long-term outcomes between the 2 groups, including mortality and rehospitalization within 60 days. Finally, ultrafiltration patients were more likely to experience serious adverse events (72% vs 57%; P = .03) during the 60-day follow-up period, mainly due to kidney failure and intravenous catheter-related complications. Although the outcomes assessed were objective, the nonmasked methodology of this study may have introduced a bias on the part of the investigators as to how aggressively they pursued the 2 therapies.