Diuretic Resistance: What is it

1
Diuretic Resistance What is it?

• Inadequate response to diuretic therapy
• Represents an extension of cardiorenal syndrome
• Failure to respond to IV loop diuretics
• Decreased efficacy of diuretics with prolonged
  treatment

2
Disadvantages of Conventional Diuretic Therapy in
CHF

• Has potential to activate neurohormonal
  vasoconstrictor systems
• Can cause electrolyte abnormalities
• Has been associated with increased risk of
  morbidity and mortality
• Can lead to development of pre-renal azotemia
• May result in diuretic resistance

3
Ultrafiltration in CHF Patients Principles and
Benefits

• Provides an additional modality for fluid removal
• Allows for a predictable amount of fluid to be
  removed
• Rapidly removes salt and water (up to 500 cc/hr)
• Safer than diuretics because removal of salt and
  water is isotonic

4
Use of Ultrafiltration in CHF

• Ultrafiltration can be beneficial in
• Acutely decompensated CHF patients with obvious
  volume overload
• Diuretic-resistant patients
• Renally impaired patients
• Hospitalized heart failure patients

5
Multidisciplinary Approach to Successful Adoption
of Ultrafiltration

• Many departments/personnel should be educated and
  involved
• ICU
• IV team
• Nephrologists
• Other cardiologists
• Nurses
• Emergency department
• Telemetry unit

6
Early Ultrafiltration in Patients with
Decompensated Heart Failure and Observed
Resistance to Intervention with Diuretic Agents
(EUPHORIA) Trial

• Single center, prospective trial (n 20)
  comparing the safety of reducing length of
  hospitalization by early ultrafiltration compared
  with IV diuretics and/or vasoactive drugs in
  decompensated CHF patients with diuretic
  resistance
• Early ultrafiltration decreased hospital length
  of stay and number of re-hospitalizations
  clinical benefits sustained up to 90 days

7
Relief for Acutely Fluid-Overloaded Patients with
Decompensated Congestive Heart Failure
(RAPID-CHF) Trial

• Multicenter, randomized trial comparing the
  effects of ultrafiltration (n 20) to usual care
  (n 20) in hospitalized patients with
  decompensated HF
• Early ultrafiltration was well-tolerated and
  resulted in significantly greater weight loss and
  net fluid removal compared to usual care

8
Ultrafiltration versus IV Diuretics for Patients
Hospitalized for Acute Decompensated Congestive
Heart Failure (UNLOAD) Trial

• Prospective, randomized trial comparing
  ultrafiltration and aggressive IV diuretic
  therapy in acutely decompensated HF patients
• Patients had to have 2 signs of volume
  overload, be randomized within 24 hours of
  admission, be hemodynamically stable, and have no
  prior treatment with IV vasoactive drugs

9
UNLOAD Primary Endpoint Results

• At 48 hours, significantly greater amount of
  weight loss seen with ultrafiltration (5 kg vs
  3.1 kg) as compared to IV diuretics
• Dypsnea scores significant and similar in both
  groups

10
UNLOAD Secondary Endpoint Results

• Net fluid loss at 48 hours greater in
  ultrafiltration group than standard care group
• At 90 days, ultrafiltration resulted in
• 48 ? in of patients requiring
  re-hospitalizations for HF
• 53 ? in absolute of re-hospitalizations
• 62 ? in length of re-hospitalizations
• 53 ? in of emergency department or unscheduled
  office visits for HF