Diuretic ResistanceWhat is it by paulj


									 Diuretic Resistance: What is it?

• Inadequate response to diuretic
• Represents an extension of
  cardiorenal syndrome
• Failure to respond to IV loop diuretics
• Decreased efficacy of diuretics with
  prolonged treatment
  Disadvantages of Conventional
        Diuretic Therapy in CHF

• Has potential to activate
  neurohormonal vasoconstrictor
• Can cause electrolyte abnormalities
• Has been associated with increased
  risk of morbidity and mortality
• Can lead to development of pre-renal
• May result in diuretic resistance
  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
  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
      Multidisciplinary Approach to
            Successful Adoption of
• Many departments/personnel should
  be educated and involved
  –   ICU
  –   IV team
  –   Nephrologists
  –   Other cardiologists
  –   Nurses
  –   Emergency department
  –   Telemetry unit
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
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
      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
      UNLOAD: Primary Endpoint

• 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
   UNLOAD: Secondary Endpoint

• 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

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