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Loop diuretics VS venous ultrafiltration in cardio-renal syndrome Radek Debiec SHO Renal Medicine LGH Sept 2013

Loop diuretics VS venous ultrafiltration in cardio-renal syndrome

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Loop diuretics VS venous ultrafiltration in cardio-renal syndrome. Radek Debiec SHO Renal Medicine LGH Sept 2013. Heart failure. Multi-factorial, heterogeneous syndrome where signs and symptoms result from cardiac dysfunction (1) - PowerPoint PPT Presentation

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Page 1: Loop diuretics VS venous  ultrafiltration  in cardio-renal syndrome

Loop diuretics VS venous ultrafiltration in cardio-renal syndrome

Radek DebiecSHO Renal MedicineLGH Sept 2013

Page 2: Loop diuretics VS venous  ultrafiltration  in cardio-renal syndrome

Heart failure• Multi-factorial, heterogeneous syndrome where signs

and symptoms result from cardiac dysfunction(1)

•  Prevalence of estimated at 1–2% in the western

world; incidence 5–10/1000 *year (2)

• 1 year mortality 1960s =28%; mortality 1990s-28%

(1) Guidelines of the European Society of Cardiology.

(2) Clinical epidemiology of heart failure. Heart. 2007:93:1137-46.

(3) Long term trends in trends in the incidence of and survival with heart failure. N Engl J Med 2002;347:1397-402

Page 3: Loop diuretics VS venous  ultrafiltration  in cardio-renal syndrome

Cardio-renal syndrome• Syndrome where cardiac dysfunction leads to

deterioration of renal function

- present in around 30% of patients

- associated with longer hospital stay

- hospital readmission

- increased mortality

Cardiorenal Rescue Study in Acute Decompensated Heart Failure: Rationale and Design of CARRESS-HF, for the Heart Failure Clinical

Research Network. J. Card. Fail. 2012;18:176-182

Page 4: Loop diuretics VS venous  ultrafiltration  in cardio-renal syndrome

CARRESS-HF Study - rationale

•Ultrafiltration is an acceptable option for patients

with congestion resistant to medical treatment

• Ultrafiltration is superior to iv diuretics in treatment of

acute exacerbation of heart failure

• ??? Is ultrafiltration better in a setting of initially

impaired renal function

Cardiorenal Rescue Study in Acute Decompensated Heart Failure: Rationale and Design of CARRESS-HF, for the Heart Failure Clinical

Research Network. J. Card. Fail. 2012;18:176-182

Page 5: Loop diuretics VS venous  ultrafiltration  in cardio-renal syndrome

CARRESS-HF Study•Multicentre, prospective, randomised, control trial

stepped pharmacological approach VS venous

ultrafiltration

•Acute decompensated heart failure and evidence

of renal injury

•Intention to treat principle

Cardiorenal Rescue Study in Acute Decompensated Heart Failure: Rationale and Design of CARRESS-HF, for the Heart Failure Clinical

Research Network. J. Card. Fail. 2012;18:176-18

Page 6: Loop diuretics VS venous  ultrafiltration  in cardio-renal syndrome

CARRESS-HF inclusion criteria

• 2+ peripheral oedema

• JVP ≥10cm

• Pulmonary oedema/pleural effusions on

CXR

• Evidence of deterioration of renal function

(increase of 26.5mmol from baseline)

Page 7: Loop diuretics VS venous  ultrafiltration  in cardio-renal syndrome

CARRESS-HF – therapeutic intervention

• 2l fluid restriction and low salt diet

• Continuation of ACE-I, b-blockers, digoxin

Ultrafiltration of 200ml/hr +

discontinuation of iv diuretics

Stepped pharmacological approach

Management was to be continued until clinical decongestion: JVP≤ 8cm No more than trace of peripheral oedema and lack of orthopnoea

Page 8: Loop diuretics VS venous  ultrafiltration  in cardio-renal syndrome

CARRESS-HF – end points• Primary end-point: weight and creatinine change

after 96 hours from randomisation

• Secondary end points

-rate of clinical decongestion

-general well being scores

• Patients followed up until 60 days after the study

Page 9: Loop diuretics VS venous  ultrafiltration  in cardio-renal syndrome

CARRESS-HF – results

• 94 patients enrolled to each group

• Median age 68 years

• 75% males

• 85% HTN

• 66% DM

• IHD as a main cause of the heart failure

Page 10: Loop diuretics VS venous  ultrafiltration  in cardio-renal syndrome

CARRESS-HF – results

• Study terminated earlier due to lack of

evidence of benefit and excess adverse

events in the ultrafiltration group

Page 11: Loop diuretics VS venous  ultrafiltration  in cardio-renal syndrome

CARRESS-HF – results

Page 12: Loop diuretics VS venous  ultrafiltration  in cardio-renal syndrome

CARRESS-HF – results• No difference between time to discharge

• No difference in the rate of clinical decongestion

• No difference in the scores of dyspnoea or well being

• Higher prevalence of adverse events in ultra filtration

group (72% vs 52%)

• Significantly higher mortality in the ultrafiltration

group at 60 day observation (17% vs 13%)

Page 13: Loop diuretics VS venous  ultrafiltration  in cardio-renal syndrome

CARRESS-HF – positives

• Important clinical question

• Well designed

• Open protocol resembles real life clinical

scenario

Page 14: Loop diuretics VS venous  ultrafiltration  in cardio-renal syndrome

CARRESS-HF – drawbacks• ? Heterogeneity between centres

• Heterogeneous group of patients (aetiology;

systolic diastolic function impairment)

• 30% of ultrafiltration patients were treated with

diuretics afterwards, but before 96 hour

assessment

• Clinical vs biochemical outcomes

Page 15: Loop diuretics VS venous  ultrafiltration  in cardio-renal syndrome

HF stupid questions

• Most sensitive symptom of HF?

• Most specific symptom of HF?

• Most specific sign of HF?

• 1 year and 5 year mortality in HF?

Management of acute decompensated heart failure CMAJ. 2007 March 13; 176(6): 797–805.

Page 16: Loop diuretics VS venous  ultrafiltration  in cardio-renal syndrome

Thank you