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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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Loop diuretics VS venous ultrafiltration in cardio-renal syndrome
Radek DebiecSHO Renal MedicineLGH Sept 2013
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
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
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
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
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)
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
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
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
CARRESS-HF – results
• Study terminated earlier due to lack of
evidence of benefit and excess adverse
events in the ultrafiltration group
CARRESS-HF – results
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%)
CARRESS-HF – positives
• Important clinical question
• Well designed
• Open protocol resembles real life clinical
scenario
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
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.
Thank you