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Ultrafiltration as a Therapy Option
for Diuretic Resistance:
Inpatient & Outpatient
Case Studies
Beth Davidson DNP, ACNP, CCRN
Kristi Hayes MSN, FNP
St. Thomas Hospital
Nashville, TN
Objectives

Review the epidemiology and pathophysiology
of diuretic-resistant, acute heart failure

Identify volume overload treatment options

Review/discuss case studies of diureticresistance and use of ultrafiltration for volume
removal
Epidemiology of Heart Failure (HF)
Population
Group
Total
population
Prevalence
Incidence
Mortality
Hospital
Discharges
5,000,000
550,000
57,218
1,093,000
Cost
$29.6
billion
 Heart
failure is a major public health problem resulting in
substantial morbidity and mortality
 Major
cost-driver of HF is high incidence of
hospitalizations
 JCAHO
has initiated quality care indicators for hospitalized
HF patients
 CMS
reimbursement for readmission < 30 days = $ 0
Insult
Cardiac
Dysfunction
Neurohormonal
Activation
Decompensated
Heart Failure
LV Remodeling
Hemodynamic
Decompensation
 RAAS/SNS
 Catecholamine
 Preload
 Endothelin
 Afterload
Renal
Vasoconstriction/
Fluid Retention
Fluid Overload
Symptoms
Morbidity
Death
↓ Cardiac Output
ACC/AHA Guidelines:
Management of Fluid Status

Patients should not be discharged from the
hospital until a stable and effective diuretic
regimen is established, and ideally, not until
euvolemia is achieved

Patients who are sent home before these goals
are reached are at high risk of recurrence of
fluid retention and early readmission because
unresolved edema may itself attenuate the
response to diuretics
Diuretics
Current “Standard of Care”
Diuretics…
More diuretics...
Still more diuretics…
Change in Weight During Hospitalization
Outcomes with Standard Care
Enrolled Discharges (%)
Evidence of Incomplete Relief From Congestion
Nearly 50% of ADHF
27%
patients discharged with
weight gain or losing
26%
less than 5 lbs
30
25
20
13%
15
10
7%
16%
6%
3%
5
0
(<-20)
(–20 to –15) (-15 to –10) (–10 to –5) (–5 to 0)
(0 to 5)
Change in Weight (lbs)
(5 to 10)
2%
(>10)
Outcomes with Standard Care
Hospital
Readmissions
Mortality
50%
50%
33%
37%
20%
30
Days
12%
3
6
Months Months
30
12
Days Months
5
Years
Patients have persistently high event rates despite use of
evidence-based therapies…
Effect of Loop Diuretics on RAAS in Cardiac Failure
CARDIAC
FAILURE
Left Ventricular
Dysfunction
Loop Diuretic
Inhibition of Macula
Densa
Cardiac
Remodeling and
Fibrosis
Increased ReninAngiotensin
Increased
Aldosterone
Current Options May Have
Undesirable Clinical Impacts

Favorable aspects of diuretic therapy


Increases urine output; reduces total body volume
Adverse aspects of diuretic therapy
•
Direct activation of renin-angiotensin-aldosterone system
•
Enhanced myocardial aldosterone uptake
•
Loss of K, Mg, Ca, secondary myocyte Ca loading
•
Indirect reduction of cardiac output
•
Increased total systemic vascular resistance
•
Reduced natriuresis and GFR
•
Associated with increased morbidity and mortality
Diuretics and ADHF

No consensus dosing guidelines

No common definition of diuretic resistant

No long-term studies of diuretic therapy for the
treatment of heart failure

No outcomes data regarding morbidity and
mortality
14):39-42.
Diuretic Resistance

Can be described as a clinical state in which the
diuretic response is diminished or lost before the
therapeutic goal of relief from edema has been
reached

Affects 20%–30% of patients with HF
Diuretic Resistance: Two Types

“Braking” phenomenon


A decrease in response to a diuretic after the first
dose has been administered
Long-term tolerance

Tubular hypertrophy to compensate for salt loss
Diuretic Therapeutic Dilemma

Diminished renal function and concurrent
sodium and water retention in ADHF presents a
therapeutic dilemma with regard to sub-maximal
diuretic therapy

Fluid removal by ultrafiltration may be
recommended in this clinical setting
What is Aquapheresis?
 Method to safely achieve euvolemia
 Simplified form of ultrafiltration
 Inpatient or outpatient settings
 ICU, CCU, MICU, telemetry, step-down,
observation, ED, outpatient clinics
 Peripheral or central venous access
 Flexible access sites and catheters
 Diverse physician prescription
 Highly automated operation
 No clinically significant impact on electrolyte
balance, blood pressure, or heart rateor heart
rate*
Fluid Removal by Ultrafiltration
 Ultrafiltration can remove
fluid from the blood at the
same rate that fluid can be
naturally recruited from the
tissue
 The transient removal of
blood illicits compensatory
mechanisms, termed plasma
or intravascular refill (PR),
aimed at minimizing this
reduction
Interstitial
Space (edema)
Na
P
H2O
Na
UF
K
K
PR
P
Na Vascular
Space
Vascular
Space
Na
The EUPHORIA Study



Single center, prospective study, 20 patients
Initial UF within 12 hours of hospitalization and
before any significant administration of IV
diuretics and/or vasoactive drugs
Results



Removed an average of 8.6 liters of fluid
60% of patients were discharged in ≤ 3 days
Average hospitalization was 3.7 days
The EUPHORIA Study

Rehospitalization

In the three months preceding ultrafiltration:
10 hospitalizations in 9 patients

After ultrafiltration:
1 readmission for ADHF within 30 days
The UNLOAD Study



200 patients (100 each arm) randomized, multicenter study comparing ultrafiltration versus
standard care for acutely decompensated
patients
Superior salt & water removal/weight loss
At 48 hours, ultrafiltration demonstrated
38% greater weight loss
 28% greater net fluid loss


At 90 days, reduced readmissions
50% reduction in re-hospitalization episodes
 63% reduction in total re-hospitalized days
 52% reduction in emergency department or clinic
visits

ACC/AHA Guidelines:
Class IIa, Level of Evidence B
I IIa IIb III
Ultrafiltration is reasonable for patients with
refractory congestion not responding to medical
therapy
Aquapheresis is now ranked HIGHER in the
Level of Evidence than:
- salt restriction
- strict I/Os
- higher doses of loop diuretics
- addition of a second diuretic
- continuous infusion of a loop diuretic
- vasodilators – IV nitroglycerin, nesiritide
- IV inotropes
All of these are Level of Evidence: C
Case Study







68 yo WM
Diastolic heart failure
Ischemic heart disease
 CAB 4/06
HTN
Afibrillation/flutter
Anemia
Hospitalized every
6 months for
exacerbation
Case Study: Inpatient Therapy

Inpatient ultrafiltration – January 2010
Access issues – extended length catheter (ELC)
 Creatinine 1.5
2.9 after 48 hrs of treatment


Creatinine 1.6 at discharge
Therapy/ACEI discontinued
 Diuresed with IV lasix continuous infusion
 LOS = 5 days
 Net volume loss = 7 kgs

Case Study: Outpatient Therapy

1st treatment- 2/22/10
ELC catheter
 1850 cc ultrafiltrate over 7 hrs
 Wt loss = 2 lbs
 Serum Cre = 1.8 pre and at termination of therapy
 Hct 29 – sent home with hemoccult cards


Positive x 3- referred to PCP – no follow-up
Case Study: Outpatient Therapy


2nd treatment – 3/26/10
ELC catheter and 18 g peripheral IV


2130 ultrafiltrate over 6.5 hrs



Access issues!
Also treated with Lasix 240mg IV due to loss of time
waiting for access
Serum Cre = 1.7 pre and post termination of
therapy
Hct 26 - referred to Hematology
Saint Thomas Hospital:
Inpatient Outcomes




54 UF treatments from 5/1/08 – 6/1/10
Average treatment time = 37 hours, 28 minutes
Average fluid removal = 6.15 liters/circuit
Minimal adverse events
9 episodes of worsening renal insufficiency
 No significant electrolyte disturbances
 No significant hypotension
 1 asymptomatic, small apical pneumothorax
 6 minor bleeding episodes – epistaxis, line insertion
site, generalized “oozing”

Saint Thomas Hospital:
Inpatient Outcomes

Readmissions < 30 days





1 re-admitted with LOC changes
2 discharged to hospice
 ultrafiltration for palliation
1 patient, 5 re-admissions
 now on dialysis for volume control
 no readmits since dialysis except for recent hip fracture
1 expired within 90 days of readmission
1 patient, 2 re-admissions
 suspect non-compliance – eating Whopper at discharge!
Saint Thomas Hospital:
Outpatient Outcomes


1st outpatient treatment –
January 19, 2010
13 treatments – 7 pts




avg treatment time 5.79 hrs
avg volume removal 1.49 L
1 repeated hospitalization
 now on peritoneal
dialysis
1 deceased

1 ARF




patient did not follow
medication discharge
instructions
Effective in keeping pts
out of hospital > 30 days
Need more data
Pt satisfaction and QOL
are most important!
Advanced Heart Failure Clinic
Saint Thomas Hospital
Another satisfied customer…
Challenges and
Opportunities for Improvement




Early identification of patients that could benefit
from outpatient therapy to decrease readmission
within 30 days
Process improvement – timely, efficient IV
access to allow faster initiation of therapy
Patient education – medications, line care,
follow-up appointments, etc…
Anticoagulation – preserve integrity of circuit
Any questions?
Contact Information
Beth Davidson DNP, ACNP
[email protected]
Kristi Hayes MSN, FNP
[email protected]