Early ultrafiltration in patients with decompensated heart failure and diuretic resistance.

OBJECTIVES We sought to determine if ultrafiltration before intravenous (IV) diuretics in patients with decompensated heart failure and diuretic resistance results in euvolemia and early discharge without hypotension or worsening renal function. BACKGROUND Heart failure patients with renal insufficiency and diuretic resistance have increased hospital mortality and length of stay. Peripheral veno-venous ultrafiltration may re-establish euvolemia and diuretic responsiveness. METHODS Ultrafiltration was initiated within 4.7 +/- 3.5 h of hospitalization and before IV diuretics in 20 heart failure patients with volume overload and diuretic resistance (age 74.5 +/- 8.2 years; 75% ischemic disease; ejection fraction 31 +/- 15%) and continued until euvolemia. Re-evaluation was each hospital day, at 30 days, and at 90 days. RESULTS A total of 8,654 +/- 4,205 ml were removed with ultrafiltration. Twelve patients (60%) were discharged in < or =3 days. One patient was readmitted in 30 days. Weight (p = 0.006), Minnesota Living with Heart Failure scores (p = 0.003), and Global Assessment (p = 0.00003) improved after ultrafiltration and at 30 and 90 days. Median B-type natriuretic peptide levels decreased after ultrafiltration (from 1,230 pg/ml to 788 pg/ml) and at 30 days (815 pg/ml) (p = 0.035). Blood pressure, renal function, and medications were unchanged. CONCLUSIONS In heart failure patients with volume overload and diuretic resistance, ultrafiltration before IV diuretics effectively and safely decreases length of stay and readmissions. Clinical benefits persist at three months.