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

2. 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

3. 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

4. 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

5. 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

6. 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)

7. 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

8. 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

9. 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

10. CARRESS-HF – results Study terminated earlier due to lack of evidence of benefit and excess adverse events in the ultrafiltration group

11. CARRESS-HF – results

12. 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%)

13. CARRESS-HF – positives Important clinical question Well designed Open protocol resembles real life clinical scenario

14. 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

15. 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.

16. Thank you