Division of Cardiology Duke University Medical Center Durham NC.
Duke Clinical Research Institute Durham NC.
J Am Heart Assoc. 2020 Dec 15;9(24):e015752. doi: 10.1161/JAHA.119.015752. Epub 2020 Dec 8.
Background Ultrafiltration is not commonly used because of higher incidence of worsening renal function without improved decongestion. We examined differential outcomes of high versus low fluid removal and preserved versus reduced ejection fraction (EF) in CARRESS-HF (Cardiorenal Rescue Study in Acute Decompensated Heart Failure). Methods and Results Baseline characteristics in the ultrafiltration arm were compared according to 24-hour ultrafiltration-based fluid removal above versus below the median. Patients were stratified by EF (≤40% or >40%). We compared clinical parameters of clinical decongestion during the hospitalization based on initial (≤24 hours) response to ultrafiltration. Cox-proportional hazards models were used to identify associations between fluid removal <24 hours and composite of death, hospitalization, or unscheduled outpatient/emergency department visit during study follow-up. The intention-to-treat analysis included 93 patients. Within 24 hours, median fluid removal was 1.89 L (Q1, Q3: 1.22, 3.16). The high fluid removal group had a greater urine output (9.08 versus 6.23 L, =0.027) after 96 hours. Creatinine change from baseline to 96 hours was similar in both groups (0.10 mg/dL increase, =0.610). The EF >40% group demonstrated larger increases of change in creatinine (=0.023) and aldosterone (=0.038) from baseline to 96 hours. Among patients with EF >40%, those with above median fluid removal (n=17) when compared with below median (n=17) had an increased rate of the combined end point (87.5% versus 47.1%, =0.014). Conclusions In patients with acute heart failure, higher initial fluid removal with ultrafiltration had no association with worsening renal function. In patients with EF >40%, ultrafiltration was associated with worsening renal function irrespective of fluid removal rate and higher initial fluid removal was associated with higher rates of adverse clinical outcomes, highlighting variable responses to decongestive therapy.
由于肾功能恶化的发生率增加而没有改善充血，超滤并未广泛应用。我们在 CARRESS-HF（急性失代偿性心力衰竭的心脏肾脏抢救研究）中检查了高与低液体清除率和射血分数（EF）保留与降低对不同结局的影响。
根据超滤后 24 小时基于超滤的液体清除量高于或低于中位数，比较超滤臂中的基线特征。根据 EF（≤40%或>40%）对患者进行分层。我们根据超滤初始（≤24 小时）反应比较了住院期间临床充血缓解的临床参数。使用 Cox 比例风险模型确定超滤后<24 小时液体清除与研究随访期间死亡、住院或非计划性门诊/急诊就诊的复合终点之间的关联。意向治疗分析包括 93 例患者。在 24 小时内，中位液体清除量为 1.89 L（Q1，Q3：1.22，3.16）。高液体清除组在 96 小时后尿量更大（9.08 与 6.23 L，=0.027）。两组基线至 96 小时时肌酐的变化相似（增加 0.10 mg/dL，=0.610）。EF>40%组从基线至 96 小时时肌酐（=0.023）和醛固酮（=0.038）的变化更大。在 EF>40%的患者中，与中位数以下（n=17）相比，中位数以上（n=17）液体清除的患者联合终点发生率增加（87.5%与 47.1%，=0.014）。
在急性心力衰竭患者中，超滤初始较高的液体清除与肾功能恶化无关。在 EF>40%的患者中，超滤与肾功能恶化有关，而与液体清除率无关，较高的初始液体清除与不良临床结局的发生率较高相关，突出了对充血性治疗的不同反应。
