Ultrafiltration (UF) is a dialysis modality consisting of the removal of water and solutes through a semipermeable membrane. It can be used in patients with decompensated heart failure (HF) with volume overload despite maximum diuretic therapy. Its use on hospital wards, using peripheral venous access, facilitates its availability. We analyzed the experience with UF via peripheral venous access performed on hospital wards in patients with advanced HF refractory to diuretics.

This was a retrospective study. From March 2019 to December 2021, the procedure was performed in 16 patients admitted with congestion resistant to diuretics (congestive signs and symptoms despite treatment with high-dose intravenous furosemide with sequential nephron blockade). UF was performed using a 5-Fr venous line with 18-G dual lumen (PowerMidline, Bard Access Systems, USA) shortened to 10cm and placed in the basilic vein or two 18-G peripheral venous lines (BD Nexiva Diffusics Closed IV Catheter System, USA), normally in the same arm. The device used was Aquadex SmartFlow System (Nuwellis Inc, USA). The starting parameters were: blood flow, 40mL/min; UF rate, 150mL/h. During UF (programmed for 24h), all diuretics were stopped.

The patients had a mean age of 73.6 years, and 75% were men. The predominant underlying heart disease was chronic ischemic heart disease. The most common reason for admission was systemic congestion alone or with associated pulmonary congestion. The mean time until starting UF was 7 days. The previous mean IV furosemide dose was 250mg/day.

When comparing the stable baseline status with the admission for decompensation (baseline vs admission), we saw that, in the period leading up to the admission, there was a reduction in the diuresis volume (> 300mL/day) and a weight a gain (> 6kg). Both variables improved with UF (pre-UF vs post-UF). Thus, this treatment reduced the mean weight by 4kg and increased the diuresis volume by 500mL. The weight loss from UF was maintained at the time of discharge (table 1 and figure 1).

Figure 1.

A: changes in body weight and diuresis in the different study phases. B: advantages of peripheral ultrafiltration. PostUF: after ultrafiltration; PreUF: before ultrafiltration. The values in the lower part represent the p values between the different study phases.

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Renal function (creatinine and glomerular filtration rate) showed a significant deterioration (p<.05) during the decompensation episode (baseline vs admission). At discharge (pre-UF vs discharge), these parameters had improved (P<.05) (table 1). There was a reduction in almost all drugs with a diuretic effect at discharge compared with the stable baseline situation before the decompensation (table 1). The mean UF rate was 120mL/h, with a total extraction volume from UF of around 3.5 L. The total volume loss was almost 6 L. There were no significant complications related to the procedure (table 1).

In this study we have been able to confirm the effectiveness of peripheral UF in terms of a substantial weight reduction due to the negative balance caused by UF and the increase in diuresis that occurs with it, without a deleterious effect on renal function.

Of note, most studies have been carried out with conventional UF, which requires high flows, a central line, and dialysate.1,2 However, for several years now, peripheral access UF devices have been available, which allow the treatment to be carried out with low flows and provide a slow UF, which is better tolerated by patients with HF.

The advantages of UF (figure 1B) include better control of the speed and volume of fluid removal, greater net sodium loss (the ultrafiltrate product is isotonic), and less neurohormonal activation.3 Stopping diuretics allowed the nephrons to rest,3–5 which, added to the decongestion, promotes the recovery of their sensitivity to diuretic therapy.4–6 Therefore, the patients in this series were discharged on lower diuretic doses than their baseline, with a lower weight than at admission, and a greater diuresis than baseline and admission. There are other techniques that are used in the long-term treatment of these patients, such as peritoneal dialysis, but this therapeutic option requires preparation and abdominal surgery. UF is a good technique for the maintenance of patients who are candidates for peritoneal dialysis until it can be started.

This study has some limitations, in particular the small number of patients and the lack of a randomized control group. Nonetheless, we did not find any studies in the literature that systematically perform this technique using peripheral access.

In conclusion, UF in patients with decompensated HF and congestion resistant to combined diuretic therapy is effective, safe, and simple to perform on a conventional hospital ward and using peripheral venous access.