Beth Davidson DNP, ACNP, CCRN Kristi Hayes MSN, FNP St. Thomas Hospital Nashville, TN
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Transcript of Beth Davidson DNP, ACNP, CCRN Kristi Hayes MSN, FNP St. Thomas Hospital Nashville, TN
Ultrafiltration as a Therapy Option for
Diuretic Resistance: Inpatient & Outpatient
Case StudiesBeth Davidson DNP, ACNP,
CCRNKristi Hayes MSN, FNP
St. Thomas HospitalNashville, TN
Objectives Review the epidemiology and
pathophysiology of diuretic-resistant, acute heart failure
Identify volume overload treatment options
Review/discuss case studies of diuretic-resistance and use of ultrafiltration for volume removal
Epidemiology of Heart Failure (HF)
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
Population Group Prevalence Incidence Mortality
Hospital Discharges Cost
Total population 5,000,000 550,000 57,218 1,093,000 $29.6
billion
Insult
Cardiac Dysfunction
LV Remodeling
HemodynamicDecompensation
Preload Afterload
↓ Cardiac Output Renal
Vasoconstriction/Fluid Retention
NeurohormonalActivation RAAS/SNS Catecholamine Endothelin
Fluid Overload Symptoms
MorbidityDeath
Decompensated
Heart Failure
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
DiureticsCurrent “Standard of Care”
Diuretics…
More diuretics...
Still more diuretics…
7% 6%13%
26%
27%
16%
3% 2%
05
10
15
20
25
30
Enro
lled
Dis
char
ges
(%)
(<-20) (–20 to –15) (-15 to –10) (–10 to –5) (–5 to 0) (0 to 5) (5 to 10) (>10)
Change in Weight (lbs)
Nearly 50% of ADHF patients discharged with
weight gain or losing less than 5 lbs
Evidence of Incomplete Relief From Congestion
Change in Weight During Hospitalization
Outcomes with Standard Care
20%
50%
30Days
3Months
Hospital Readmissions
12%
50%
30Days
12Months
Mortality
33%
5Years
6Months
37%
Patients have persistently high event rates despite use of evidence-based therapies…
Outcomes with Standard Care
Loop Diuretic Inhibition of Macula
Densa
Increased Renin-Angiotensin
IncreasedAldosterone
Cardiac Remodeling and
Fibrosis
Left Ventricular Dysfunction
CARDIACFAILURE
Effect of Loop Diuretics on RAAS in Cardiac Failure
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
Current Options May Have Undesirable Clinical Impacts
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
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*
What is Aquapheresis?
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
Fluid Removal by Ultrafiltration
VascularSpace
UF
VascularSpace
InterstitialSpace (edema)Na
Na
Na
Na
K
P
H2O
K
P
PR
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, multi-center 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
Ultrafiltration is reasonable for patients with refractory congestion not responding to medical therapy
ACC/AHA Guidelines: Class IIa, Level of Evidence B
I IIa IIb III
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
Access issues! 2130 ultrafiltrate over 6.5 hrs
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 andOpportunities 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?