Volume-Guided Venous To Venous Ultrafiltration In Hospitalized Heart Failure Patients

Abstract

Background Patients with heart failure often have wide variations in intravascular volume (Total Blood Volume (TBV) and Red Blood Cell Volume (RBCV)) that are part of the pathophysiology, symptomatology, and disease progression of their syndrome. Indirect volume measurements cannot measure intravascular volume with precision, often leaving clinicians without clear volume-guided treatment strategies. Ultrafiltration (UF) is a treatment capable of removing fluid from the body without changing RBCV or removing serum proteins and large molecules. Blood volume analysis (BVA) provides several patient specific metrics including TBV, plasma volume (PV), and RBCV as well as providing a normalized hematocrit (nHct), a reflection of the anticipated pHct after volume correction. Goals of using UF are safe removal of fluid without creation of hypovolemia and without exceeding the plasma refill rate. We report below two cases of heart failure patients co-managed using BVA and UF. Methods/Results Two men aged 83 and 64 years were admitted to the hospital for volume overload and management. Each was initially treated with intense IV diuresis which produced worsening renal insufficiency. At that time BVA confirmed increased total intravascular volume for which UF was initiated. Monitoring of the gap between the peripheral hematocrit and the normalized hematocrit allowed safe and adequate decongestion. Significant volume removal corelated with clinical improvement and the patients were discharged 3-4 days following combined use of BVA and UF. Table 1 summarizes these outcomes and documents the rise in pHct (Patient 2) as it approaches the nHct, signaling sufficient volume removal. Conclusions While the synergy of combining BVA with UF has been envisioned for more than a decade, limited information is available to understand the optimal use and define the value of combining these valuable tools. Earlier use of BVA in these two patients could have prevented acute renal injury from intensified diuresis, and by instituting UF, the kidneys could be provided with a ‘diuretic holiday’. Further, the normalized hematocrit, determined by BVA, provides clinicians with a specific metric to monitor UF progress and adequacy. Combined use of BVA and UF should improve outcomes in hospitalized diuretic-resistant or renal insufficient patients. Clinical trials of their combination need to be designed and completed. Patients with heart failure often have wide variations in intravascular volume (Total Blood Volume (TBV) and Red Blood Cell Volume (RBCV)) that are part of the pathophysiology, symptomatology, and disease progression of their syndrome. Indirect volume measurements cannot measure intravascular volume with precision, often leaving clinicians without clear volume-guided treatment strategies. Ultrafiltration (UF) is a treatment capable of removing fluid from the body without changing RBCV or removing serum proteins and large molecules. Blood volume analysis (BVA) provides several patient specific metrics including TBV, plasma volume (PV), and RBCV as well as providing a normalized hematocrit (nHct), a reflection of the anticipated pHct after volume correction. Goals of using UF are safe removal of fluid without creation of hypovolemia and without exceeding the plasma refill rate. We report below two cases of heart failure patients co-managed using BVA and UF. Two men aged 83 and 64 years were admitted to the hospital for volume overload and management. Each was initially treated with intense IV diuresis which produced worsening renal insufficiency. At that time BVA confirmed increased total intravascular volume for which UF was initiated. Monitoring of the gap between the peripheral hematocrit and the normalized hematocrit allowed safe and adequate decongestion. Significant volume removal corelated with clinical improvement and the patients were discharged 3-4 days following combined use of BVA and UF. Table 1 summarizes these outcomes and documents the rise in pHct (Patient 2) as it approaches the nHct, signaling sufficient volume removal. While the synergy of combining BVA with UF has been envisioned for more than a decade, limited information is available to understand the optimal use and define the value of combining these valuable tools. Earlier use of BVA in these two patients could have prevented acute renal injury from intensified diuresis, and by instituting UF, the kidneys could be provided with a ‘diuretic holiday’. Further, the normalized hematocrit, determined by BVA, provides clinicians with a specific metric to monitor UF progress and adequacy. Combined use of BVA and UF should improve outcomes in hospitalized diuretic-resistant or renal insufficient patients. Clinical trials of their combination need to be designed and completed.