Clinical Investigation
Prompt Reduction in Intra-Abdominal Pressure Following Large-Volume Mechanical Fluid Removal Improves Renal Insufficiency in Refractory Decompensated Heart Failure

https://doi.org/10.1016/j.cardfail.2008.02.010Get rights and content

Abstract

Background

Our group recently reported that elevated intra-abdominal pressure (IAP, defined as ≥ 8 mm Hg) can be associated with renal dysfunction in patients with advanced decompensated heart failure (ADHF). We hypothesize that in the setting of persistently elevated IAP and progressive renal insufficiency refractory to intensive medical therapy, mechanical fluid removal can be associated with improvements in IAP and renal function.

Methods and Results

The renal and hemodynamic profiles of 9 consecutive, volume-overloaded subjects with ADHF and elevated IAP, refractory to intensive medical therapy, were prospectively collected. All subjects experienced progressive elevation of serum creatinine and IAP in response to intravenous loop diuretics. Within 12 hours after mechanical fluid removal via paracentesis (n = 5, mean volume removed 3187 ± 1772 mL) or ultrafiltration (n = 4, mean volume removed 1800 ± 690 mL), there was a significant reduction in IAP (from 13 ± 4 mm Hg to 7 ± 2 mm Hg, P = .001), with corresponding improvement in renal function (serum creatinine from 3.4 ± 1.4 mg/dL to 2.4 ± 1.1 mg/dL, P = .01) without significantly altering any hemodynamic measurement.

Conclusion

In volume-overloaded patients admitted with ADHF refractory to intensive medical therapy, we observed a reduction of otherwise persistently elevated IAP with corresponding improvement in renal function after mechanical fluid removal.

Section snippets

Patient Population

We prospectively enrolled consecutive subjects (aged ≥ 18 years), with symptomatic heart failure (New York Heart Association class III and IV), who underwent a right-sided heart catheterization for intensive medical therapy of ADHF at the Cleveland Clinic heart failure intensive care unit between March 1, 2007, and June 30, 2007. Subjects who met the following inclusion criteria were enrolled in the study: 1) markedly impaired systolic left ventricular function defined by left ventricular

Baseline Characteristics and Medical Treatment

A total of 9 subjects met eligibility criteria for the study, with 5 of the group receiving paracentesis and 4 of the group receiving ultrafiltration. Baseline characteristics and medical treatment during admission of the subjects are summarized in Table 1. All subjects underwent intensive medical therapy for an average of 12 hours before commencing mechanical fluid removal. As expected, subjects who underwent large-volume paracentesis had extensive abdominal ascites documented by ultrasound.

Discussion

There are several key findings in our hypothesis-generating study. First, we identified the association between the presence of refractory, volume-overloaded ADHF and further increase in IAP. Furthermore, this pathophysiologic link probably is associated with the presence of worsening renal function despite intensive medical therapy. Second, we identified the effectiveness of large-volume mechanical fluid removal (by paracentesis or ultrafiltration, whenever applicable) in achieving effective

Conclusions

Large-volume mechanical fluid removal can achieve a reduction of otherwise persistently elevated IAP with corresponding improvement in renal function in selected volume-overloaded patients admitted with ADHF refractory to intensive medical therapy. Further studies are warranted to determine the clinical utility of IAP measurements in this challenging patient population.

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