case study
Ultrafiltration for
Fluid Volume Overload in Congestive Heart Failure with Renal Insufficiency
Chief Complaint
The patient was a 73 year old male with atrial fibrillation,
coronary artery disease with previous inferior MI, preserved left
ventricular systolic function, mild pulmonary hypertension, and
renal insufficiency who presented to the hospital with complaints
of shortness of breath and fatigue while performing activities of
daily living.
History of Present
Illness
The patient was volume overloaded and had failed outpatient
attempts to adequately diurese using oral and IV diuretics, and
a short course of nesiritide. At the time of admission, his serum
creatinine was 3.1 mg/dl and his BNP level was 1200. His hospitalization
was complicated by a new diagnosis of multiple myeloma, and as part
of an evaluation for renal dysfunction, a renal ultrasound demonstrated
severe right sided and mild left sided hydronephrosis. The patient
underwent bilateral ureteral stenting with subsequent significant
bleeding from his urinary tract resulting in a hematocrit of 23.
Because of increasing resistance to diuretics and worsening heart
failure symptoms, a cardiology consult was obtained on hospital
day 13.
Case Details
At the time of consultation, his physical examination was remarkable
for a chronically ill appearing man who looked older than his stated
age. His blood pressure was 100/58, pulse 118 and irregular. Jugular
venous pulsations were seen 3 cm above the clavicle with the patient
at 90 degrees. Bilateral coarse crackles were heard throughout the
lungs. The abdomen was firm and distended. Anasarca was present
with 4+ edema from the feet to the lumbosacral area. Pertinent objective
data at time of consult included a chest x-ray that showed cardiomegaly,
pulmonary vascular congestion and bilateral pleural effusions.
Despite controlling the patient’s heart rate
and several days of achieving net negative diuresis with high dose
continuous intravenous infusion of lasix and nesiritide, there was
little change in the patient’s edema and chest x-ray. Therefore,
peripheral veno-venous ultrafiltration was performed (Aquadex FlexFlow,
CHF Solutions Inc.). A 16 gauge, 35 cm peripheral catheter was placed
in the basilic vein under fluoroscopic guidance for blood withdrawal
and an 18 gauge standard peripheral IV catheter was placed in the
opposite arm for blood return. The nursing staff from a telemetry
unit, primed the blood circuit, administered a 1600 unit heparin
bolus and followed-up with an infusion of heparin at 120 units/hour
administered through the access port (pre-filter) of the system’s
withdrawal line. Ultrafiltration therapy removed 4 liters of plasma
water over an 8 hour period. Identical treatments were administered
on days 17 and 18, removing a total of 12 liters over 3 treatments.
Additionally, this controlled and stable fluid removal allowed the
patient to receive a blood transfusion without worsening congestion.
On day 18, the patient’s exam was much improved.
His lungs were clearer, his edema was markedly improved and his
jugular venous pulsations were not seen above the clavicle with
the patient at 90 degrees. The serum creatinine was 2.4 mg/dl. His
symptoms were much improved. The patient was transitioned to oral
diuretics and discharged to home on hospital day 21.
Discussion
Fluid overload can be challenging to treat in patients showing resistance
to conventional diuretics and/or a poor response to natriuretic
peptides to stimulate urine output. In this case, ultrafiltration
provided a rapid, predictable and safe removal of 12 liters of plasma
water while maintaining hemodynamic stability and serum electrolytes.
This therapy also allowed the patient to receive the benefits of
blood transfusion. Because of concerns about the patient’s
bleeding from his urinary tract, the usual systemic anticoagulation
was successfully avoided by heparinizing the circuit pre-filter.
Case history courtesy of:
Kathy A. Crispell, M.D.
Assistant Professor of Medicine/Cardiology
Kaiser Sunnyside Medical Center
Clackamas, Oregon
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