Ultrafiltration for acute decompensated heart failure: a systematic review and meta-analysis of randomized controlled trials

Purpose: Current clinical guidelines recommend that ultrafiltration (UF) should be reserved for use in patients with Acute Decompensated Heart Failure (ADHF) who are unresponsive or resistant to diuretics. However, its efficacy and safety remain unknown. We systematically reviewed the available randomized data on the efficacy and safety of UF in ADHF. Methods: MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched in January 2013 to identify Randomized Controlled Trials (RCTs) evaluating UF in ADHF patients. Outcomes of interest included net fluid loss, net weight loss, all-cause mortality, all-cause rehospitalization and adverse events. A random-effects model was used to calculate mean differences (MDs) and odds ratios (ORs) for continuous and dichotomous data, respectively, with 95% Confidence Intervals (CIs). Statistical heterogeneity was assessed by I2 statistic (25% ≤ 50% ≤ 75% for low, moderate and high heterogeneity, respectively). Results: Eleven studies enrolling 614 participants were included in systematic review and data of ten (n=604) studies were meta-analyzed. A total of 302 (50%) participants were randomized to UF. Comparison arms consisted of intravenous diuretics (6 studies), no treatment (2 studies) and unspecified conventional therapy (2 studies; "standard HF therapies" and "conventional management"). Compared to control, treatment of UF was associated with significant net fluid loss (MD 1.43, 95% CI 0.51-2.35, P=0.002) and net weight loss (MD 1.64, 95% CI 0.04-3.24, P=0.04), with moderate to substantial statistical heterogeneity across studies (I2=50% and 70%, respectively). There were no significant differences in all-cause mortality (OR 1.08, 95% CI 0.63-1.86, P=0.77) or all-cause rehospitalization (OR 0.89, 95% CI 0.39-2.00, P=0.77). Analysis of adverse events was inconclusive since only one study reported event numbers. Conclusions: Our meta-analysis shows that the use of UF is effective in reducing fluid and body weight, with no significant benefit in mortality or rehospitalization. Available randomized evidence on the effects of UF in ADHF is limited and underpowered. Data from well-conducted randomized clinical studies of adequate power are much needed to establish the role of UF in ADHF patients for whom conventional HF treatment is unsuccessful or contraindicated.