Association of haemodynamic changes measured by serial central venous saturation during ultrafiltration for acutely decompensated heart failure with diuretic resistance and change in renal function Ali Vazir a,b,c, ⁎, Victoria L. Simpkin a , Philip Marino d , Andrew Ludman a , Winston Banya f , Guido Tavazzi e,g , Anthony J. Bastin b , Sarah Trenfield b , Arshad Ghori b , Peter D. Alexander b , Mark Griffiths e , Susanna Price e , Rakesh Sharma a,c , Martin R. Cowie a,c a Department of Cardiology, NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom b High Dependency Unit, Royal Brompton Hospital, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom c National Heart & Lung Institute, Imperial College London, United Kingdom d Critical Care, Guys' and St Thomas' NHS Foundation trust, London, United Kingdom e Adult Intensive Care Unit, Royal Brompton Hospital, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom f Department of Statistics, Royal Brompton Hospital, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom g University of Pavia, Foundation Policlinico San Matteo, IRCCS. Piazzale Golgi 2, Pavia, Italy abstract article info Article history: Received 23 April 2016 Accepted 24 June 2016 Available online 28 June 2016 Background: Patients with acute decompensated heart failure with diuretic resistance (ADHF-DR) have a poor prognosis. The aim of this study was to assess in patients with ADHF-DR, whether haemodynamic changes during ultrafiltration (UF) are associated with changes in renal function (Δcreatinine) and whether Δcreatinine post UF is associated with mortality. Methods: Seventeen patients with ADHF-DR underwent 20 treatments with UF. Serial bloods (4–6 hourly) from the onset of UF treatment were measured for renal function, electrolytes and central venous saturation (CVO 2 ). Univariate and multivariate analysis were performed to assess the relationship between changes in markers of haemodynamics [heart rate (HR), systolic blood pressure (SBP), packed cell volume (PCV) and CVO 2 ] and Δcreatinine. Patients were followed up and mortality recorded. Cox-regression survival analysis was performed to determine covariates associated with mortality. Results: Renal function worsened after UF in 17 of the 20 UF treatments (baseline vs. post UF creatinine: 164 ± 58 vs. 185 ± 69 μmol/l, P b 0.01). ΔCVO 2 was significantly associated with Δcreatinine [β-coefficient of -1.3 95%CI (-1.8 to -0.7), P b 0.001] and remained significantly associated with Δcreatinine after considering changes in SBP, HR and PCV [P b 0.001]. Ten (59%) patients died at 1-year and 15(88%) by 2-years. Δcreatinine was indepen- dently associated with mortality (adjusted-hazard ratio 1.03 (1.01 to 1.07) per 1 μmol/l increase in creatinine; P = 0.02). Conclusions: Haemodynamic changes during UF as measured by the surrogate of cardiac output was associated with Δcreatinine. Worsening renal function at end of UF treatment occurred in the majority of patients and was associated with mortality. © 2016 Published by Elsevier Ireland Ltd. Keywords: Heart failure Ultrafiltration Worsening renal function Central venous saturation 1. Introduction Heart failure is a complex clinical syndrome characterized by the re- duced ability of the heart to pump blood around the body. The overall burden of HF on western health care systems is high, such that in the United States the cost is over $30.7 billion for 2013, 68% of which was attributed to hospital care [1]. Acute decompensated heart failure (ADHF) is a leading cause of hospital admissions, with volume overload being the hallmark of this condition. With advancing disease frequently patients may display ‘diuretic resistance’ [2,3]. One approach for treating fluid retention in patients with diuretic resistance, as recom- mended in international guidelines, is to mechanically remove fluid with devices that can perform ultrafiltration (UF) [4,5]. Data from sever- al studies in patients with acute decompensated heart failure suggests that a significant proportion of patients develop worsening renal func- tion, however this is likely to be transient and to date not reported to be associated with adverse outcome [5–9]. However in a recent study International Journal of Cardiology 220 (2016) 618–622 ⁎ Corresponding author. Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, NIHR Cardiovascular Biomedical Research Unit, National Heart and Lung Institute, Imperial College London, Sydney Street, London SW3 6NP, United Kingdom. E-mail address: a.vazir@imperial.ac.uk (A. Vazir). http://dx.doi.org/10.1016/j.ijcard.2016.06.186 0167-5273/© 2016 Published by Elsevier Ireland Ltd. Contents lists available at ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard