Ultrafiltration for management of fluid overload in patients with heart failure

Heart failure is the number one cause of death in the United States and a significant burden to the healthcare system. One of the primary complications of heart failure is fluid overload, for which current treatments are limited. Medical therapy is first-line; however, rates of diuretic insensitivity are high, medications are not easily titrated, and they do not address the underlying physiologic derangement that leads to hypervolemia. Removal of isotonic fluid via hemofiltration and peritoneal dialysis is an understudied but promising therapy that enables decongestion without maladaptive stimulation of fluid retention pathways. Published studies report conflicting data on long-term outcomes of ultrafiltration but reach consensus on greater and more durable volume reduction with ultrafiltration than conventional medical therapy. These studies are noteworthy for their neglect to standardize both patient selection and fluid removal protocol, which likely contribute to outcome variation. Novel technology in preclinical testing includes implantable ultrafiltration, which has potential to treat volume overload while minimizing the adverse effects associated with conventional hemofiltration. We performed a literature review of English-language studies on hemo- and peritoneal filtration for management of fluid overload in congestive heart failure. Also included is a discussion of the pathophysiology of congestive heart failure and first-line management as well as emerging technologies for ultrafiltration.