Fluid overload is a common medical problem that can be caused by a number of medical conditions -- including kidney failure, metabolic disease and heart failure -- and some surgeries and medications. But patients with heart failure represent the largest group of fluid-overloaded patients.
A common symptom associated with heart failure is troubled breathing or shortness of breath (dyspnea). This is the result of excess fluid in the lungs (pulmonary edema). As fluid buildup increases, difficulty breathing may become serious enough to interfere with sleep.
Fluid accumulation, or edema, can cause swelling of various parts of the body. Excess fluid retained by the body may result in weight gain, which sometimes occurs fairly quickly.
Another common symptom of heart failure is fatigue or tiredness. As fluid buildup increases and the heart's pumping capacity decreases, heart failure patients tire more and more easily. At first, activities like climbing stairs are difficult, but eventually, everyday activities such as walking and getting dressed are hard, too.
The traditional treatment for heart failure patients with symptoms of fluid overload is administration of diuretic drugs. However, this often doesn't work very well. Most hospitalizations for heart failure are due to fluid overload in patients for whom oral diuretics are no longer effective, according to data from the Acute Decompensated Heart Failure National Registry (ADHERE), the largest national heart failure registry, which launched in 2001. About 90 percent of hospitalized patients in the registry received intravenous diuretic drugs, but records show that, upon discharge from the hospital, many of them still had symptoms of fluid overload. The high rate of hospital readmissions in this group of patients may be, in part, a result of their persistent fluid overload.
In about 25 percent to 30 percent of heart failure patients with fluid overload who are treated with diuretics, the elimination of excess fluid stops before completion. This condition is called diuretic resistance. Doctors often try to overcome diuretic resistance by modifying the dose or method of administration of the diuretic drugs or by using combinations of diuretic drugs (they act in different ways and in different parts of the kidney). Sometimes, changing from an intermittent dose of oral diuretic to an intravenous diuretic can lead to more effective elimination of excess fluid.
Experience has shown, however, that it often isn't possible to effectively treat diuretic resistance. Some recent studies have also raised concerns about the safety of diuretics for heart failure patients with fluid overload -- their use in this patient population resulted in an increased risk of death.
Because diuretics stop working for many people with advanced heart failure, scientists began looking for another way to treat fluid overload, and they developed a procedure known as ultrafiltration. In this procedure, the patient's fluid-overloaded blood is withdrawn and -- before being returned to the patient -- passed through a filter that removes excess fluid. The UNLOAD study, which we'll learn about on the next page, compared the safety and efficacy of ultrafiltration with that of diuretic drugs.
Results of the UNLOAD Study
The official name of the UNLOAD study is "Ultrafiltration versus IV Diuretics for Patients Hospitalized for Acute Decompensated Congestive Heart Failure." Two hundred patients were enrolled in the trial, and they were divided into two groups -- one received diuretic treatment and the other received ultrafiltration treatment.
The study showed that hospitalized heart failure patients receiving ultrafiltration therapy lost more weight (from fluid loss) and experienced greater net fluid loss than patients treated primarily with diuretics. By 90 days after treatment, the ultrafiltration group had spent significantly fewer days in the hospital and had fewer repeat hospitalizations for heart failure. The group that received ultrafiltration also had fewer trips to the emergency room for heart failure and fewer unscheduled visits to the doctor for heart failure.
Ultrafiltration can remove as much as a pound of excess salt and water from the bloodstream each hour. Most patients undergoing this procedure stay in the hospital for an average of about three to four days.
For more information about heart failure, please take a look at the links on the next page.
- How Your Heart Works
- How Your Lungs Work
- How Your Kidneys Work
- How Blood Works
- How Ultrafiltration Works
- How Vasodilator Drugs Work
- How Fluid Overload and Edema Work
- How Orthopnea Works
- How Jugular Venous Distension Works
- How Heart Failure Affects Quality of Life
- How Inotropic Drugs Work
- How Diuretics Work
- How Low-Sodium Diets Work
More Great Links
- Adams KF, Lindenfeld J, Arnold JMO, et al. Heart Failure Society of America (HFSA) 2006 Comprehensive Heart Failure Practice Guideline. J Cardiac Failure 2006;12:e1-e122.
- Agostoni P, Marenzi G, Lauri G, et al. Sustained improvement in functional capacity after removal of body fluid with isolated ultrafiltration in chronic cardiac insufficiency: failure of furosemide to provide the same result. Am J Med. 1994;96:191-199.
- Agostoni P, Marenzi GC, Pepi M, et al. Isolated ultrafiltration in moderate congestive heart failure. J Am Coll Cardiol. 1993;21:424-431.
- Ahmed A, Young JB, Love TE, et al. A propensity-matched study of the effects of chronic diuretic therapy on mortality and hospitalization in older adults with heart failure. Int J Cardiol. 2007. [Epub ahead of print].
- Bart B, Boyle A, Bank AJ, et al. The RAPID Study: Ultrafiltration versus usual care for hospitalized patients with heart failure: the Relief for Acutely Fluid-Overloaded Patients With Decompensated Congestive Heart Failure. J Am Coll Cardiol. 2005;46:2043-2046.
- Costanzo MR, Guglin ME, Saltzberg MT, et al. The UNLOAD Study: Ultrafiltration versus intravenous diuretics for patients hospitalized for acute decompensated heart failure. J Am Coll Cardiol. 2007; 49:675-683. www.unloadstudy.com
- Costanzo MR, Saltzberg M, O'Sullivan J, et al. The EUPHORIA Study: Early ultrafiltration in patients with decompensated heart failure and diuretic resistance. J Am Coll Cardiol. 2005;46:2047-2051.
- Elkayam U, Hatamizadeh P, Janmohamed M. The challenge of correcting volume overload in hospitalized patients with decompensated heart failure. J Am Coll Cardiol. 2007;49:684-686.
- Eshaghian S, Horwich TB, Fonarow GC. Relation of loop diuretic dose to mortality in advanced heart failure. Am J Cardiol. 2006;97:1759-1764.
- Jaski B, Ha J, Denys BG, et al. The SAFE Study: Peripherally inserted veno-venous ultrafiltration for rapid treatment of volume overloaded patients. J Card Fail. 2003;9:227-231.
- Marenzi G, Lauri G, Grazi M, et al. Circulatory response to fluid overload removal by extracorporeal ultrafiltration in refractory congestive heart failure. J Am Coll Cardiol. 2001;38:963-968.
- Mehta RL, Pascual MT, Soroko S, et al. Diuretics, mortality, and nonrecovery of renal function in acute renal failure. JAMA. 2002;288:2547-2553.
- Pepi M, et al. Sustained cardiac diastolic changes elicited by ultrafiltration in patients with moderate congestive heart failure: pathophysiological correlates. Br Heart J. 1993;70:135-140.