Aquapheresis: An Institutional Experience
Keywords:Aquapheresis, ultrafiltration, volume overload
Background: Aquapheresis (AQ) consists of the extracorporeal extraction of plasma water from the vascular space across a semipermeable membrane in response to a transmembrane pressure gradient. The primary utilization of AQ has been in the management of patients with diuretic resistant heart failure with a treatment goal directed to quickly eliminate the excess fluid and optimize volume status. This modality is similar to isolated ultrafiltration performed on those patients requiring dialysis, but utilizes a machine that is smaller and easier to initiate and operate compared with traditional dialysis equipment.
Method: A retrospective study that describes the indications in which AQ was utilized at Lenox Hill Hospital. The patient list was generated by searching for the keyword “Aquaph” in our electronic health record (EHR) orders. Patients were categorized based on hospital location and indication of AQ therapy. Additional information includes duration of treatment (days), changes in creatinine (start of AQ to stop of AQ), and total volume removed.
Results: The search generated 28 patients; five were excluded as AQ was not initiated. In the remaining 23 patients, the mean aquapheretic volume per day was 1954 mls, with no significant change in creatinine. Indications for AQ broke out into five main categories: cardiogenic shock including post cardiothoracic procedure (10 pts); anasarca (5 pts); ATN with volume overload (4 pts); ESKD with bridge ultrafiltration between hemodialysis treatments (2 pts); and post-op volume overload (2 pts).
Conclusion: We found that aquapheresis can be utilized in situations other than diuretic resistant heart failure. Also to consider, is the ease in which this less complicated aquapheresis equipment can be operated compared to the more complex hemodialysis equipment.
Agostoni P, Marenzi G, Lauri G, et al. 1994. 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. 96(3):191-199.
Bart BA, Goldsmith SR, Lee KL, et al. 2012. Cardiorenal rescue study in acute decompensated heart failure: Rationale and design of CARRESS-HF, for the heart failure clinical research network. J Card Fail. 18(3):176-182.
Bart BA, Goldsmith SR, Lee KL, Givertz MM, O’Connor CM, Bull DA, Redfield MM, Deswal A, Rouleau JL, LeWinter MM, Ofili EO, Stevenson LW, Semigran MJ, Felker GM, Chen HH, Hernandez AF, Anstrom KJ, McNulty SE, Velazquez EJ, Ibarra JC, Mascette AM BE. 2012. Ultrafiltration in decompensated heart failure with cardiorenal syndrome. N Engl J Med. 367(24):2296-2304.
Constantinescu AR, Adler JL, Watkins E, et al. 2019. Aquapheresis (AQ) in Tandem with Extracorporeal Membrane Oxygenation (ECMO) in Pediatric Patients. J Extra Corpor Technol. 51(3):163-168.
Costanzo MR. 2019. Ultrafiltration in Acute Heart Failure. Card Fail Rev. 5(1):9-18.
Costanzo MR. 2020. The Cardiorenal Syndrome in Heart Failure. Heart Fail Clin. 16(1):81-97.
Costanzo MR, Guglin ME, Saltzberg MT, et al. 2007. Ultrafiltration Versus Intravenous Diuretics for Patients Hospitalized for Acute Decompensated Heart Failure. J Am Coll Cardiol. 49(6):675-683.
Costanzo MR, Negoianu D, Jaski BE, et al. 2016. Aquapheresis Versus Intravenous Diuretics and Hospitalizations for Heart Failure. JACC Hear Fail. 4(2):95-105.
Ellison DH. 2019. Clinical pharmacology in diuretic use. Clin J Am Soc Nephrol. 14(8):1248-1257.
Eknoyan G. 1997. A History of Diuretics. In: Diuretic Agents. 3-28.
Grodin JL, Carter S, Bart BA, Goldsmith SR, Drazner MH, Tang WHW. 2018. Direct comparison of ultrafiltration to pharmacological decongestion in heart failure: a per-protocol analysis of CARRESS-HF. Eur J Heart Fail. 20(7):1148-1156.
Jaski BE, Ha J, Denys BG, Lamba S, Trupp RJ, Abraham WT. 2003. Peripherally inserted veno-venous ultrafiltration for rapid treatment of volume overloaded patients. J Card Fail. 9(3):227-231.
Kazory A, Costanzo MR. 2018. Extracorporeal Isolated Ultrafiltration for Management of Congestion in Heart Failure and Cardiorenal Syndrome. Adv Chronic Kidney Dis. 25(5):434-442.
Ronco C, Ricci Z, Bellomo R, Bedogni F. 2001. Extracorporeal ultrafiltration for the treatment of overhydration and congestive heart failure. Cardiology. 96(3-4):155-168.
Stason WB, Cannon PJ, Heinemann HO, Laragh JH. 1966. Furosemide. A clinical evaluation of its diuretic action. Circulation. 34(5):910-920.
Ter Maaten JM, Rao VS, Hanberg JS, et al. 2017. Renal tubular resistance is the primary driver for loop diuretic resistance in acute heart failure. Eur J Heart Fail. 19(8):1014-1022.