Abstract
Aims
Patients with heart failure (HF) admitted for decompensation often require high doses of intravenous diuretics. This study aims to analyse whether the use of peripheral ultrafiltration (UF) in patients hospitalized for acute HF with systemic‐predominant congestion results in better hydric control, renal protection, and reduction of hospital stay compared with conventional treatment.
Methods and results
This study was a retrospective, comparative, single‐centre study of 56 patients admitted for HF with systemic congestion with a poor diuretic response after diuretic escalation. One group underwent peripheral UF (35 patients) and others were maintained on intense diuretic treatment (control group, 21 patients). The diuretic response and days of hospital stay were compared between and within groups. The baseline characteristics of both groups were similar: males with right ventricular failure and renal dysfunction. The inter‐group analysis showed that patients who received UF had better glomerular filtration rate (GFR; UF: 39.2 ± 18.2 vs. control: 28.7 ± 13.4 mL/min; P = 0.031) and higher diuresis (UF: 2184 ± 735 vs. control: 1335 ± 297 mL; P = 0.0001) at hospital discharge despite less need for diuretic drugs. Days of hospital stay were shorter in the UF group (UF: 11.7 ± 10.1 vs. control: 19.1 ± 14.4 days; P = 0.027). Intra‐group analysis showed that patients receiving UF improved GFR, increased diuresis, and reduced weight at discharge (P < 0.001), whereas patients on conventional treatment only experienced improved weight but worsening renal function at discharge.
Conclusions
In patients with acute HF with systemic congestion and diuretic resistance, UF compared with conventional treatment produces greater decongestion and renal protection, reduces the total diuretic load, and shortens the length of hospital stay.
Keywords: Acute heart failure, Congestion, Peripheral ultrafiltration, Hydric control, Renal protection, Hospital stay
Introduction
Acute decompensation due to systemic congestion in patients with heart failure (HF) is a relatively common event that can occur in up to 17% of patients hospitalized in a Cardiology Department. 1 The usual treatment consists of an escalation of diuretic drugs to produce a sequential blockade of the nephron and achieve significant negative balances, resulting in symptomatic improvement and reduced congestion. 2 Sometimes, a sufficient diuretic response, weight reduction, and reduced congestion are not achieved. This occurs primarily when there is impaired renal function with marked right ventricular dysfunction. 3 It is in this context that we can increase or maintain intensive diuretic treatment or reduce it and associate ultrafiltration (UF) with peripheral venous access as decongestant therapy. Previous studies have demonstrated the usefulness of this technique and its applicability via peripheral access in the hospital ward. 4 This study hypothesized that UF in patients with insufficient diuretic response would be more effective than increasing diuretic drugs for fluid and weight loss, which could reduce the number of days of hospital stay. Thus, this study aimed to analyse whether, in patients with HF admitted for systemic congestion and poor diuretic response, the use of peripheral UF vs. increased diuretic treatment leads to a bigger increase in diuresis and a shorter hospital stay.
Methods
This study used retrospective, comparative, single‐centre analysis of 56 patients admitted from January 2020 to September 2022 for decompensated HF with systemic‐predominant congestion. After admission, all patients underwent diuretic escalation according to the protocol established in the centre's Cardiology Department. Diuretic escalation protocol includes intravenous furosemide with or without hypertonic saline, to sequentially add mineralocorticoid receptor antagonists (MRAs)/thiazide, acetazolamide/glucose cotransporter type 2 inhibitors, or tolvaptan.
After reaching high doses of furosemide perfusion (>120 mg/day), and when diuresis and weight reduction were not considered sufficient, UF was performed in the hospital ward via two peripheral venous lines. This group (35 patients) was compared with a control group with similar characteristics adjusted for renal function, right ventricular dysfunction, and elevated CA125 (carcinoembryonic antigen) values but not receiving UF (21 patients). Assignment to the UF or control group was at the discretion of the clinical cardiologist directly responsible for the patient, as this technique was not standardized at the time in the centre's Cardiology Department.
A poor diuretic response was considered when, despite administration of >120 mg of furosemide by infusion, the diuretic response was less than desired with the stagnation of weight loss. 2
The UF procedure in all cases was single and was performed via two Introcan Safety B/Braun® peripheral venous lines, usually in the same arm for better patient mobility: 18 G with cephalic access and 20 G in the forearm or dorsum of the hand. Occasionally, access was via a 5 Fr BARD PowerMidline® type PICC line with two 18 G lumens shortened to 10 cm implanted in the basilic vein. The line with the best flow rate was chosen and assigned to the extraction. The device used was the Nuwellis Aquadex SmartFlow®. This system was chosen because it is FDA approved as a suitable treatment for effective fluid management in patients with diuretic resistance.
The system was flushed with 1 L of saline to which 10 000 IU of heparin sodium was added. The anticoagulation used during the procedure was related to the patient's baseline anticoagulation therapy. Thus:
In patients treated with antivitamin K, the international normalized ratio (INR) was checked to be between 2 and 3, and 20 mg iv enoxaparin was added at the start of UF.
Patients treated with direct‐acting oral anticoagulants were switched to low‐molecular‐weight heparin at a rate of 1 mg/kg/12 h subcutaneously (adjusted for renal function) with a supplement of 20 mg iv at the start of UF.
Patients not anticoagulated, or with enoxaparin at prophylactic doses, were anticoagulated at full doses with enoxaparin according to renal function. For maintenance of the UF system, a washout was performed every 4 h with 20 mL of the heparinized saline used for flushing, through each of the lines. The same was done extraordinarily if any of the pressures (extraction, filtrate, or return) persistently remained above 200 mmHg.
The starting parameters were similar in all cases. That is, blood flow was 40 mL/min and UF rate was 150 mL/h, although modifications were dependent on the clinical situation and/or interest in achieving a greater negative balance and/or suction or return alerts. During the duration of UF (scheduled for 24 h), all diuretics were suspended to try to reverse diuretic resistance, except for MRAs due to its prognostic effect.
The variables collected focused on the cardiac status on admission, diuretics during hospitalization and at discharge, and response to UF vs. maximum dose of diuretics and short‐term follow‐up. In terms of follow‐up time, the time of discharge has been selected because two in‐hospital treatments that are not maintained after hospital discharge are being compared; longer follow‐up would be influenced by many more diverse variables, so it would be difficult to attribute the observed differences to the treatment administered during hospital admission.
The investigation conforms with the principles outlined in the Declaration of Helsinki and was approved by the Biomedical Research Ethics Committee.
Statistical analysis
Qualitative variables are expressed as percentages and quantitative variables as mean and standard deviation or as median and interquartile range when the distribution of values was not normal (P < 0.05 in the Kolmogorov–Smirnov test). Comparison between quantitative variables was performed using Student's t‐test for independent samples in the comparison between groups. Intra‐group comparison was performed using Student's t‐test for paired samples. For the comparative analysis between qualitative variables, Pearson's χ 2 test was applied. A P‐value of <0.05 was considered significant. Statistical analysis was performed using SPSS Statistics Version 27® software and Stata Statistics/Data Analysis 16.1 Serial Number 501606323439.
Results
Baseline characteristics and ultrafiltration parameters
The majority of patients were male, with a mean age of 70 years. The most frequent aetiologies of HF were cardiomyopathy, ischaemic or non‐ischaemic. The cause of decompensation was infection in eight patients (14%), arrhythmias in four patients (7%), and myocardial ischaemia in three patients (5%). In the remaining patients, decompensation occurred without a clear identifiable cause. The more common comorbidities were arterial hypertension and diabetes mellitus. Patients frequently had previous admissions, biventricular dysfunction, and very high biomarkers of tissue congestion (CA125) and myocardial stress [N‐terminal pro‐brain natriuretic peptide (NT‐proBNP)] (Table 1 ). Regarding access in the UF group, one patient had mild superficial thrombophlebitis, with no other complications related to vascular access. Ultrafiltration parameters are shown in Table 2.
Table 1.
Baseline characteristics at entry
| UF patients n = 35 | Control group n = 21 | P | |
|---|---|---|---|
| Age (years) a | 69.3 ± 12.0 | 74.2 ± 9.1 | 0.106 |
| Male sex (n, %) | 23 (66) | 13 (62) | 0.781 |
| Baseline pathology (n, %) | |||
| Non‐ischaemic CM | 10 (29) | 6 (29) | 0.930 |
| Ischaemic CM | 11 (31) | 7 (33) | 0.883 |
| Congenital heart disease | 3 (9) | 1 (5) | 0.592 |
| Valvulopathies | 7 (20) | 5 (24) | 0.737 |
| Others | 4 (7) | 2 (9) | 0.595 |
| Comorbidities (n, %) | |||
| Arterial hypertension | 15 (43) | 9 (43) | 0.980 |
| Diabetes mellitus | 21 (60) | 12 (57) | 0.833 |
| COPD | 7 (20) | 3 (14) | 0.857 |
| Severe PHT | 4 (11) | 2 (10) | 0.823 |
| Dyslipidaemia | 5 (14) | 3 (14) | 0.693 |
| SAHS | 5 (14) | 2 (10) | 0.917 |
| Permanent AF | 8 (23) | 6 (29) | 0.873 |
| CKD | 31 (89) | 18 (86) | 0.754 |
| Previous admissions < 3 months (n, %) | 14 (40) | 8 (38) | 0.888 |
| Echocardiography and analytics | |||
| LVEF < 40% (n, %) | 26 (74) | 15 (71) | 0.815 |
| RVEF reduced (n, %) | 31 (86) | 16 (76) | 0.650 |
| Creatinine a | 1.84 ± 0.77 | 1.75 ± 0.70 | 0.915 |
| Glomerular filtration rate a | 42.2 ± 23.1 | 41.5 ± 23.3 | 0.222 |
| CA125 b | 267 (165) | 253 (177) | 0.241 |
| NT‐proBNP b | 22 361 (10 524) | 20 482 (10 123) | 0.478 |
AF, atrial fibrillation; CA125, carcinoembryonic antigen; CKD, chronic kidney disease; CM, cardiomyopathy; COPD, chronic obstructive pulmonary disease; LVEF, left ventricular ejection fraction; n/%, number of cases and corresponding percentage; NT‐proBNP, N‐terminal pro‐brain natriuretic peptide; PHT, pulmonary hypertension; RVEF, right ventricular ejection fraction; SAHS, sleep apnoea‐hypopnoea syndrome; UF, ultrafiltration.
Mean and standard deviation.
Median and interquartile range.
Table 2.
Ultrafiltration parameters
| UF rate (mL/h) | 131.5 ± 29.2 |
| Duration (h) | 28.3 ± 17.0 |
| Volume extracted (mL) | 3752 ± 2456 |
| Glomerular filtration rate post‐UF (mL/min) | 35.5 ± 21.1 |
| Na+ post‐UF (mEq/L) | 138 ± 5.5 |
| K+ post‐UF (mEq/L) | 4.0 ± 0.6 |
| Haemoglobin post‐UF (mg/dL) | 11.2 ± 2.3 |
| Haematocrit post‐UF (%) | 35.1 ± 6.4 |
UF, ultrafiltration.
UF incidents: Recurrent pressure alarms with need for UF removal < 24 h in three patients. Coagulation with need for system change on five occasions in two patients.
Comparison between groups
By the fourth day, patients received high doses of diuretic combinations with poor response. It was at this point that one group of patients was chosen to undergo UF and others to continue with the treatment. Comparison between these groups at the time of this decision showed no significant differences. In both, the number of diuretics and diuretic doses administered was very high with significant renal dysfunction (Table 3). Patients who received UF at discharge had higher glomerular filtration rate (GFR; UF: 39.2 ± 18.2 vs. control: 28.7 ± 13.4 mL/min; P = 0.031) and higher diuresis (UF: 2184 ± 735 vs. control: 1335 ± 297 mL; P = 0.0001) with less need for MRA (UF: 66% vs. control: 100%; P = 0.007) and lower doses of furosemide (UF: 102.76 ± 22.5 vs. control: 122.5 ± 37.26 mg/day; P = 0.021) and tolvaptan (UF: 23.18 ± 14.01 vs. control: 36.00 ± 8.22 mg/day; P = 0.03). Days of hospital stay were shorter in the UF group (UF: 11.7 ± 10.1 vs. control: 19.1 ± 14.4 days; P = 0.027) (Table 4). There were seven in‐hospital deaths: three in the UF group and four in the conventional diuretic treatment group. Therefore, total in‐hospital mortality was 12.5%, with no differences between the groups.
Table 3.
Patients' characteristics at the assignment moment (UF vs. control group)
| UF patients n = 35 | Control group n = 21 | P | |
|---|---|---|---|
| Diuretic escalation days a | 3.91 ± 1.15 | 3.86 ± 1.06 | 0.854 |
| Diuretic treatment (n, %) | |||
| Furosemide | 35 (100) | 21 (100) | 1.000 |
| Furosemide + 3HSS | 15 (43) | 10 (48) | 0.729 |
| Furosemide iv (mg/day) a | 236.9 ± 79.7 | 249.5 ± 69.4 | 0.442 |
| MRA | 26 (74) | 17 (81) | 0.806 |
| MRA (mg/day) a | 49.0 ± 34.2 | 52.6 ± 31.1 | 0.274 |
| Thiazide | 21 (60) | 15 (71) | 0.565 |
| Thiazide (mg/day) a | 28.0 ± 11.8 | 28.3 ± 12.0 | 0.101 |
| Acetazolamide | 9 (26) | 5 (24) | 0.873 |
| Acetazolamide (mg/day) a | 250 ± 0.0 | 250 ± 0.0 | 1.000 |
| Tolvaptan | 15 (43) | 8 (38) | 0.944 |
| Tolvaptan (mg/day) a | 31.0 ± 13.3 | 32.5 ± 19.9 | 0.187 |
| SGLT2i | 16 (46) | 9 (43) | 0.949 |
| SGLT2i (mg/day) a | 10 ± 0.0 | 10 ± 0.0 | 1.000 |
| Analytic a | |||
| Glomerular filtration rate (CKD‐EPI) | 32.4 ± 20.5 | 34.6 ± 20.4 | 0.296 |
| Creatinine pre‐UF (mg/dL) | 2.3 ± 1.0 | 2.1 ± 0.9 | 0.462 |
| Haemoglobin pre‐UF (g/dL) | 11.5 ± 2.3 | 11.2 ± 2.2 | 0.362 |
| Haematocrit pre‐UF (%) | 35.9 ± 6.5 | 35.3 ± 6.2 | 0.268 |
| K+ pre‐UF (mEq/L) | 4.2 ± 0.7 | 4.3 ± 0.8 | 0.369 |
| Na+ pre‐UF (mEq/L) | 137.9 ± 5.9 | 137.4 ± 5.1 | 0.256 |
| Otros a | |||
| Diuresis pre‐UF (mL/day) | 1403 ± 582 | 1303 ± 304 | 0.496 |
| Weight pre‐UF (kg) | 81.1 ± 16.3 | 77.2 ± 12.6 | 0.405 |
3HSS, 3% hypertonic saline solution; CKD‐EPI, Chronic Kidney Disease Epidemiology Collaboration; MRA, mineralocorticoid receptor antagonist; SGLT2i, sodium–glucose cotransporter type 2 inhibitors; UF, ultrafiltration.
The dosage of diuretics, as well as the calculation of statistical differences between them, is exclusively between the patients who took them.
Mean and standard deviation.
Table 4.
Patients' characteristics at hospital discharge
| UF patients n = 35 | Control group n = 21 | P | |
|---|---|---|---|
| Duration of entry (days) | 11.7 ± 10.1 | 19.1 ± 14.4 | 0.027 |
| Analytic, weight, diuresis a | |||
| Glomerular filtration rate (CKD‐EPI) | 39.2 ± 18.2 | 28.7 ± 13.4 | 0.031 |
| Creatinine (mg/dL) | 2.0 ± 1.0 | 2.4 ± 1.0 | 0.149 |
| Haemoglobin (g/dL) | 11.5 ± 2.2 | 11.2 ± 1.7 | 0.399 |
| Haematocrit (%) | 36.1 ± 6.5 | 35.2 ± 4.3 | 0.418 |
| K+ (mEq/L) | 4.0 ± 0.6 | 4.3 ± 0.5 | 0.057 |
| Na+ (mEq/L) | 138 ± 5 | 139 ± 5 | 0.478 |
| Diuresis at discharge | 2184 ± 735 | 1335 ± 297 | 0.0001 |
| Discharge weight | 75.2 ± 15.8 | 75.0 ± 12.4 | 0.085 |
| No. of diuretics at discharge a | 2.59 ± 1.86 | 2.75 ± 1.12 | 0.69 |
| Oral diuretic treatment (n, %) | |||
| Furosemide | 35 (100) | 21 (100) | 1 |
| Furosemide (mg/day) a | 102.76 ± 22.5 | 122.5 ± 37.26 | 0.021 |
| MRA (%) | 23 (66) | 21 (100) | 0.007 |
| MRA (mg/day) a | 32.96 ± 23.32 | 46.25 ± 29.55 | 0.1 |
| Thiazide (%) | 17 (49) | 14 (67) | 0.290 |
| Thiazide (mg/day) a | 25.00 ± 11.18 | 29.46 ± 11.61 | 0.286 |
| Acetazolamide (%) | 5 (14) | 4 (19) | 0.925 |
| Acetazolamide (mg/day) a | 250.00 ± 00.00 | 250.00 ± 00.00 | 1.000 |
| Tolvaptan (%) | 12 (34) | 8 (38) | 0.773 |
| Tolvaptan (mg/day) a | 23.18 ± 14.01 | 36.00 ± 8.22 | 0.03 |
| SGLT2i | 18 (51) | 11 (52) | 0.836 |
| SGLT2i (mg/day) a | 10.00 ± 0.00 | 10.00 ± 0.00 | 1.000 |
CKD‐EPI, Chronic Kidney Disease Epidemiology Collaboration; MRA, mineralocorticoid receptor antagonist; SGLT2i, sodium–glucose cotransporter type 2 inhibitors; UF, ultrafiltration.
The dosage of diuretics, as well as the calculation of statistical differences between them, is exclusively between the patients who took them.
Mean and standard deviation.
Intra‐group comparison
In the group of patients undergoing UF, a comparison of the situation before allocation and at discharge showed that these patients had an improvement in GFR, an increase in urine output, and a reduction in creatinine and weight at discharge (P < 0.001) (Figure 1 ). Patients in the control group also experienced some improvement from the time of allocation to hospital discharge, but only in weight reduction (P < 0.001); there was no change in urine output (P = 0.445) and there was a deterioration in renal function (GFR: P = 0.054, creatinine: P = 0.027) (Figure 2 ).
Figure 1.
Renal function, urine output, and weight in the ultrafiltration group.
Figure 2.
Renal function, diuresis, and weight in the control group.
Discussion
Within the natural history of patients diagnosed with HF, the need for urgent medical attention and hospital admission due to decompensation is common. The most common reason for admission is pulmonary or pulmonary and systemic congestion. However, a subgroup of these patients presents with a clinical picture marked primarily by systemic‐predominant congestion. 3 The usual approach during the first days of hospital stay is to progressively increase the dose of loop diuretics and add others (sequential nephron blockade). However, sometimes, there is a poor diuretic response due to resistance to these drugs. It is in this context that UF could improve the situation and would be more beneficial than maintaining intensive diuretic treatment. This study has shown that, in this clinical profile of patients, the use of peripheral UF in the hospital ward compared with conventional treatment produces greater decongestion with greater renal protection and, in addition, reduces the total diuretic load at discharge and shortens the number of days of hospital stay.
In this study, the mean age of the patients was ~72 years and the most frequent underlying heart disease was ischaemic heart disease. In this respect, patients are older than in other UF studies [mean age of 67 years in the Aquapheresis vs. Intravenous Diuretics and Hospitalization for Heart Failure (AVOID‐HF) study 5 and 69 years in the Cardiorenal Rescue Study in Acute Decompensated Heart Failure (CARRESS‐HF) trial]. 6 Otherwise, the clinical profile is similar in the studies, with a majority of males and ischaemic aetiology and the common presence of other cardiovascular risk factors (arterial hypertension and diabetes mellitus). Most of the patients in the present analysis have HF with reduced ejection fraction (HFrEF), consistent with the usual UF studies. However, all patients were included in the analyses regardless of left ventricular ejection fraction, since, in 2013, a study conducted in HF with preserved ejection fraction showed that, with UF, the response in these patients who fulfil the indication is similar to those of HFrEF in terms of weight, hydroelectrolyte alterations, and mortality. 7
The UF model chosen is a peripheral venous access UF, a technique that uses a portable UF console together with a disposable extracorporeal blood circuit. It allows effective sodium and water removal across a semi‐permeable membrane, in response to a transmembrane gradient created by the hydrostatic pressure difference. 8 Thus, the ultrafiltrate product is isotonic, whereas the diuresis produced by loop diuretics is predominantly hypotonic, so UF removes more sodium (and less potassium) than diuretics, for an equivalent volume loss. Therefore, the favourable effects are not reproduced by equivalent fluid volume removal by a high‐dose intravenous diuretic. Potential advantages of UF include greater control over the rate and volume of fluid removal, greater net sodium loss, and less neurohormonal activation. 8 , 9
Regarding the comparison between the two groups (UF vs. conventional treatment), it was found that patients who received UF had a shorter hospital stay, with higher diuresis and lower weight. In this regard, some previous studies support these results. Thus, in 2005, the Relief for Acutely Fluid‐Overloaded Patients with Decompensated Congestive Heart Failure (RAPID‐CHF) trial was the first randomized controlled study of UF as a treatment for acute HF in 40 patients and proved that fluid clearance at 24 h and dyspnoea and HF symptoms at 48 h were significantly improved with UF. 10 In the same line, in 2007, the UNLOAD trial (Ultrafiltration Versus Intravenous Diuretics for Patients Hospitalized for Acute Decompensated Heart Failure), the largest in the field, showed that compared with patients receiving intravenous loop diuretics, those randomized to the UF arm had greater weight and fluid loss at 48 h and a 53% reduction in the risk of rehospitalization for HF at 90 days (P = 0.037). 11 However, other major studies had shown less encouraging results. The 2012 CARRESS‐HF trial demonstrated that a stepwise pharmacological treatment algorithm was superior and safer than a fixed rate of 200 mL/h UF for the preservation of renal function at 96 h. 6 , 12 Therefore, there is still interest in finding out the effects of this therapy in real clinical practice, beyond the contradictory results of previous studies. Furthermore, UF patients at discharge had better renal function compared with the control group, consistent with the results of the Continuous Ultrafiltration for Congestive Heart Failure (CUORE) clinical trial. 13 This is probably due to several factors. On the one hand, during UF, all diuretics were discontinued except for MRA; this is an action already reported in the literature in some of the main studies on UF in HF. 5 , 6 , 11 , 14 As HF progresses and the dose of diuretic treatment is increased, the kidney becomes less responsive to diuretics by several mechanisms: increased venous pressure, decreased renal perfusion, erratic absorption of diuretics, neurohormonal activation, hypotonic urine elimination, nephron resistance due to receptor overexpression and escape mechanisms, and so forth. 15 Discontinuing diuretics during UF allows the nephron to rest and decreases nephron resistance to drugs. 15 , 16 , 17 This, added to the decongestion carried out by the isotonic plasma volume extracted during UF, favours the recovery of its sensitivity to diuretic treatment, by reversing the pathophysiological mechanisms that acted on it. 15 , 16 , 18 These facts are reflected in our results; during the UF process itself, despite the absence of diuretic treatment and already obtaining negative fluid balances through extraction by the machine, an increase in diuresis was observed in our patients concerning the pre‐UF period, when they received full tolerated doses of diuretics.
This study has some limitations, such as the number of cases in the control group, but these were the patients admitted in that period with similar characteristics to the UF group. Being retrospective, there was no clear time of assignment to the control group, although we chose the time at which diuretic treatment was clinically stabilized according to medical criteria, which occurred 3.86 ± 1.06 days after admission. Despite its retrospective nature, all data were completed prospectively during admission and at patient discharge in the database available in the HF Unit of the department. Another limitation was that assignment to one group or the other depended on the attending physician, although the baseline clinical profile of both groups was the same. Despite these limitations, it should be noted that there are few rigorous clinical trials of UF as a treatment for HF, and most are small, retrospective, uncontrolled, and with short follow‐up. In addition, most UF studies are performed with conventional UF devices (which require high flows and therefore a central catheter). There are no studies in the literature that compare with a control group the peripheral venous route performed in a conventional cardiology hospital ward in real clinical practice. Finally, in all patients in the series, UF was performed by the same HF Unit staff. This is an initial experience, which of course needs to be tested with a larger number of patients.
In conclusion, in patients with HF hospitalized for systemic‐predominant congestion with an insufficient diuretic response after initial diuretic escalation, UF produces greater decongestion, greater renal protection, and a reduction in the total diuretic burden compared with conventional treatment. In addition, UF also reduces hospital stay.
Conflict of interest
None declared.
Funding
No funding sources.
López‐Vilella, R. , Guerrero Cervera, B. , Sánchez‐Lázaro, I. , Donoso Trenado, V. , Soldevila Orient, A. , Devesa Such, R. , Martínez Dolz, L. , Sánchez Pérez, P. , and Almenar Bonet, L. (2023) Therapeutic approach in heart failure with poor diuretic response: peripheral ultrafiltration vs. conventional treatment. ESC Heart Failure, 10: 2290–2297. 10.1002/ehf2.14386.
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