Chief Complaint
The patient was a 73 year old male with atrial fibrillation, coronary artery disease with previous inferior MI, preserved left ventricular systolic function, mild pulmonary hypertension, and renal insufficiency who presented to the hospital with complaints of shortness of breath and fatigue while performing activities of daily living.

History of Present Illness
The patient was volume overloaded and had failed outpatient attempts to adequately diurese using oral and IV diuretics, and a short course of nesiritide. At the time of admission, his serum creatinine was 3.1 mg/dl and his BNP level was 1200. His hospitalization was complicated by a new diagnosis of multiple myeloma, and as part of an evaluation for renal dysfunction, a renal ultrasound demonstrated severe right sided and mild left sided hydronephrosis. The patient underwent bilateral ureteral stenting with subsequent significant bleeding from his urinary tract resulting in a hematocrit of 23. Because of increasing resistance to diuretics and worsening heart failure symptoms, a cardiology consult was obtained on hospital day 13.

Case Details
At the time of consultation, his physical examination was remarkable for a chronically ill appearing man who looked older than his stated age. His blood pressure was 100/58, pulse 118 and irregular. Jugular venous pulsations were seen 3 cm above the clavicle with the patient at 90 degrees. Bilateral coarse crackles were heard throughout the lungs. The abdomen was firm and distended. Anasarca was present with 4+ edema from the feet to the lumbosacral area. Pertinent objective data at time of consult included a chest x-ray that showed cardiomegaly, pulmonary vascular congestion and bilateral pleural effusions.

Despite controlling the patient’s heart rate and several days of achieving net negative diuresis with high dose continuous intravenous infusion of lasix and nesiritide, there was little change in the patient’s edema and chest x-ray. Therefore, peripheral veno-venous our system filtration was performed. A 16 gauge, 35 cm peripheral catheter was placed in the basilic vein under fluoroscopic guidance for blood withdrawal and an 18 gauge standard peripheral IV catheter was placed in the opposite arm for blood return. The nursing staff from a telemetry unit, primed the blood circuit, administered a 1600 unit heparin bolus and followed-up with an infusion of heparin at 120 units/hour administered through the access port (pre-filter) of the system’s withdrawal line. filtration therapy removed 4 liters of plasma water over an 8 hour period. Identical treatments were administered on days 17 and 18, removing a total of 12 liters over 3 treatments. Additionally, this controlled and stable fluid removal allowed the patient to receive a blood transfusion without worsening congestion.

On day 18, the patient’s exam was much improved. His lungs were clearer, his edema was markedly improved and his jugular venous pulsations were not seen above the clavicle with the patient at 90 degrees. The serum creatinine was 2.4 mg/dl. His symptoms were much improved. The patient was transitioned to oral diuretics and discharged to home on hospital day 21.

Discussion
Fluid overload can be challenging to treat in patients showing resistance to conventional diuretics and/or a poor response to natriuretic peptides to stimulate urine output. In this case, filtration provided a rapid, predictable and safe removal of 12 liters of plasma water while maintaining hemodynamic stability and serum electrolytes. This therapy also allowed the patient to receive the benefits of blood transfusion. Because of concerns about the patient’s bleeding from his urinary tract, the usual systemic anticoagulation was successfully avoided by heparinizing the circuit pre-filter.

Case history courtesy of:

Assistant Professor of Medicine/Cardiology

Oregon