Coverage Policy Manual
Policy #: 2006038
Category: Medicine
Initiated: December 2006
Last Review: October 2018
  Ultrafiltration in Decompensated Heart Failure

Description:
Congestive heart failure is a relatively common problem and frequently results in hospitalizations and readmissions. Various approaches are being explored in treating these patients, especially those who are refractory (unresponsive) to conventional therapy. Ultrafiltration is one technique receiving increasing publicity for a possible role in hospitalized patients with marked volume overload from congestive heart failure. Ultrafiltration is a process to remove fluid from the blood by using pressure differentials during treatment with a dialysis machine or similar filtration device.
 
Proponents of this technique suggest that it may offer the potential for greater and more expeditious volume and sodium removal compared with conventional therapies. Ultrafiltration is generally used for those with decompensated heart failure whose fluid overload is unresponsive to medical management. In some recent studies, this technique is also referred to as aquapheresis. Work is also beginning on newer devices which could allow for continuous ultrafiltration in ambulatory patients.  For example, in 2006, researchers at UCLA reported on use of a continuous device in animals (Gura, 2006).
 
In June 2002, the “Aquadex™ FlexFlow™ System” (CHF Solutions) was cleared for marketing by the FDA through the 510(k) process. An updated/amended 510(k) approval (classified as a high permeability dialysis system) was given in September 2007 following some modifications. The FDA determined that this device was substantially equivalent to existing devices for use in temporary (up to 8 hours) ultrafiltration treatment of patients with fluid overload who have failed diuretic therapy, and for extended (longer than 8 hours) ultrafiltration treatment of patients with fluid overload who have failed diuretic therapy and require hospitalization.
  
There is no specific CPT code for this procedure.  This procedure should be billed with 90999 - unlisted dialysis procedure, inpatient or outpatient.

Policy/
Coverage:
Effective December 2012
The use of ultrafiltration for the treatment of decompensated heart failure does not meet benefit certificate primary coverage criteria due to lack of scientific evidence of effectiveness in improving health outcomes as determined by a randomized controlled trial.
 
For contracts without primary coverage criteria, the use of ultrafiltration for the treatment of decompensated heart failure is considered investigational and is not covered.  Investigational services are exclusions in the member benefit contract.
 
Effective prior to December 2012
 The use of ultrafiltration for the treatment of decompensated heart failure does not meet benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes. This treatment is currently being studied in a randomized controlled trial.
 
For contracts without primary coverage criteria, the use of ultrafiltration for the treatment of decompensated heart failure is considered investigational and is not covered.  Investigational services are exclusions in the member benefit contract.

Rationale:
In evaluating this technology, the primary question is whether or not this intervention improves important health outcomes. While removal of fluid and sodium (and weight) is important, these are viewed as surrogate outcomes. Information will be needed about impact on survival, hospitalization, complications, and quality of life for this treatment compared to comparable groups receiving conventional treatment. Since this treatment does not directly impact cardiac function, the overall impact on outcomes is difficult to predict. The studies published to date are very limited, both in terms of study population and in terms of duration of follow-up.
 
Bart and colleagues reported on a small randomized trial looking at safety and efficacy involving a total of 40 hospitalized patients with heart failure in which an 8-hour ultrafiltration (UF) session with usual care was compared to usual care alone.  The primary endpoint was weight (fluid) loss after 24 hours. Weight loss was 2.5 kg in the experimental group and 1.86 kg in the usual care group (p=0.24); differences in fluid removal (4650 vs. 2838) were statistically significant.
 
Costanza reported results on use of ultrafiltration before diuretics in 20 patients with heart failure and diuretic resistance.  They found both volume reduction and loss of weight. They also indicated that length of hospital stay was reduced.
 
Results of a larger randomized study, the UNLOAD clinical trial (UltrafiltratioN vs. intravenous diuretics for patients hospitaLized fOr Acute Decompensated congestive heart failure), were reported at the 2006 American College of Cardiology Scientific Session and are summarized on the manufacturer’s website.  In this study, 200 patients at 28 sites were randomized to received ultrafiltration or standard care. The summary results indicate that use of ultrafiltration resulted in a 30 to 40% greater weight and fluid loss. They also reported a reduction in readmissions during a 90 day period following hospital discharge.
 
Finally, Dable reported results in nine patients with acute decompensated heart failure.  They used a “portable” machine with peripheral IV catheters that did not require dialysis or intensive care unit. The mean length of time for ultrafiltration was 33 hours with removal of a mean volume of 7.0 liters and mean weight loss of 6.2 kgs.
 
At this time, there is limited published evidence to evaluate the impact of this technique on important clinical outcomes. There is much activity in this area as reflected through abstracts from scientific meetings. However, many of the reports are case series. The published clinical trials involve small numbers of patients and report short-term to intermediate outcomes. Results of the UNLOAD study, once published, may provide further useful information. However, based on the current published information, the data do not provide sufficient information to evaluate the impact on relevant outcomes. Thus, this is considered investigational.
 
2009 Update
Costanza and colleagues published results from the UNLOAD clinical trial which was a randomized prospective multi-center trial of early ultrafiltration compared to intravenous diuretics in 200 patients that were hospitalized with heart failure and hypervolemia (Costanza et al, 2007).  Ultrafiltration was given without a standard protocol versus intravenous diuretics using a defined protocol.  At 48 hours, the weight loss was greater in the ultrafiltration group (5.0± 3.1 kg) than in the standard group (3.1± 3.5 kg).  Dyspnea scores were similar in both groups at 48 hours and 8 hours after randomization. There was no difference in serum creatinine levels between the two groups and the number of deaths between the groups was similar.  Follow-up in this study was complete at 90 days post randomization.
 
In 2009 the ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure were published.  Ultrafiltration received a level IIa recommendation for patients with refractory end-stage heart failure not responding to medical therapy.  However, this class of recommendation suggests that “additional studies with focused objectives are needed” (Jessup et al, 2009).
 
In an editorial by Elkayam et al, the authors point out that even though there was a larger overall fluid loss in the UNLOAD study with ultrafiltration versus diuretics, there was no impact on the length of hospital stay. “Although there are potential theoretical advantages to removal of excess volume with ultrafiltration compared to diuretics, the validity of such a concept needs to be proven in larger studies designed to compare efficacy, safety, and cost-effectiveness of a comparable net fluid loss with these 2 therapeutic modalities in patients with CHF due to both systolic and diastolic LV dysfunction” (Elkayam et al, 2007).
 
In summary, there is a lack of scientific evidence that ultrafiltration is effective in improving health outcomes on a long-term basis (beyond 90 days) or is as cost-effective as diuretics. Therefore, the policy remains unchanged.
 
2010 Update
The policy was updated with a MEDLINE search through May 2010. No publications from randomized, clinically controlled trials were identified. One additional case study was published during this period. Of note, several clinical trials have begun recruiting subject according to the www.ClinicalTrials.gov website. A multicenter, randomized controlled trial (NCT00608491) is currently being conducted using ultrafiltration versus standard medical drug therapy in the treatment of patient with acute decompensated heart failure and cardiorenal syndrome.
 
A study by Giglioli et al. from Italy compared hemodynamic parameters in 15 patients before and after slow continuous ultrafiltration (SCUF). Each patient was NYHA Class III or IV at the onset of treatment. Hemodynamic parameters were measured using a pressure recording analytical method (PRAM), described as a minimally invasive monitor in the radial artery. Also measured were reductions in weight, edema, dyspnea, response to diuretics and B-type natriuretic peptide (BNP) level (Giglioli, 2010). The authors were able to demonstrate a significant inverse relationship between volumes of fluid removed utilizing this SCUF method and clinical measures of weight (-7.4%, p < 0.01), edema and dyspnea, diuretic resistance, and plasma BNP levels (21,810 +/- 13,016 to 8,581 +/- 5,549, p <0.01). Secondary endpoints of hemodynamic measures utilizing PRAM monitor were observed to correlate positively in cardiac output, contractile cardiac efficiency, and reduced systemic vascular resistance.
 
This study does not include a comparison to standard therapies. Given the small study size, the lack of a control group and the focus on the unique hemodynamic measures of PRAM, this study does not lead to a change in the policy statement.
 
In 2008, researchers in Italy also published a case series on wearable device on humans. Six subjects with volume overload were treated for 6 hours with the novel system. Fluid removal rate ranged from 116ml/hr to 288ml/hr, at an overall average blood flow rate at 116ml/min. Sodium removal averaged 151 mmol over the six hours. Each patient in the study maintained cardiovascular stability (Ronco, 2008).  The authors speculate that a device designed to operate continuously at a slower hourly rate would avoid the cardiovascular instability that requires monitoring, and could have an impact on outcomes.
 
Technology Assessments, Guidelines and Position Statements
 
Two recently published consensus statements give limited recommendations regarding the clinical value of ultrafiltration in the treatment of patients with heart failure. The European Society of Cardiology Task Force's guidelines on the diagnosis and treatment of acute heart failure stated that ultrafiltration should be considered to reduce fluid overload in selected patients, and to correct hyponatremia in symptomatic patients that are refractory to diuretics (Dickstein, 2008). The guidelines noted, however, that the appropriate selection criteria for ultrafiltration have not been established. The 2009 ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults (under Recommendations for Hospitalized Patient) lists ultrafiltration as a Class IIa recommendation (benefit greater than risk, additional studies needed) and a Level of Evidence of B (conflicting evidence) (Jessup, 2009). The new recommendation states “Ultrafiltration is reasonable for patients with refractory congestion not responding to medical therapy.”
 
Summary
 
The quality of the evidence to date remains limited. Ninety day readmission appears to be reduced in the ultrafiltration group in one study, but otherwise no studies to date address long-term mortality or morbidity, or quality of life outcomes. Clinical trials currently underway may provide information that the existing body of evidence does not possess.
 
2012 Update
A search of the MEDLINE database was conducted through September 2012.  There was no new information identified that would prompt a change in the coverage statement. The following is a summary of the key identified literature.
 
The evidence on the efficacy of ultrafiltration consists of one multicenter RCT, the UNLOAD trial, and several smaller, single-center RCTs. The UNLOAD trial reports on physiologic and clinical outcomes, while the single-center studies primarily report on physiologic outcome measures. The UNLOAD trial was discussed previously in an earlier update.
 
Single-center studies published since the last policy update are summarized as follows:
 
Badawy et al. Badawy and colleague performed an RCT of 40 patients with heart failure in Egypt (Badawy, 2012). Patients were randomized to 72 hours of ultrafiltration versus diuretics. Weight loss and total fluid output were greater in the ultrafiltration group, and length of stay in the ICU was less for the ultrafiltration group. There were no significant differences between groups in 30-day mortality, cardiac output, or stroke volume.
 
Hanna et al. This single-center study from the US evaluated 36 patients with advanced heart failure admitted to the ICU (Hanna, 2012). Patients were randomized to ultrafiltration or conventional care. The primary endpoint was the time required for the pulmonary capillary wedge pressure to be maintained at 18mmHg or lower for four consecutive hours, and there was no significant difference on this endpoint between groups. There were also no significant differences in kidney function, cardiac biomarkers, or adverse events. The ultrafiltration group had a significantly greater weight reduction, a higher total volume of fluid removed, and a shorter length of stay.
 
The Effects of Ultrafiltration versus diuretics on clinical, biohumoral and hemodynamic variables in patients with decompensated heart failure (ULTRADISCO) study randomized 30 patients to ultrafiltration or diuretics (Giglioli, 2011). There was improvement for the ultrafiltration group on a number of hemodynamic measures, including cardiac index, stroke volume index, cardiac power output, cardiac efficiency, and systemic vascular resistance. There were no significant differences between groups on symptom scores, NYHA class, amount of fluid removed, or creatinine levels.
 
Ongoing Clinical Trials
The CARESS-HF trial is an ongoing multicenter RCT sponsored by the National Heart Lung and Blood Institute (Bart, 2012). The objective of this trial is to determine whether ultrafiltration is superior to diuretic therapy for patients presenting with heart failure, fluid overload, and worsening renal impairment. The main outcomes of the trial are reductions in weight and improvement in renal function at 96 hours of treatment. Planned enrollment is for approximately 200 patients, and enrollment is scheduled to be completed sometime in 2012.
 
The AVOID-HF trial (NCT01474200), a multicenter randomized, open-label trial sponsored by Gambro Renal Products, Inc., is currently recruiting patients. The purpose of the trial is to assess the number of heart failure events after receiving Aquapheresis versus intravenous diuretics. Enrollment began in January 2012 and is scheduled to be completed in February 2014.
 
Summary
The evidence on ultrafiltration for refractory heart failure is insufficient to form conclusions on whether health outcomes are improved. Several randomized studies report improvements on physiologic measures, and some report reductions in ICU stay and/or readmissions for heart failure. However, these trials do not demonstrate improvement on relevant clinical outcomes, and the improvements in physiologic parameters and utilization measures are not consistent across studies. In addition, the available trials have methodologic limitations, and the outcomes reported are short to medium term. Finally, this treatment is currently being studied in two large multicenter trials.
 
Addendum to 2012 Update
In December, 2012, Bart and colleagues published results of the CARRESS study,  a randomized controlled trial of ultrafiltration in decompensated congestive heart failure (Bart, 2012).  In this trial 188 patients with decompensated heart failure were randomly assessed to receive ultrafiltration or stepped pharmacological therapy. Ultrafiltration was inferior to pharmacologic therapy as measured by change in the serum creatinine level and body weight 96 hours after enrollment. At 96 hours, the mean change in the creatinine level was greater in the pharmacologic group as compared to those in the ultrafiltration group.  No significant difference was noted in weight loss between the two groups. Ultrafiltration was associated with a higher rate of serious adverse events.
 
In summary, there is a lack of scientific evidence that ultrafiltration improves health outcomes in the treatment of decompensated heart failure.
  
2014 Update
A literature search conducted through September 2014 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
Systematic reviews and meta-analyses
Four systematic reviews (including two meta-analyses) of RCTs have been published (Zhi, 2013; De Vecchis, 2014; Kwong, 2014; Wen, 2013).  All of the reviews found ultrafiltration resulted in significantly greater weight loss and fluid removal than diuretic therapy. Three reviews found no significant differences in adverse events (Zhi, 2013; De Vecchis, 2014; Wen, 2013).and one found the evidence to be inconclusive (Kwong, 2014). Two reviews reported on all-cause mortality and rehospitalizations and found no significant differences between ultrafiltration and diuresis(Zhi, 2013; Kwong, 2014).Additionally, one review found no significant differences in dyspnea score or increase in creatinine levels Zhi, 2013). Limitations reported in the review included small studies sizes and publication biases.
 
CUORE trial. Marenzi et al. reported on a randomized trial of 56 consecutively hospitalized heart failure patients without severe renal insufficiency who were treated with ultrafiltration (n=27) or standard medical therapy (n=29) (Marenzi, 2014). All patients had left ventricular ejection fraction of 40% or less and fluid overload of 4 kg or more of recent weight gain and were partially responsive to diuretic therapy. The primary endpoint was the incidence of heart failure related rehospitalizations during the 1 year after treatment. Four rehospitalizations occurred in the ultrafiltration group which was significantly lower than the 30 rehospitalizations that occurred in the control group (hazard ratio 0.14, 95% confidence interval 0.04-0.48; p=0.002). In the 1-year follow-up, in the ultrafiltration group, there were 7 deaths (26%) vs. 11 (38%) in the control group (p=0.33). Weight loss at discharge was similar in both groups. (p=0.75).
 
Ongoing Clinical Trials
A search of online site ClinicalTrials.gov on May 25, 2013 identified one Phase 4 ongoing study incorporating ultrafiltration in heart failure patients. In theTolvaptan/Ultrafiltration in the Treatment of Acute Heart Failure (TUF) study, 45 patients will be randomized to usual care, usual care plus tolvaptan or ultrafiltration (NCT01863511). The largest study, the AVOID-HF (Aquapheresis versus Intravenous Diuretics and Hospitalizations for Heart Failure) trial, was terminated early due to patient recruitment challenges (NCT01474200). In this randomized trial, ultrafiltration was to be compared with intravenous diuretics in 810 patients at 40 sites in the United States.
 
2015 Update
A literature search conducted through September 2015 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
A meta-analysis published in 2015, based on 9 trials, reported findings similar to previous analyses (Ebrahim, 2015).  A key finding was that although ultrafiltration was associated with significantly greater weight loss in patients with acutely decompensated HF compared to diuretics, all cause mortality rates did not differ between treatments.
 
2016 Update
A literature search conducted through September 2016 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
Cheng and colleagues published a systematic review and meta-analysis of 7 RCTs (total N=569 participants) evaluating ultrafiltration in decompensated heart failure patients with renal insufficiency (Cheng, 2013). A pooled analysis of 5 RCTs did not find a significant difference between groups in all-cause mortality (odds ratio, 0.95; 95% confidence interval [CI], 0.58 to 1.55; p=0.83). Other analyses conducted by Cheng and colleagues found significantly greater weight and fluid loss with ultrafiltration. In a pooled analysis of 4 RCTs, there was significantly greater weight loss in 48 hours in the ultrafiltration group than in the control group (weighted mean difference [WMD], 1.59; 95% CI, 0.32 to 2.86; p=0.01). Similarly, a pooled analysis of 5 RCTs found significantly greater fluid volume loss in the ultrafiltration group than in the control group (WMD=1.23; 95% CI, 0.63 to 1.82; p<0.001). Data on adverse events were not pooled but the authors reported that rates were similar in both groups.
 
In 2016, Costanzo and colleagues reported on the AVOID-HF (Aquapheresis versus Intravenous Diuretics and Hospitalization for Heart Failure) trial (Costanzo, 2016). This unblinded multicenter RCT tested a strategy of adjustable ultrafiltration and compared it to adjustable intravenous loop diuretic treatment. Eligibility included hospitalization with a primary diagnosis of acute decompensated heart failure, and participants were randomized within 24 hours of hospital admission. The trial originally aimed to include 810 patients and the sample size calculation determined that this number of participants was needed to have sufficient power for the primary end point. However, after enrolling 224 (27.5%) patients, the study sponsor terminated the study due to slow enrollment. The analysis reports on 221 patients (110 in the ultrafiltration group, 111 in the diuretic group) enrolled at the time of study termination. The primary end point, a composite variable comprised of heart failure rehospitalization or unscheduled or outpatient or emergency department treatment for heart failure, occurred in 25% of the ultrafiltration group and 35% of the diuretic group (exact numbers not reported). The difference in event rates between groups was not statistically significant (p=0.106). By 90 days, death occurred in 17 (15%) ultrafiltration patients and 14 (13%) diuretic patients, p=0.827). The proportion of patients who experienced any adverse event or any serious adverse event did not differ significantly between groups, but the ultrafiltration group (15%) experienced significantly more serious adverse events determined to be related to study therapy than the diuretic group (5%; p=0.026).
 
Ongoing and Unpublished Clinical Trials
A search of ClinicalTrials.gov in August 2016 did not identify any ongoing or unpublished trials that would likely influence this review.
 
2017 Update
A literature search conducted using the MEDLINE database through September 2017 did not reveal any new information that would prompt a change in the coverage statement.
 
2018 Update
A literature search was conducted through September 2018.  There was no new information identified that would prompt a change in the coverage statement.  

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Adams KF, Fonarow GC, et al.(2005) Characteristics and outcomes of patients hospitalized for heart failure in the United States: rationale, design, and preliminary observations from the first 100,000 cases in the Acute Decompensated Heart Failure National Registry (ADHERE). Am Heart J, 2005; 149:209-16.

Badawy SS, Fahmy A(2012) Efficacy and cardiovascular tolerability of continuous veno-venous hemodiafiltration in acute decompensated heart failure: a randomized comparative study. J Crit Care 2012; 27(1):106 e7-13.

Bart BA, Boyle A, et al.(2005) Ultrafiltration versus usual care for hospitalized patients with heart failure: the Relief for Acutely Fluid-Overloaded Patients with Decompensatd Congestive Heart Failure (RAPID-CHF) trial. J Am Coll Cardiol, 2005; 46:2043-6.

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 2012; 18(3):176-82.

Bart BA, Goldsmith SR, Lee KL, et al.(2012) Ultrafiltration in decompensated heart failure with cardiorenal syndrome. N Engl J Med 2012;367:2296-2304.

Cheng Z, Wang L, Gu Y, et al.(2015) Efficacy and safety of ultrafiltration in decompensated heart failure patients with renal insufficiency. Int Heart J. May 13 2015;56(3):319-323.

CHF Solutions.(2006) Ultrafiltration's immediate and long-term benefits demonstrated in heart failure patients. www.chfsolutions.com/unload_lbct.html.

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 2007;49(6):676-683.

Costanzo MR, Negoianu D, Jaski BE, et al.(2016) Aquapheresis versus intravenous diuretics and hospitalizations for heart failure. JACC Heart Fail. Feb 2016;4(2):95-105.

Costanzo MR, Saltzberg M, et al.(2005) Early ultrafiltration in patients with decompensated heart failure and diuretic resistance. J Am Coll Cardiol, 2005; 46:2147-51.

Costanzo MR.(2006) The role of ultrafiltration in the management of heart failure. Curr Treat Options Cardiovasc Med, 2006; 8:301-9.

De Vecchis R, Esposito C, Ariano C.(2014) Efficacy and safety assessment of isolated ultrafiltration compared to intravenous diuretics for acutely decompensated heart failure: a systematic review with meta-analysis. Minerva Cardioangiol 2014; 62(2):131-46.

Dickstein K, Cohen-Solal A, Filippatos G et al.(2008) Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008. Eur J Heart Fail 2008; 10(10):933-89.

Ebrahim B, Sindhura K, Okoroh J, et al.(2015) Meta-Analysis of Ultrafiltration versus Diuretics Treatment Option for Overload Volume Reduction in Patients with Acute Decompensated Heart Failure. Arq Bras Cardiol. Jan 27 2015;0. PMID 25626761

Effectiveness of ultrafiltration in treating people with acute decompensated heart failure and cardiorenal syndrome (The CARRESS Study). NCT00608491. Clinical Trials.gov.

Elkayam U, Hatamizadeh P, Janmohamed M.(2007) The challenge of correcting volume overload in hospitalized patients with decompensated heart failure. J Am Coll Cardiol 2007;49(6):684-686.

Giglioli C, Landi D, Cecchi E et al.(2011) Effects of ULTRAfiltration vs. DIureticS on clinical, biohumoral and haemodynamic variables in patients with deCOmpensated heart failure: the ULTRADISCO study. Eur J Heart Fail 2011; 13(3):337-46.

Giglioli C, Landi D, Gensini GF et al.(2010) Cardiac efficiency improvement after slow continuous ultrafiltration is assessed by beat-to-beat minimally invasive monitoring in congestive heart failure patients: a preliminary report. Blood Purif 2010; 29(1):44-51.

Gura V, Beizai M, et al.(2006) Continuous renal replacement therapy for congestive heart failure: the wearable continuous ultrafiltration system. ASAIO J, 2006; 52:59-61.

Hanna MA, Tang WH, Teo BW et al.(2012) Extracorporeal ultrafiltration vs. conventional diuretic therapy in advanced decompensated heart failure. Congest Heart Fail 2012; 18(1):54-63.

Jessup M, Abraham W, Casey D et al.(2009) 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2009; 119(14):1977-2016.

Jessup M, Costanzo MR.(2007) The Cardiorenal Syndrome: Do we need a change of strategy or a change of tactics? J Am Coll Cardiol 2007;53(7):597-599.

Kwong JS, Yu CM.(2014) Ultrafiltration for acute decompensated heart failure: a systematic review and meta-analysis of randomized controlled trials. Int J Cardiol 2014; 172(2):395-402.

Marenzi G, Muratori M, Cosentino ER et al.(2014) Continuous ultrafiltration for congestive heart failure: the CUORE trial. J Card Fail 2014; 20(1):9-17.

Ronco C, Nalesso F, Brendolan A et al.(2008) A wearable hemofilter for continuous ambulatory ultrafiltration. Kidney Int 2008; 73(4):497-502.

Study of heart failure hospitalizations after aquapheresis therapy copared to intravenous (IV) diuretic treatment (AVOID-HF) www.clinicaltrials.gov. Last accessed October 2012.

Tang WH.(2012) Reconsidering ultrafiltration in the acute cardiorenal syndrome. N Engl J Med 2012:367: 2351-2352.

Wen H, Zhang Y, Zhu J et al.(2013) Ultrafiltration versus intravenous diuretic therapy to treat acute heart failure: a systematic review. Am J Cardiovasc Drugs 2013; 13(5):365-73.

Zhi Q, Liang JC.(2013) Diuretics and ultrafiltration in acute heart failure syndrome. Int Heart J 2013; 54(6):390-4.


Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
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