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Table 2 Treatment guidelines for the early UF group

From: Early continuous ultrafiltration in Chinese patients with congestive heart failure (EUC-CHF): study protocol for an open-label registry-based prospective clinical trial

General Comments:
1. Once an initial UF rate is chosen, avoid increasing the UF rate unless there are clear indications to do so.
2. Because patients’ plasma refill rate usually declines as fluid is removed, it should be expected that UF rate will need to be decreased during the course of therapy.
3. a IV inotropes if SBP < 110 mmHg and EF < 40% or RV systolic dysfunction.
b Nitroglycerin or Nesiritide if SBP > 120 mmHg (any EF) and Severe Symptoms
A. Choose Initial UF Rate:
 SBP < 100 mmHg: 150 cc/hr.
 SBP 100-120 mmHg: 200 cc/hr.
 SBP > 120 mmHg: 250 cc/hr
B. Decrease starting UF rate by 50 cc/hr if any of the following are present:
a. RV > LV systolic dysfunction
b. sCr increase 0.3 mg/dl above recent baseline
c. Baseline sCr > 2.0 mg/dl
d. History of instability with diuresis or UF in the past
C. Re-evaluate UF rate every 6 h:
1. Evaluate recent BP, HR, UO, sCr, HCT, Net intake/output
2. Consider decreasing UF rate by 50 cc/hr. and checking STAT sCr (unless sent in past 2 h) if:
  a. sCr rise > 15% or > 0.2 mg/dl (whichever is less) compared to prior measurement
  b. HCT rises by > 5% compared to prior measurement
  c. resting SBP decreases > 10 mmHg compared to prior 6 h, but remains > 80 mmHg
  d. UO drops > 50% compared to prior 6 h, but remains > 125 cc/6 h
  e. resting HR increases by > 20 bpm compared to prior 6 h, but remains < 120 bpm
3. Strongly consider holding UF and checking STAT sCr if:
  a. sCr rise by > 30% or > 0.4 mg/dl (whichever is less) compared to prior measurement
  b. HCT rises by > 10% compared to prior measurement
  c. resting SBP decreases > 20 mmHg compared to prior 6 h or is < 80 mmHg
  d. UO < 125 cc/6 h
  e. resting HR increases by 30 bpm compared to prior 6 h or is > 120 bpm
4. If UF held, re-evaluate after laboratory values are available:
  a. If hemodynamics is stable and sCr has plateaued, then consider re-starting UF at rate 50-100 cc/hr. less than previous rate
  b. If persistent volume overload is present, then consider:
   i. Adjusting doses of IV inotropes in patients with LVEF < 40% or RV systolic dysfunction
   ii. Weaning venodilators, especially in patients with HFpEF
   iii. Right heart catheterization
D. Consider completion of UF therapy If ONE of the following occurs:
1. Resolution of congestion (all of following):
  a. Jugular venous pressure < 8 cm H2O
  b. No orthopnea
  c. Trace or no peripheral edema
2. Best Achievable “Dry Weight” has been reached
  a. Evidence of poor tolerance of fluid removal
AND
b. UF rate < 100 cc/hr. or net negative < 1 l/24 h
3. Persistent elevation in sCr > 1.0 mg/dl above baseline at start of UF treatment
4. Persistent hemodynamic instability
E. After completion of UF Therapy:
1. If satisfactory “dry weight” has been reached AND sCr is stable:
  a. Initiate oral loop diuretics with goal to keep net even (new dose of loop diuretics may be less than baseline dose in some patients)
  b. GDMT
2. If sCr, hemodynamics, or UO are NOT stable:
  a. Hold diuretics until sCr is stable for minimum of 12 h, then:
   i. If “Dry Weight” /adequate decongestion has been reached then initiate oral diuretics as above
   ii. If “Dry Weight”/adequate decongestion has NOT been reached then initiate IV diuretics
  b. If elevated sCr or hemodynamic instability persist, then consider bolus of IV fluids
  1. Abbreviations: BP Blood Pressure, BPM Beats per Minute, GDMT Guidelines Directed Medical Therapy, HR Heart Rate, IV Intravenous, LV Left Ventricle, RV Right ventricle, SBP Systolic Blood Pressure, sCr Serum creatinine level, UF Ultrafiltration, UO Urine Output