Redefining the therapeutic objective in decompensated heart failure: Hemoconcentration as a surrogate for plasma refill rate

Background: Acute decompensated heart failure is a growing epidentiologic problem about which little consensus exists OD guidelines and recommendations for therapy. Methods and Results: Available databases suggest that a large percentage of patients are being inadequately decongested while hospitalized, resulting in poor clinical outcomes. This is partly from a lack of an appropriate target to define therapeutic success. The demonstration of a prerenal state by blood work does not indicate adequate decongestion but rather means that the rate of fluid removal has exceeded the plasma refill rate. Hemoconcentration, as evidenced by a rising hematocrit is an appropriate surrogate to indicate that the plasma refill rate has been exceeded by the rate of fluid removal. This surrogate of plasma refill rate can be easily and continuously measured by using an in-line hematocrit sensor during ultrafiltration therapy. Conclusion: We propose that the therapeutic objective in acute decompensated heart failure should be redefined and that the rate of volume extraction should be adjusted to approximate the plasma refill rate and that complete decongestion will have occurred only once hemoconcentration is observed at minimal rates of volume extraction.