Place of peritoneal dialysis in the management of treatment-resistant congestive heart failure
2006; Elsevier BV; Volume: 70; Linguagem: Inglês
10.1038/sj.ki.5001918
ISSN1523-1755
AutoresRajnish Mehrotra, Pranay Kathuria,
Tópico(s)Potassium and Related Disorders
ResumoToday, peritoneal dialysis (PD) is considered synonymous with renal replacement therapy used for the management of patients with end-stage renal disease. However, over the 83 years since Ganter first used PD in humans, it has been used for the management of diverse clinical conditions like congestive heart failure (CHF), pancreatitis, psoriasis, and hypothermia as well as to deliver intraperitoneal chemotherapy, in the absence of end-stage renal disease.1.Mehrotra R. Peritoneal dialysis in adult patients without end-stage renal disease.Adv Perit Dial. 2000; 16: 67-72PubMed Google Scholar Of all these other conditions, CHF and intraperitoneal chemotherapy probably remain potentially important therapeutic uses of PD.1.Mehrotra R. Peritoneal dialysis in adult patients without end-stage renal disease.Adv Perit Dial. 2000; 16: 67-72PubMed Google Scholar,2.Mehrotra R. Khanna R. Peritoneal ultrafiltration for chronic congestive heart failure: rationale, evidence and future.Cardiology. 2001; 96: 177-182Crossref PubMed Scopus (43) Google Scholar In this paper, we review the rationale, reported clinical experience, and challenges in the utilization of PD for the management of treatment-resistant CHF. It is estimated that CHF affects approximately 5 million Americans, representing 2.3% of the population; over 550 000 new cases are diagnosed annually. In 2003, CHF was the primary or secondary cause for over 1 million hospital admissions and contributed to about 57 000 deaths in the United States.3.Thom T. Haase N. Rosamond W. et al.Heart Disease and Stroke Statistics – 2006 Update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee.Circulation. 2006; 113: e85-e115Crossref PubMed Scopus (2662) Google Scholar The term 'cardiorenal syndrome' has been used recently to refer to the presence or development of renal dysfunction in patients with CHF. Several studies have documented the high prevalence of renal dysfunction in the presence of CHF. The Acute Decompensated Heart Failure National Registry has compiled a large database of patients with heart failure requiring hospitalization in the United States.4.Adams K.F. Fonarow G.C. Emerman C.L. et al.ASACa: 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: 209-216Abstract Full Text Full Text PDF PubMed Scopus (1649) Google Scholar Among 105 388 patients in a recent report from this registry, 30% had an additional diagnosis consistent with chronic kidney disease. The serum creatinine exceeded 2.0 mg/dl among 20% of the patients, was higher than 3.0 mg/dl in nine patients, and 5% were receiving dialysis therapy. Surprisingly, 46% of registry patients had normal or only mild impairment in systolic function.4.Adams K.F. Fonarow G.C. Emerman C.L. et al.ASACa: 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: 209-216Abstract Full Text Full Text PDF PubMed Scopus (1649) Google Scholar In another prospective study of 6427 patients with clinical diagnosis of CHF and angiographically proven coronary artery disease, 39% had creatinine clearances <60 ml/min.5.Ezekowitz J. McAlister F.A. Humphries K.H. et al.The association among renal insufficiency, pharmacotherapy, and outcomes in 6427 patients with heart failure and coronary artery disease.J Am Coll Cardiol. 2004; 44: 1587-1592Abstract Full Text Full Text PDF PubMed Scopus (314) Google Scholar Not only does renal dysfunction appears to be highly prevalent at the time of admission, it often worsens during the course of hospital stay. In two different studies, 72–75% of patients had an increase in serum creatinine by at least 0.1 mg/dl.6.Gottlieb S.S. Abraham W. Butler J. et al.The prognostic importance of different definitions of worsening renal function in congestive heart failure.J Card Fail. 2002; 8: 136-141Abstract Full Text Full Text PDF PubMed Scopus (487) Google Scholar,7.Smith G.L. Vaccarino V. Kosiborod M. et al.Worsening renal function: what is a clinically meaningful change in creatinine during hospitalization with heart failure?.J Card Fail. 2003; 9: 13-25Abstract Full Text Full Text PDF PubMed Scopus (293) Google Scholar Furthermore, 20–24% of individuals experienced a rise in serum creatinine of ≥0.5 mg/dl. In both these studies, the degree of worsening of renal function was associated with higher risk for death.6.Gottlieb S.S. Abraham W. Butler J. et al.The prognostic importance of different definitions of worsening renal function in congestive heart failure.J Card Fail. 2002; 8: 136-141Abstract Full Text Full Text PDF PubMed Scopus (487) Google Scholar,7.Smith G.L. Vaccarino V. Kosiborod M. et al.Worsening renal function: what is a clinically meaningful change in creatinine during hospitalization with heart failure?.J Card Fail. 2003; 9: 13-25Abstract Full Text Full Text PDF PubMed Scopus (293) Google Scholar These data suggest that 'cardiorenal' syndrome is a common clinical problem and it identifies a subset of patients with CHF with a high likelihood of an adverse clinical outcome. There are several reasons that may account for the high frequency of the coexistence of cardiac and renal dysfunction. First, both CHF and chronic kidney disease share a common group of risk factors like hypertension, diabetes mellitus, and atherosclerosis. Second, some of the neurohormonal systems activated in response to the changes in cardiopulmonary pressures in CHF have the potential to cause progressive damage to both the kidney and the heart. Thus, it has been proposed that sustained activation of the renin–angiotensin–aldosterone system and the sympathetic nervous system may lead to myocardial apoptosis and fibrosis, left ventricular hypertrophy, and worsening heart failure on one hand and glomerulosclerosis and tubulointerstitial fibrosis on the other.8.Brewster U.C. Setaro J.F. Perazella M.A. The renin–angiotensin–aldosterone system: cardiorenal effects and implications for renal and cardiovascular disease states.Am J Med Sci. 2003; 326: 15-24Abstract Full Text Full Text PDF PubMed Scopus (195) Google Scholar,9.Chatterjee K. Neurohormonal activation in congestive heart failure and the role of vasopressin.Am J Cardiol. 2005; 95: 8B-13BAbstract Full Text Full Text PDF PubMed Scopus (159) Google Scholar Third, the compromise in renal function may also be a result of decreased perfusion of the kidneys in the presence of CHF.10.Heywood J.T. The cardiorenal syndrome: lessons from the ADHERE database and treatment options.Heart Fail Rev. 2004; 9: 195-201Crossref PubMed Scopus (114) Google Scholar, 11.Gheorghiade M. De Luca L. Fonarow G.C. et al.Pathophysiologic targets in the early phase of acute heart failure syndromes.Am J Cardiol. 2005; 19: 11G-17GAbstract Full Text Full Text PDF Scopus (231) Google Scholar, 12.Gil P. Justo S. Castilla M.A. et al.Cardio-renal insufficiency: the search for management strategies.Curr Opin Nephrol Hypertens. 2005; 14: 442-447Crossref PubMed Scopus (20) Google Scholar However, studies by Ljungman et al.13.Ljungman S. Laragh J.H. Cody R.J. Role of the kidney in congestive heart failure. Relationship of cardiac index to kidney function.Drugs. 1990; 39: 10-21Crossref PubMed Scopus (240) Google Scholar suggest that renal blood flow may be preserved till the cardiac index falls below 1.5 l/m2. Further, in individual patients, other causes of reduced renal perfusion may be operative like hypovolemia (decreased preload), neurohormonal-mediated vasoconstriction (increased afterload), in association with very high venous pressures.10.Heywood J.T. The cardiorenal syndrome: lessons from the ADHERE database and treatment options.Heart Fail Rev. 2004; 9: 195-201Crossref PubMed Scopus (114) Google Scholar, 11.Gheorghiade M. De Luca L. Fonarow G.C. et al.Pathophysiologic targets in the early phase of acute heart failure syndromes.Am J Cardiol. 2005; 19: 11G-17GAbstract Full Text Full Text PDF Scopus (231) Google Scholar, 12.Gil P. Justo S. Castilla M.A. et al.Cardio-renal insufficiency: the search for management strategies.Curr Opin Nephrol Hypertens. 2005; 14: 442-447Crossref PubMed Scopus (20) Google Scholar, 14.Firth J.D. Raine A.E. Ledingham J.G. Raised venous pressure: a direct cause of renal sodium retention in oedema?.Lancet. 1988; 1: 1033-1035Abstract PubMed Scopus (230) Google Scholar Treatments for heart failure such as diuretics and drugs inhibiting the renin–angiotensin system also have the potential to worsen renal function, especially among patients with advanced CHF or those with pre-existing renal disease. The goals of treatment of heart failure are to improve symptoms, prolong survival, and slow the progression of disease. Most patients with heart failure respond favorably to conventional pharmacological and non-pharmacological interventions. A small group of CHF patients, estimated to be between 50 000 and 200 000 individuals in the United States, are resistant to conventional therapy.15.Hunt S.A. Baker D.W. Chin M.H. et al.ACC/AHA Guidelines for the evaluation and management of chronic heart failure in the adult: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.Circulation. 2001; 104: 2996-3007Crossref PubMed Scopus (1175) Google Scholar,16.Felker G.M. O'Connor C.M. Inotropic therapy for heart failure: an evidence-based approach.Am Heart J. 2001; 142: 393-401Abstract Full Text Full Text PDF PubMed Scopus (196) Google Scholar Most, if not all, patients with treatment-resistant CHF have underlying cardiorenal syndrome. Numerous interventions have been tried in these individuals with treatment-resistant CHF and include intravenous inotropic therapy, dual chamber pacing or resynchronization therapy, mechanical circulatory support, cardiac transplantation, and hospice care. Newer surgical techniques are also being studied in this patient population including left ventricular reconstruction and external compression and splinting.15.Hunt S.A. Baker D.W. Chin M.H. et al.ACC/AHA Guidelines for the evaluation and management of chronic heart failure in the adult: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.Circulation. 2001; 104: 2996-3007Crossref PubMed Scopus (1175) Google Scholar, 17.Adams K.F. Lindenfeld J. Arnold J.M.O. et al.HFSA 2006 Comprehensive Heart Failure Practice Guideline.J Card Fail. 2006; 12: e1-e122Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 18.Hunt S.A. Abraham W.T. Chin M.H. et al.ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, in (vol 2006), American College of Cardiology Web Site.http://www.acc.org/clinical/guidelines/failure//index.pdfDate: 2005Google Scholar, 19.Cleland J.G. Daubert J.C. Erdmann E. et al.The effect of cardiac resynchronization on morbidity and mortality in heart failure.N Engl J Med. 2005; 352: 1539-1549Crossref PubMed Scopus (5203) Google Scholar, 20.McMurray J.J. Pfeffer M.A. Heart failure.Lancet. 2005; 365: 1877-1889Abstract Full Text Full Text PDF PubMed Scopus (674) Google Scholar Numerous symptoms in patients with treatment-resistant CHF can be attributed to the retention of salt and water. These patients, almost invariably with cardiorenal syndrome, are refractory to diuretic therapy, and often develop hyponatremia and hyperkalemia. All these reasons make ultrafiltration strategies particularly attractive in the management of patients with refractory CHF. In this review, we focus on the role of ambulatory peritoneal ultrafiltration in the management of refractory CHF. As salt and water overload as well as azotemia are cardinal manifestations of treatment-resistant CHF, the ultrafiltration strategy used should be successful in removing salt and water as well as the nitrogenous wastes that accumulate secondary to renal insufficiency. PD achieves these goals by two important physiologic processes – diffusion and convection. Diffusion involves the movement of solutes from an area of high concentration to low concentration. Convection is the removal of water from the blood stream into the peritoneal cavity. The driving force for the convective removal during PD depends upon the osmotic agent (see below). Some of the water removed with convection contains dissolved solutes – thus, many solutes are removed via both diffusion and convection. The diffusive and convective processes appear to occur through three different kinds of pores – ultra-small (aquaporins or water channels), small, and large.21.Rippe B. Stelin G. Simulations of peritoneal solute transport during CAPD. Application of two-pore formalism.Kidney Int. 1989; 35: 1234-1244Abstract Full Text PDF PubMed Scopus (196) Google Scholar,22.Rippe B. Stelin G. Haraldsson B. Computer simulations of peritoneal fluid transport in CAPD.Kidney Int. 1991; 40: 315-325Abstract Full Text PDF PubMed Scopus (257) Google Scholar The determinants of ultrafiltration or removal of water with PD are summarized in Table 1. All commercially available PD solutions contain an agent that enhances the removal of fluid from the peritoneal capillaries. Traditionally, dextrose has been used as an osmotic agent to induce ultrafiltration. At any given point of time, the net ultrafiltration reflects a balance of transcapillary ultrafiltration, fluid reabsorption across the peritoneum, and lymphatic absorption;23.Mactier R.A. Khanna R. Twardowski Z. et al.Contribution of lymphatic absorption to loss of ultrafiltration and solute clearances in continuous ambulatory peritoneal dialysis.J Clin Invest. 1987; 80: 1311-1316Crossref PubMed Scopus (90) Google Scholar,24.Nolph K.D. Mactier R. Khanna R. et al.The kinetics of ultrafiltration during peritoneal dialysis: the role of lymphatics.Kidney Int. 1987; 32: 219-226Abstract Full Text PDF PubMed Scopus (62) Google Scholar only the transcapillary ultrafiltration is potentially modifiable. The rate of transcapillary ultrafiltration is dependent upon the osmotic force, which in turn can be increased by increasing the dextrose concentration in the instilled dialysate. Commercially available peritoneal dialysate, thus, are available with three different concentrations of dextrose – 1.5, 2.5, and 4.25%. This, in turn, allows flexibility in tailoring the osmotic force to the need for fluid removal. The instantaneous transcapillary ultrafiltration rate is highest at the time of instillation of dialysate into the peritoneal cavity.24.Nolph K.D. Mactier R. Khanna R. et al.The kinetics of ultrafiltration during peritoneal dialysis: the role of lymphatics.Kidney Int. 1987; 32: 219-226Abstract Full Text PDF PubMed Scopus (62) Google Scholar Over the duration of dwell, the glucose in the dialysate is absorbed into the systemic circulation and is further diluted by the ultrafiltrate.24.Nolph K.D. Mactier R. Khanna R. et al.The kinetics of ultrafiltration during peritoneal dialysis: the role of lymphatics.Kidney Int. 1987; 32: 219-226Abstract Full Text PDF PubMed Scopus (62) Google Scholar Thus, over the duration of dwell, the osmotic gradient dissipates and transcapillary ultrafiltration diminishes. There comes a point when the rate of fluid reabsorption may exceed the transcapillary ultrafiltration leading to a decrease in net fluid removed.24.Nolph K.D. Mactier R. Khanna R. et al.The kinetics of ultrafiltration during peritoneal dialysis: the role of lymphatics.Kidney Int. 1987; 32: 219-226Abstract Full Text PDF PubMed Scopus (62) Google Scholar If the fluid is allowed to stay within the peritoneal cavity for a long-enough duration, the patient may experience negative net ultrafiltration wherein the drain volume is smaller than the instilled volume. It follows, then, that short frequent exchanges with dextrose would maximize fluid removal with dextrose-based dialysate. Furthermore, the rate of dissipation of the osmotic gradient is dependent upon the peritoneal transport rate – an intrinsic function of the peritoneum readily ascertained by the peritoneal equilibration rate.25.Twardowski Z.J. Nolph K.D. Khanna R. et al.Peritoneal equilibration test.Perit Dial Bull. 1987; 7: 138-147Crossref Google Scholar Thus, patients with high or high average peritoneal transport rate are more likely to have negative net ultrafiltration with longer dwell times using dextrose-based dialysate. These patients are more likely to benefit from shorter dwell times with dextrose-based dialysate or the use of alternative osmotic agents like icodextrin.Table 1Determinants of ultrafiltration with peritoneal dialysisPatient-related factors Peritoneal transport rateDialysis prescription Volume of dialysate Osmotic/oncotic agent Dextrose or icodextrin Tonicity of dextrose-based dialysate (1.5, 2.5, or 4.25%) Duration of dwell Shorter dwells with dextrose Long dwells with icodextrinPD, peritoneal dialysis. Open table in a new tab PD, peritoneal dialysis. In addition to water, removal of sodium is important to achieve euvolemia. Early in the duration of dwell, most of the water is solute free as the osmotic force exerted by dextrose results in fluid removal via the aquaporins.26.Nolph K.D. Hano J.E. Teschan P.E. Peritoneal sodium transport during hypertonic peritoneal dialysis. Physiologic mechanisms and clinical implications.Ann Int Med. 1969; 70: 931-941Crossref PubMed Scopus (79) Google Scholar,27.Devuyst O. Nielsen S. Cosyns J.P. et al.Aquaporin-1 and endothelial nitric oxide synthase expression in capillary endothelia of human peritoneum.Am J Physiol. 1998; 275: H234-H242PubMed Google Scholar This forms the physiologic basis for sodium sieving, a decrease in the sodium concentration in the dialysate during the first 60 min of dwell with dextrose-based dialysis solution.26.Nolph K.D. Hano J.E. Teschan P.E. Peritoneal sodium transport during hypertonic peritoneal dialysis. Physiologic mechanisms and clinical implications.Ann Int Med. 1969; 70: 931-941Crossref PubMed Scopus (79) Google Scholar The sodium removed during PD enters the peritoneal cavity via diffusion as well as via convection across the small pores of the peritoneum. An understanding of peritoneal physiology of salt and removal can help selecting appropriate dwell times with PD that maximize the possibility of achieving euvolemia. Thus, dwell times should be short enough to exploit the high transcapillary ultrafiltration early on to maximize water removal but should be long enough to allow the removal of enough sodium as well. Commercially available PD solutions do not contain any potassium. This could be a potential advantage as amelioration of hyperkalemia may allow one to use the optimal doses of drugs like angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, aldosterone antagonists, or beta blockers. However, there is also a greater potential for the development of hypokalemia, which in turn could precipitate serious arrhythmias in patients with underlying heart disease. Similarly, the peritoneal dialysate has low concentrations of magnesium and patients would need to be monitored for hypomagnesemia secondary to the diffusive removal of this electrolyte – another potentially arrhythmogenic condition. Over the past decade, at least two new non-dextrose-based PD solutions have become available. Amino-acid PD fluids, used as a nutritional supplement and as a part of glucose sparing prescriptions, use osmotic force to generate ultrafiltration.28.Jones M. Hagen T. Boyle C.A. et al.Treatment of malnutrition with 1.1% amino acid peritoneal dialysis solution: results of a multicenter outpatient study.Am J Kidney Dis. 1998; 32: 761-769Abstract Full Text PDF PubMed Scopus (157) Google Scholar Icodextrin-based PD solutions use oncotic force rather than an osmotic force to generate ultrafiltration.29.Ho-dac-Pannekeet M.M. Schouten N. Langendijk M.J. et al.Peritoneal transport characteristics with glucose polymer based dialysate.Kidney Int. 1996; 50: 979-986Abstract Full Text PDF PubMed Scopus (167) Google Scholar Icodextrin is an oligosaccharide with an average molecular weight of about 17 000 Da. The oncotic force exerted by this molecule pulls fluid into the peritoneal cavity probably through the small pores without any significant sodium sieving.29.Ho-dac-Pannekeet M.M. Schouten N. Langendijk M.J. et al.Peritoneal transport characteristics with glucose polymer based dialysate.Kidney Int. 1996; 50: 979-986Abstract Full Text PDF PubMed Scopus (167) Google Scholar However, the fluid removal is slower. Furthermore, icodextrin is absorbed much more slowly from the peritoneal cavity, largely through the lymphatics. This allows the oncotic pressure to be maintained for longer periods of time. For these reasons, icodextrin is best suited for single, long dwells complementing the dextrose-based solutions that generate superior ultrafiltration with shorter dwells. After the first description of peritoneal ultrafiltration for the management of treatment-resistant CHF, several investigators have reported their experience with this therapeutic strategy.2.Mehrotra R. Khanna R. Peritoneal ultrafiltration for chronic congestive heart failure: rationale, evidence and future.Cardiology. 2001; 96: 177-182Crossref PubMed Scopus (43) Google Scholar,30.Schneirson S.J. Continuous peritoneal irrigation in the treatment of intractable edema of cardiac origin.Am J Med Sci. 1949; 218: 76-79Crossref PubMed Scopus (48) Google Scholar As outlined above, short, frequent exchanges using dextrose-based dialysate would be the most efficient strategy for peritoneal ultrafiltration in this setting. Based upon the published reports, an ultrafiltration rate of 67–568 ml/min can be achieved using the commercially available dextrose-based solutions.2.Mehrotra R. Khanna R. Peritoneal ultrafiltration for chronic congestive heart failure: rationale, evidence and future.Cardiology. 2001; 96: 177-182Crossref PubMed Scopus (43) Google Scholar As expected, short-term peritoneal ultrafiltration in patients with treatment-resistant acute volume overload is associated with amelioration of hyponatremia,31.Cairns K.B. Porter G.A. Kloster F.E. et al.Clinical and hemodynamic results of peritoneal dialysis for severe cardiac failure.Am Heart J. 1968; 76: 227-234Abstract Full Text PDF PubMed Scopus (42) Google Scholar,32.Malach M. Peritoneal dialysis for intractable heart failure in acute myocardial infarction.Am J Cardiol. 1972; 29: 61-63Abstract Full Text PDF PubMed Scopus (9) Google Scholar reduction in plasma volume 31.Cairns K.B. Porter G.A. Kloster F.E. et al.Clinical and hemodynamic results of peritoneal dialysis for severe cardiac failure.Am Heart J. 1968; 76: 227-234Abstract Full Text PDF PubMed Scopus (42) Google Scholar,33.Mailloux L.U. Swartz C.D. Onesti G. et al.Peritoneal dialysis for refractory congestive heart failure.JAMA. 1967; 199: 873-878Crossref PubMed Scopus (36) Google Scholar and pulmonary capillary wedge pressure, and restoration of diuretic responsiveness31.Cairns K.B. Porter G.A. Kloster F.E. et al.Clinical and hemodynamic results of peritoneal dialysis for severe cardiac failure.Am Heart J. 1968; 76: 227-234Abstract Full Text PDF PubMed Scopus (42) Google Scholar, 33.Mailloux L.U. Swartz C.D. Onesti G. et al.Peritoneal dialysis for refractory congestive heart failure.JAMA. 1967; 199: 873-878Crossref PubMed Scopus (36) Google Scholar, 34.Shilo S. Slotki I.N. Iaina A. Improved renal function following acute peritoneal dialysis in patients with intractable congestive heart failure.Israel J Med Sci. 1987; 23: 821-824PubMed Google Scholar (Table 2). The latter is probably a result of improved renal hemodynamics; use of PD has been shown to result in an increase in inulin clearance, para-amino hippurate clearance, and a reduction in filtration fraction in patients with treatment-resistant CHF.34.Shilo S. Slotki I.N. Iaina A. Improved renal function following acute peritoneal dialysis in patients with intractable congestive heart failure.Israel J Med Sci. 1987; 23: 821-824PubMed Google Scholar Not withstanding these demonstrated benefits, ease of use and demonstrated benefits of extracorporeal ultrafiltration has largely supplanted the inpatient use of PD for the management of acute volume overload associated with treatment-resistant CHF.35.Costanzo M.R. Saltzberg M. O'Sullivan J. Sobotka P. Early ultrafiltration in patients with decompensated heart failure and diuretic resistance.J Am Coll Cardiol. 2005; 46: 2047-2051Abstract Full Text Full Text PDF PubMed Scopus (213) Google Scholar,36.Bart B.A. Boyle A. Bank A.J. et al.Ultrafiltration versus usual care for hospitalized patients with heart failure: the relief for acutely fluid-overloaded patients with decompensated congestive heart failure (RAPID-CHF) trial.J Am Coll Cardiol. 2005; 46: 2043-2046Abstract Full Text Full Text PDF PubMed Scopus (324) Google Scholar However, if extracorporeal therapies are not available or possible, PD can be effectively used for the management of CHF.Table 2Potential roles of ambulatory peritoneal ultrafiltration in patients with refractory congestive heart failureRestore diuretic responsivenessBridge therapy (e.g., valve repair/replacement or cardiac transplantation)Palliative therapy Improve symptoms and exercise tolerance Preserve residual renal function (compared to extracorporeal ultrafiltration) Reduce hospitalizations Improve quality of life Open table in a new tab The role of peritoneal ultrafiltration in the long-term management of treatment-resistant CHF has not been formally evaluated in clinical trials and the published literature is restricted to case series and case reports. These reports are very likely to suffer from publication bias as well as selection bias. With these limitations in mind, it still appears likely that ambulatory peritoneal ultrafiltration probably is beneficial for a subgroup of patients with treatment-resistant CHF. Patients with treatment-resistant CHF often suffer great morbidity, largely from repeated hospitalizations related to recurrent worsening of volume overload. Furthermore, the clinical course of these patients imposes a significant financial burden on third-party payors. Long-term use of extracorporeal ultrafiltration, while feasible, suffers from several limitations. Extracorporeal therapy invariably requires patients to return to health-care facilities and fluid removal is often complicated by hypotension. In this context, peritoneal ultrafiltration is particularly attractive for the management of refractory CHF. In addition to the benefit of restoring diuretic responsiveness among individuals with volume overload, the potential role for ambulatory ultrafiltration is summarized in Table 2. Thus, sustained ultrafiltration with chronic PD has been reported to be successful in maintaining euvolemia until patients undergo definitive therapy like valve replacement surgery or coronary revascularization or cardiac transplantation.31.Cairns K.B. Porter G.A. Kloster F.E. et al.Clinical and hemodynamic results of peritoneal dialysis for severe cardiac failure.Am Heart J. 1968; 76: 227-234Abstract Full Text PDF PubMed Scopus (42) Google Scholar, 37.Weinrauch L.A. Kaldany A. Miller D.G. et al.Cardiorenal failure: treatment of refractory biventricular failure by peritoneal dialysis.Uremia Invest. 1984; 8: 1-8Crossref PubMed Scopus (10) Google Scholar, 38.Ryckelynck J.P. Lobbedez T. Valette B. et al.Peritoneal ultrafiltration and treatment-resistant heart failure.Nephrol Dial Transplant. 1998; 13: 56-59Crossref PubMed Scopus (51) Google Scholar Alternatively, if definitive therapy is not feasible, ambulatory ultrafiltration has been successful in providing significant palliation of patients with treatment-resistant CHF. Salt and water removal with PD are associated with an improvement in functional status in over 90% of patients; the pooled data on the change in functional status with use of peritoneal ultrafiltration from several published studies are summarized in Figure 1.38.Ryckelynck J.P. Lobbedez T. Valette B. et al.Peritoneal ultrafiltration and treatment-resistant heart failure.Nephrol Dial Transplant. 1998; 13: 56-59Crossref PubMed Scopus (51) Google Scholar, 39.Kim D. Khanna R. Wu G. et al.Successful use of peritoneal dialysis in refractory heart failure.Perit Dial Bull. 1985; 5: 127-130Google Scholar, 40.McKinnie J.J. Bourgeois R.J. Husserl F.E. Long-term therapy for heart failure with continuous ambulatory peritoneal dialysis.Arch Intern Med. 1985; 145: 1128-1129Crossref PubMed Scopus (33) Google Scholar, 41.Rubin J. Ball R. Continuous ambulatory peritoneal dialysis as treatment of severe congestive heart failure in the face of chronic renal failure. Report of eight cases.Arch Intern Med. 1986; 146: 1533-1535Crossref PubMed Scopus (37) Google Scholar, 42.Mousson C. Tanter Y. Chalopin J.M. et al.Treatment of refractory congestive cardiac insufficiency by continuous peritoneal dialysis. Long-term course.Presse Med. 1988; 17: 1617-1620PubMed Google Scholar, 43.König P.S. Lhotta K. Kronenberg F. et al.CAPD: a successful treatment in patients suffering from therapy-resistant congestive heart failure.Adv Perit Dial. 1991; 7: 97-101PubMed Google Scholar, 44.Stegmayr B.G. Banga R. Lundberg L. et al.PD treatment for severe congestive heart failure.Perit Dial Int. 1996; 16: S231-S235PubMed Google Scholar, 45.Freida P. Ryckelynck J.P. Potier J. et al.Place de l'ultrafiltration peritoneale dans le traitement medical de l'insuffisance cardiaque au stade IV de la NYHA.Bull Dial Perit. 1995; 5: 7-18Google Scholar, 46.Tormey V. Conlon P.J. Farrell J. et al.Long-term successful management of refractory congestive cardiac failure by intermittent ambulatory peritoneal ultrafiltration.QJM. 1996; 89: 681-683Crossref PubMed Scopus (29) Google Scholar, 47.Bilora F. Petrobelli F. Boccioletti V.F.P. Treatment of heart failure and ascites with ultrafiltration in patients with intractable alcoholic cardiomyopathy.Panminerva Med. 2002; 44: 23-25PubMed Google Scholar, 48.Ortiz A.M. Acosta P.A. Corbalan R. Jalil J.E. Long-term automated peritoneal dialysis in patients with refractory congestive heart failure.Adv Perit Dial. 2003; 19: 77-80PubMed Google Scholar, 49.Gotloib L. Fudin R. Yakubovich M. Vienken J. Peritoneal dialysis in refractory end-stage congestive heart failure: a challenge facing a no-win situation.Nephrol Dial Transplant. 2005; 20: vii32-vii36Crossref PubMed Scopus (73) Google Scholar Furthermore, virtually all of the studies that have addressed the effect of ambulatory peritoneal ultrafiltration on hospitalizations, have demonstrated a significant reduction in the number of hospital days per patient (Figure 2).38.Ryckelynck J.P. Lobbedez T. Valette B. et al.Peritoneal ultrafiltration and treatment-resistant heart failure.Nephrol Dial Transplant. 1998; 13: 56-59Crossref PubMed Scopus (51) Google Scholar, 41.Rubin J. Ball R. Continuous ambulatory peritoneal dialysis as treatment of severe congestive heart failure in the face of chronic renal failure. Report of eight cases.Arch Intern Med. 1986; 146: 1533-1535Crossref PubMed Scopus (37) Google Scholar, 46.Tormey V. Conlon P.J. Farrell J. et al.Long-term successful management of refractory congestive cardiac failure by intermittent ambulatory peritoneal ultrafiltration.QJM. 1996; 89: 681-683Crossref PubMed Scopus (29) Google Scholar, 48.Ortiz A.M. Acosta P.A. Corbalan R. Jalil J.E. Long-term automated peritoneal dialysis in patients with refractory congestive heart failure.Adv Perit Dial. 2003; 19: 77-80PubMed Google Scholar, 49.Gotloib L. Fudin R. Yakubovich M. Vienken J. Peritoneal dialysis in refractory end-stage congestive heart failure: a challenge facing a no-win situation.Nephrol Dial Transplant. 2005; 20: vii32-vii36Crossref PubMed Scopus (73) Google Scholar, 50.Freida P. Ryckelynck J.P. Potier J. et al.Place de l'ultrafiltration peritoneale dans le traitement medical de l'insuffisance cardiaque au stade IV de la NYHA.Bull Dial Perit. 1995; 5: 7-18Google Scholar, 51.Elhalel-Dranitzki M. Rubinger D. Moscovici A. et al.CAPD to improve quality of life in patients with refractory heart failure.Nephrol Dial Transplant. 1998; 13: 3041-3042Crossref PubMed Scopus (41) Google Scholar Finally, the reported complications arising from PD itself (e.g., peritonitis, hernias) appear to be no different from that experienced by end-stage renal disease patients treated with PD and the occurrence is rather low.38.Ryckelynck J.P. Lobbedez T. Valette B. et al.Peritoneal ultrafiltration and treatment-resistant heart failure.Nephrol Dial Transplant. 1998; 13: 56-59Crossref PubMed Scopus (51) Google Scholar, 40.McKinnie J.J. Bourgeois R.J. Husserl F.E. Long-term therapy for heart failure with continuous ambulatory peritoneal dialysis.Arch Intern Med. 1985; 145: 1128-1129Crossref PubMed Scopus (33) Google Scholar, 41.Rubin J. Ball R. Continuous ambulatory peritoneal dialysis as treatment of severe congestive heart failure in the face of chronic renal failure. Report of eight cases.Arch Intern Med. 1986; 146: 1533-1535Crossref PubMed Scopus (37) Google Scholar, 49.Gotloib L. Fudin R. Yakubovich M. Vienken J. Peritoneal dialysis in refractory end-stage congestive heart failure: a challenge facing a no-win situation.Nephrol Dial Transplant. 2005; 20: vii32-vii36Crossref PubMed Scopus (73) Google Scholar Even though formal assessments of quality of life have not been made, these data suggest that PD can offer significant and effective palliation of patients with treatment-resistant CHF. Finally, although the data are not consistent, it appears that PD does not alter the natural history of the disease and thus, probably has no significant effect on survival of patients with CHF.41.Rubin J. Ball R. Continuous ambulatory peritoneal dialysis as treatment of severe congestive heart failure in the face of chronic renal failure. Report of eight cases.Arch Intern Med. 1986; 146: 1533-1535Crossref PubMed Scopus (37) Google Scholar, 44.Stegmayr B.G. Banga R. Lundberg L. et al.PD treatment for severe congestive heart failure.Perit Dial Int. 1996; 16: S231-S235PubMed Google Scholar, 49.Gotloib L. Fudin R. Yakubovich M. Vienken J. Peritoneal dialysis in refractory end-stage congestive heart failure: a challenge facing a no-win situation.Nephrol Dial Transplant. 2005; 20: vii32-vii36Crossref PubMed Scopus (73) Google Scholar Not withstanding the lack of survival benefit, the published literature argues for a trial of ambulatory peritoneal ultrafiltration among patients with treatment-resistant CHF, particularly those with frequent hospitalizations.Figure 2The effect of ambulatory PD on hospitalizations of patients with severe refractory CHF.Data summarized from seven studies.38.Ryckelynck J.P. Lobbedez T. Valette B. et al.Peritoneal ultrafiltration and treatment-resistant heart failure.Nephrol Dial Transplant. 1998; 13: 56-59Crossref PubMed Scopus (51) Google Scholar, 41.Rubin J. Ball R. Continuous ambulatory peritoneal dialysis as treatment of severe congestive heart failure in the face of chronic renal failure. Report of eight cases.Arch Intern Med. 1986; 146: 1533-1535Crossref PubMed Scopus (37) Google Scholar, 46.Tormey V. Conlon P.J. Farrell J. et al.Long-term successful management of refractory congestive cardiac failure by intermittent ambulatory peritoneal ultrafiltration.QJM. 1996; 89: 681-683Crossref PubMed Scopus (29) Google Scholar, 48.Ortiz A.M. Acosta P.A. Corbalan R. Jalil J.E. Long-term automated peritoneal dialysis in patients with refractory congestive heart failure.Adv Perit Dial. 2003; 19: 77-80PubMed Google Scholar, 49.Gotloib L. Fudin R. Yakubovich M. Vienken J. Peritoneal dialysis in refractory end-stage congestive heart failure: a challenge facing a no-win situation.Nephrol Dial Transplant. 2005; 20: vii32-vii36Crossref PubMed Scopus (73) Google Scholar, 50.Freida P. Ryckelynck J.P. Potier J. et al.Place de l'ultrafiltration peritoneale dans le traitement medical de l'insuffisance cardiaque au stade IV de la NYHA.Bull Dial Perit. 1995; 5: 7-18Google Scholar, 51.Elhalel-Dranitzki M. Rubinger D. Moscovici A. et al.CAPD to improve quality of life in patients with refractory heart failure.Nephrol Dial Transplant. 1998; 13: 3041-3042Crossref PubMed Scopus (41) Google ScholarView Large Image Figure ViewerDownload Hi-res image Download (PPT) The use of PD offers great flexibility in designing a prescription that is best suited for a given patient (Table 3). Success has been reported with intermittent, self-care PD,38.Ryckelynck J.P. Lobbedez T. Valette B. et al.Peritoneal ultrafiltration and treatment-resistant heart failure.Nephrol Dial Transplant. 1998; 13: 56-59Crossref PubMed Scopus (51) Google Scholar, 46.Tormey V. Conlon P.J. Farrell J. et al.Long-term successful management of refractory congestive cardiac failure by intermittent ambulatory peritoneal ultrafiltration.QJM. 1996; 89: 681-683Crossref PubMed Scopus (29) Google Scholar, 49.Gotloib L. Fudin R. Yakubovich M. Vienken J. Peritoneal dialysis in refractory end-stage congestive heart failure: a challenge facing a no-win situation.Nephrol Dial Transplant. 2005; 20: vii32-vii36Crossref PubMed Scopus (73) Google Scholar continuous ambulatory PD,38.Ryckelynck J.P. Lobbedez T. Valette B. et al.Peritoneal ultrafiltration and treatment-resistant heart failure.Nephrol Dial Transplant. 1998; 13: 56-59Crossref PubMed Scopus (51) Google Scholar, 41.Rubin J. Ball R. Continuous ambulatory peritoneal dialysis as treatment of severe congestive heart failure in the face of chronic renal failure. Report of eight cases.Arch Intern Med. 1986; 146: 1533-1535Crossref PubMed Scopus (37) Google Scholar, 43.König P.S. Lhotta K. Kronenberg F. et al.CAPD: a successful treatment in patients suffering from therapy-resistant congestive heart failure.Adv Perit Dial. 1991; 7: 97-101PubMed Google Scholar, 51.Elhalel-Dranitzki M. Rubinger D. Moscovici A. et al.CAPD to improve quality of life in patients with refractory heart failure.Nephrol Dial Transplant. 1998; 13: 3041-3042Crossref PubMed Scopus (41) Google Scholar, 52.Mousson C. Tanter Y. Chalopin J.M. et al.Treatment of refractory congestive cardiac insufficiency by continuous peritoneal dialysis. Long-term course.Presse Med. 1988; 17: 1617-1620PubMed Google Scholar, 53.Kagan A. Rapoport J. The role of peritoneal dialysis in the treatment of refractory heart failure.Nephrol Dial Transplant. 2005; 20: vii28-vii31Crossref PubMed Scopus (28) Google Scholar automated PD,38.Ryckelynck J.P. Lobbedez T. Valette B. et al.Peritoneal ultrafiltration and treatment-resistant heart failure.Nephrol Dial Transplant. 1998; 13: 56-59Crossref PubMed Scopus (51) Google Scholar, 48.Ortiz A.M. Acosta P.A. Corbalan R. Jalil J.E. Long-term automated peritoneal dialysis in patients with refractory congestive heart failure.Adv Perit Dial. 2003; 19: 77-80PubMed Google Scholar, 53.Kagan A. Rapoport J. The role of peritoneal dialysis in the treatment of refractory heart failure.Nephrol Dial Transplant. 2005; 20: vii28-vii31Crossref PubMed Scopus (28) Google Scholar as well as use of a single night time exchange with icodextrin.54.Bertoli S.V. Ciurlino D. Maccario M. et al.Home peritoneal ultrafiltration in patients with severe congestive heart failure without end-stage renal disease.Adv Perit Dial. 2005; 21: 123-127PubMed Google Scholar,55.Raja R.M. Krasnoff S.O. Moros J.G. et al.Repeated peritoneal dialysis in treatment of heart failure.JAMA. 1970; 213: 2268-2269Crossref PubMed Scopus (13) Google Scholar In patients who do not require full dialytic support, nocturnal automated PD with dextrose-based dialysate or a single night time exchange with icodextrin are particularly conducive to patients. In patients who require full dialytic support, either continuous ambulatory PD (with or without night time icodextrin exchange) or automated PD with day time icodextrin exchange have the greatest promise to achieve euvolemia.Table 3Categories of prescriptions used for ambulatory peritoneal ultrafiltrationIntermittent peritoneal dialysis – manual or automated a. Health-care provider dependent38.Ryckelynck J.P. Lobbedez T. Valette B. et al.Peritoneal ultrafiltration and treatment-resistant heart failure.Nephrol Dial Transplant. 1998; 13: 56-59Crossref PubMed Scopus (51) Google Scholar,55.Raja R.M. Krasnoff S.O. Moros J.G. et al.Repeated peritoneal dialysis in treatment of heart failure.JAMA. 1970; 213: 2268-2269Crossref PubMed Scopus (13) Google Scholar b. Self-care38.Ryckelynck J.P. Lobbedez T. Valette B. et al.Peritoneal ultrafiltration and treatment-resistant heart failure.Nephrol Dial Transplant. 1998; 13: 56-59Crossref PubMed Scopus (51) Google Scholar, 46.Tormey V. Conlon P.J. Farrell J. et al.Long-term successful management of refractory congestive cardiac failure by intermittent ambulatory peritoneal ultrafiltration.QJM. 1996; 89: 681-683Crossref PubMed Scopus (29) Google Scholar, 49.Gotloib L. Fudin R. Yakubovich M. Vienken J. Peritoneal dialysis in refractory end-stage congestive heart failure: a challenge facing a no-win situation.Nephrol Dial Transplant. 2005; 20: vii32-vii36Crossref PubMed Scopus (73) Google ScholarContinuous ambulatory peritoneal dialysis38.Ryckelynck J.P. Lobbedez T. Valette B. et al.Peritoneal ultrafiltration and treatment-resistant heart failure.Nephrol Dial Transplant. 1998; 13: 56-59Crossref PubMed Scopus (51) Google Scholar, 41.Rubin J. Ball R. Continuous ambulatory peritoneal dialysis as treatment of severe congestive heart failure in the face of chronic renal failure. Report of eight cases.Arch Intern Med. 1986; 146: 1533-1535Crossref PubMed Scopus (37) Google Scholar, 43.König P.S. Lhotta K. Kronenberg F. et al.CAPD: a successful treatment in patients suffering from therapy-resistant congestive heart failure.Adv Perit Dial. 1991; 7: 97-101PubMed Google Scholar, 51.Elhalel-Dranitzki M. Rubinger D. Moscovici A. et al.CAPD to improve quality of life in patients with refractory heart failure.Nephrol Dial Transplant. 1998; 13: 3041-3042Crossref PubMed Scopus (41) Google Scholar, 52.Mousson C. Tanter Y. Chalopin J.M. et al.Treatment of refractory congestive cardiac insufficiency by continuous peritoneal dialysis. Long-term course.Presse Med. 1988; 17: 1617-1620PubMed Google Scholar, 53.Kagan A. Rapoport J. The role of peritoneal dialysis in the treatment of refractory heart failure.Nephrol Dial Transplant. 2005; 20: vii28-vii31Crossref PubMed Scopus (28) Google ScholarAutomated peritoneal dialysis38.Ryckelynck J.P. Lobbedez T. Valette B. et al.Peritoneal ultrafiltration and treatment-resistant heart failure.Nephrol Dial Transplant. 1998; 13: 56-59Crossref PubMed Scopus (51) Google Scholar, 48.Ortiz A.M. Acosta P.A. Corbalan R. Jalil J.E. Long-term automated peritoneal dialysis in patients with refractory congestive heart failure.Adv Perit Dial. 2003; 19: 77-80PubMed Google Scholar, 53.Kagan A. Rapoport J. The role of peritoneal dialysis in the treatment of refractory heart failure.Nephrol Dial Transplant. 2005; 20: vii28-vii31Crossref PubMed Scopus (28) Google ScholarSingle night time exchange with icodextrin54.Bertoli S.V. Ciurlino D. Maccario M. et al.Home peritoneal ultrafiltration in patients with severe congestive heart failure without end-stage renal disease.Adv Perit Dial. 2005; 21: 123-127PubMed Google Scholar Open table in a new tab In summary, renal dysfunction is common and is an adverse prognostic sign among patients with CHF. A significant minority of these patients develop resistance to conventional medical therapy. Extracorporeal ultrafiltration is effective in alleviating acute volume overload but PD is a viable therapy for ambulatory ultrafiltration. PD can be used either as a bridge therapy for definitive interventions or as palliative therapy for these patients. There is, however, a need to conduct controlled trials to define the subgroup of patients with CHF most likely to benefit from PD. This may lead to a more widespread use of the therapy in treatment-resistant CHF. Furthermore, given the lack of willingness of third-party payors to cover the costs of ambulatory peritoneal ultrafiltration, there is a need to conduct formal cost–benefit analyses of the therapy.
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