Clinical and hemodynamic results of peritoneal dialysis for severe cardiac failure

β-Blocker Use and Risk of Mortality in Heart Failure Patients Initiating Maintenance Dialysis

RATIONAL & OBJECTIVE

Beta-blockers are recommended for patients with heart failure (HF) but their benefit in the dialysis population is uncertain. Beta-blockers are heterogeneous, including with respect to their removal by hemodialysis. We sought to evaluate whether β-blocker use and their dialyzability characteristics were associated with early mortality among patients with chronic kidney disease with HF who transitioned to dialysis.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

Adults patients with chronic kidney disease (aged≥18 years) and HF who initiated either hemodialysis or peritoneal dialysis during January 1, 2007, to June 30, 2016, within an integrated health system were included.

EXPOSURES

Patients were considered treated with β-blockers if they had a quantity of drug dispensed covering the dialysis transition date.

OUTCOMES

All-cause mortality within 6 months and 1 year or hospitalization within 6 months after transition to maintenance dialysis.

ANALYTICAL APPROACH

Inverse probability of treatment weights using propensity scores was used to balance covariates between treatment groups. Cox proportional hazard analysis and logistic regression were used to investigate the association between β-blocker use and study outcomes.

RESULTS

3,503 patients were included in the study. There were 2,115 (60.4%) patients using β-blockers at transition. Compared with nonusers, the HR for all-cause mortality within 6 months was 0.79 (95% CI, 0.65-0.94) among users of any β-blocker and 0.68 (95% CI, 0.53-0.88) among users of metoprolol at transition. There were no observed differences in all-cause or cardiovascular-related hospitalization.

LIMITATIONS

The observational nature of our study could not fully account for residual confounding.

CONCLUSIONS

Beta-blockers were associated with a lower rate of mortality among incident hemodialysis patients with HF. Similar associations were not observed for hospitalizations within the first 6 months following transition to dialysis.

The Peritoneal Handling of Digoxin during CAPD

We measured digoxin concentrations in serum and dialysate from five digitalized patients on continuous ambulatory peritoneal dialysis (CAPD). Mean peritoneal clearance of digoxin was 3.6 ± 0.4 ml/min (± SEM). Mean mass transfer was 8.6 ± 0.6 μg/min. Our patients lost from 3.7 to 13.3% of their daily oral digoxin intake in dialysate. The mean dialysate over serum (D/S) digoxin ratio was 0.59 and fell between D/S creatinine (0.81) and D/S inulin (0.34). Between patients the range of this ratio was wide (0.25 to 0.90).

We also measured serial digoxin dialysate concentrations during a six hour “dwell” in one patient and determined a D/S equilibration curve. After six hours dialysate digoxin approached a plateau near 0.5. Digoxin removal per week from dialysate was two to three times greater during CAPD than that reported from IPD. Peritoneal losses of digo xin cannot be predicted for an individual patient. In four of eight digitalized patients, the cardiac drug could be discontinued suggesting a beneficial effect of long-term CAPD in controlling congestive heart failure.

Peritoneal Dialysis in Refractory Congestive Heart Failure PART II: Continuous Ambulatory Peritoneal Dialysis (CAPD)

Three patients with intractable congestive heart failure (CHF) resistant to all other therapy were treated for three, five and six months by continuous ambulatory peritoneal dialysis (CAPD). They lost eight to II kg in weight and had a marked improvement in symptoms of heart failure. Recurrent peritonitis precluded the continuation of CAPD and all three patients died within two weeks of stopping the treatment.

Successful Use of Continuous Ambulatory Peritoneal Dialysis in Refractory Heart Failure

Four patients with end-stage heart failure, massive ascites refractory to medical interventions and a variable degree of renal failure were treated successfuly with CAPD for eight to 24 months. The New York Heart Association functional class improved in all four. In two patients, who presented initially with signs and symptoms mainly of right-sided heart failure, ejection fraction improved. Each day dialysis achieved a significant degree of ultrafiltration and a negative sodium balance. We propose that CAPD is an alternative therapeutic modality in patients with severe heart failure refractory to the conventional medical treatment.

The advent of potent diuretics and preload and afterload reducing agents has had a major impact in the treatment of refractory congestive heart failure. Recently, captopril, an angiotensinconverting enzyme inhibitor, has been used with major benefit in some patients (I). However, some patients still do not respond to these treatments and their management presents a major therapeutic challenge. Furthermore, overzealous therapy with diuretics may lead to intravascular volume depletion resulting in hypotension, azotemia and electrolyte disturbances which further complicate their management.

In the past, intermittent peritoneal dialysis (IPD) or hemodialysis (HD) has been used to remove fluid from patients with intractable edema due to heart failure (2 7). But the benefit is only transient and fluid accumulates again, requiring repeated sessions of acute dialysis. However, hypotension is a frequent complication during either form of acute dialysis especially in hemodynamically unstable patients due to rapid removal of large amounts of fluid from intravascular space.

Continuous ambulatory peritoneal dialysis (CAPD), whose main characteristic is the slow continuous removal of sodium and water, offers obvious advantages in patients with intractable heart failure.

This paper describes our experience of four patients with intractable heart failure who have been treated with CAPD for eight to 24 months.

Peritoneal Dialysis in Refractory Congestive Heart Failure PART II: Continuous Ambulatory Peritoneal Dialysis (CAPD)

Three patients with intractable congestive heart failure (CHF) resistant to all other therapy were treated for three, five and six months by continuous ambulatory peritoneal dialysis (CAPD). They lost eight to II kg in weight and had a marked improvement in symptoms of heart failure. Recurrent peritonitis precluded the continuation of CAPD and all three patients died within two weeks of stopping the treatment.

The use of peritoneal dialysis in heart failure: A systematic review

Heart failure (HF) is a major cause of morbidity and mortality. Extracorporeal (EC) therapy, including ultrafiltration (UF) and haemodialysis (HD), peritoneal dialysis (PD) and peritoneal ultrafiltration (PUF) are potential therapeutic options in diuretic-resistant states. This systematic review assessed outcomes of PD and compared the effects of PD to EC. A comprehensive search of major databases from 1966 to 2017 for studies utilising PD (or PUF) in diuretic-resistant HF was conducted, excluding studies involving patients with end-stage kidney disease. Data were extracted and combined using a random-effects model, expressed as odds ratio (OR). Thirty-one studies (n = 902) were identified from 3195 citations. None were randomised trials. Survival was variable (0-100%) with a wide follow-up duration (36 h-10 years). With follow-up > 1 year, the overall mortality was 48.3%. Only four studies compared PD with EC. Survival was 42.1% with PD and 45.0% with EC; the pooled effect did not favour either (OR 0.80; 95% confidence interval (CI): 0.24-2.69; p = 0.710). Studies on PD in patients with HF reported several benefits. Left ventricular ejection fraction (LVEF) improved after PD (OR 3.76, 95%CI: 2.24-5.27; p < 0.001). Seven of nine studies saw LVEF increase by > 10%. Twenty-one studies reported the New York Heart Association status and 40-100% of the patients improved by ≥ 1 grade. Nine of 10 studies reported reductions in hospitalisation frequency and/or duration. When treated with PD, HF patients had fewer symptoms, lower hospital admissions and duration compared to diuretic therapy. However, there is inadequate evidence comparing PD versus UF or HD. Further studies comparing these modalities in diuretic-resistant HF should be conducted.

Defining the role of peritoneal dialysis in management of congestive heart failure

Introduction: Congestion is an integral component of heart failure (HF) pathophysiology and portends an adverse impact on outcome. Peritoneal dialysis (PD) is a home-based therapeutic modality that has been used in the setting of refractory congestive HF to help optimize volume status. Not only does PD allow for customized sodium and water removal, but it also provides the opportunity for the patients to fully benefit from guideline-directed medical therapy for HF that could have otherwise been challenging to use. Areas covered: Authors provide an overview of the pathophysiologic basis for the use of PD in HF, followed by a review of the findings of the main clinical trials such as the salutary impact on HF re-admissions and quality of life. Since the goals of therapy in this setting differ from those for patients with end-stage renal disease, pertinent practical considerations in the use of this modality are then discussed as well as potential barriers. Expert opinion: For patients with chronic refractory HF, PD represents an alternative to medical therapy alone. Identification of patients that would benefit most from this modality and detection of major enablers and obstacles for the implementation of this therapy should be the focus of future studies.

Nonuremic indication for peritoneal dialysis for refractory heart failure in cardiorenal syndrome type II: review and perspective

Cardiorenal syndrome (CRS) type II is a serious condition in which chronic cardiac abnormalities cause worsening kidney function, leading to permanent chronic kidney damage. Management of CRS type II coupled with diuretic-resistant congestive heart failure (CHF) has been an issue of dispute. However, since the early 1990s, reports indicating the clinical usefulness of peritoneal dialysis (PD) as maintenance therapy for intractable CHF in this population have been accumulating. The present manuscript reviews the mechanisms by which kidney dysfunction develops within CHF, and then examines recent experiences of PD as chronic supportive therapy for intractable CRS type II, reviews the contributing mechanisms, and discusses the rationale for using PD as a new therapeutic approach in the nonuremic setting of CHF.

Cardiorenal outcomes after slow continuous ultrafiltration therapy in refractory patients with advanced decompensated heart failure

OBJECTIVES

The purpose of this study was to examine the clinical outcomes of using slow continuous ultrafiltration (SCUF) in patients with acute decompensated heart failure (HF) refractory to intensive medical therapy.

BACKGROUND

Several studies have demonstrated the clinical usefulness of early SCUF in patients with acute decompensated HF to improve fluid overload and hemodynamics.

METHODS

We reviewed clinical data from 63 consecutive adult patients with acute decompensated HF admitted to the Heart Failure Intensive Care Unit from 2004 through 2009 who required SCUF because of congestion refractory to hemodynamically guided intensive medical therapy.

RESULTS

The mean creatinine level was 1.9 ± 0.8 mg/dl on admission and 2.2 ± 0.9 mg/dl at SCUF initiation. After 48 hours of SCUF, there were significant improvements in hemodynamic variables (mean pulmonary arterial pressure: 40 ± 12 mm Hg vs. 33 ± 8 mm Hg, p = 0.002, central venous pressure: 20 ± 6 mm Hg vs. 16 ± 8 mm Hg, p = 0.007, mean pulmonary wedge pressure: 27 ± 8 mm Hg vs. 20 ± 7 mm Hg, p = 0.02, Fick cardiac index: 2.2 l/min/m(2) [interquartile range: 1.87 to 2.77 l/min/m(2)] vs. 2.6 l/min/m(2) [interquartile range: 2.2 to 2.9 l/min/m(2)], p = 0.0008), and weight loss (102 ± 25 kg vs. 99 ± 23 kg, p < 0.0001). However, there were no significant improvements in serum creatinine levels (2.2 ± 0.9 mg/dl vs. 2.4 ± 1 mg/dl, p = 0.12) and blood urea nitrogen (60 ± 30 mg/dl vs. 60 ± 28 mg/dl, p = 0.97). Fifty-nine percent required conversion to continuous hemodialysis during their hospital course, and 14% were dependent on dialysis at hospital discharge. Thirty percent died during hospitalization, and 6 patients were discharged to hospice care.

CONCLUSIONS

In our single-center experience, SCUF after admission for acute decompensated HF refractory to standard medical therapy was associated with high incidence of subsequent transition to renal replacement therapy and high in-hospital mortality, despite significant improvement in hemodynamics.

An evaluation of ultrafiltration as treatment of therapy-resistant cardiac edema

In six patients with therapy-resistant cardiac edema, ultrafiltration on two consecutive days removed on an average 7750 ml fluid and reduced body weight by 7.3 kg. A difference between the mean ultrafiltration rate (17.4 ml/min) and the calculated plasma refilling rate (12.7 ml/min) led to a reduction in plasma volume during treatment together with an increase in plasma colloid osmotic pressure. Systemic blood pressure, heart rate and cardiac output were unchanged during ultrafiltration while systemic vascular resistance increased and pulmonary capillary wedge pressure and right atrial pressure decreased significantly. No complications were recorded during or after treatment. Ultrafiltration is a safe method of fluid removal in patients with therapy-resistant cardiac edema and can be used as preparation for cardiac catheterization or surgery.

Management of fluid overload in congestive heart failure: learning from a case report

A case of refractory fluid overload due to congestive heart failure and consequent renal insufficiency is reported. The case was approached multidisciplinarily, at the beginning with conservative and pharmacological therapy, subsequently with extracorporeal fluid removal in which a specific attention was payed to the maintenance of circulating blood volume and achievement of dry weight, and finally with chronic peritoneal dialysis as a maintenance therapy. The case seems to summarize the pathway of many patients seen initially in intensive care and cardiology departments and subsequently in nephrological wards.

Treatment of diuretic resistant cor pulmonale by continuous arteriovenous haemofiltration

A woman with diuretic resistant cor pulmonale had 24 litres of fluid removed over four days by arteriovenous haemofiltration. She was discharged one week later and has remained ambulant and independent for one year.

Ultrafiltration in diuretic-resistant cardiac failure

Ultrafiltration was performed in 13 patients with diuretic-resistant cardiac failure. All patients had severely distressing peripheral edema and ultrafiltration was successfully completed in 12 patients, all of whom sustained symptomatic improvement. The volume of fluid removed ranged from 3.7 to 23 L, mean 11.8 L. Weight reduction produced by ultrafiltration continued over the following week, indicating an improved response to diuretic therapy. Ultrafiltration is an effective therapeutic intervention in the management of a small but well-defined group of patients with diuretic-resistant cardiac failure.

Ultrafiltration in the management of refractory congestive heart failure

Ultrafiltration was performed in nine patients with congestive cardiac failure that was refractory to conventional medical treatment. A mean of 12 X 7 litres of fluid was removed, and there was a sustained symptomatic improvement in all patients. Weight loss continued after ultrafiltration and a sustained increase in serum sodium concentration was also noted. A transient fall in right atrial pressure was seen only at four hours after ultrafiltration. No adverse haemodynamic effects were seen four and eighteen hours after fluid removal. Intracardiac dimensions measured by echocardiography remained unchanged. Ultrafiltration can be used to relieve symptoms in patients with refractory congestive heart failure and gross oedema.

Fluid removal by haemofiltration in diuretic resistant cardiac failure

A 60 year old woman with diuretic resistant cardiac failure was treated with intermittent haemofiltration before tricuspid valve replacement. This technique can remove large quantities of fluid rapidly, thus controlling oedema and allow appropriate fluid replacement. Haemofiltration is thus a simple and safe method of managing unresponsive oedema in cardiac failure sometimes allowing corrective cardiac surgery.

Conceptual dilemmas in the classification of vasodilator drugs for severe chronic heart failure. Advocacy of a pragmatic approach to the selection of a therapeutic agent

Two distinct systems of classifying vasodilator drugs have been developed over the past decade in an attempt to guide the choice of a therapeutic agent for the patient with severe heart failure, but the merits and utility of these systems have not been critically evaluated. Vasodilator drugs may be categorized according to their peripheral site of action: an agent may exert its effects preferentially on systemic arteries, systemic veins, or on both circulations. However, changes in the peripheral circulation cannot be directly translated into an improvement in central hemodynamic variables; furthermore, immediate hemodynamic responses may not be predictive of long-term clinical efficacy. Hence, there is no evidence that characterization of patients into hemodynamic subsets determined by the findings of right heart catheterization improves the clinical outcome of vasodilator therapy in chronic heart failure. An alternative classification system groups vasodilator drugs according to their mechanism of action: an agent may possess direct vasodilating effects or may exert its actions via selective neurohumoral inhibition. However, attempts to identify patients who might be most responsive to neurohumoral antagonism by measuring plasma renin activity or circulating levels of catecholamines before treatment have not been successful in predicting the clinical responses to therapy. Because neither system of drug classification provides the clinician with useful therapeutic guidelines, patients with severe heart failure appear to be best managed using a pragmatic approach in which specific drugs that produce predictable therapeutic benefits with a low frequency of side effects are utilized preferentially. Among presently available vasodilator agents, only captopril and oral isosorbide dinitrate have been shown to produce consistent hemodynamic and clinical improvement with an acceptable degree of adverse reactions.

Hemodynamic studies in long-term peritoneal dialysis patients

A study was undertaken to evaluate the acute hemodynamic effects in ten patients from this clinic's long-term peritoneal dialysis program. With a Swan-Ganz catheter, the following parameters were measured in each patient during peritoneal dialysis: cardiac index, pulmonary artery pressure, right atrial pressure, inferior vena cava pressure, heart rate and arterial pressure. Mean predialysis cardiac index, stroke volume index and heart rate were normal. Predialysis pulmonary artery pressure and arterial pressure were slightly elevated. Mean weight loss during peritoneal dialysis was 1.6 kg. The most striking post-dialysis changes were a significant 20% decrease of the cardiac index and a 17% decrease of the pulmonary artery pressure. Heart rate and arterial pressure remained constant due to a 25% increase of total peripheral resistance. After filling the abdomen with one, two and three liters of dialysate, intra-abdominal pressure and inferior vena cava pressure increased up to 150 and 100%, respectively, whereas central hemodynamic parameters (pulmonary artery pressure, cardiac index, stroke volume index, heart rate and arterial pressure) were unchanged.

Peritoneal dialysis for pulmonary oedema after acute myocardial infarction

Four patients with intractable pulmonary oedema after acute myocardial infarction were treated with peritoneal dialysis. A negative fluid balance was rapidly achieved in three patients, two of whom ultimately survived. The fourth patient, who had complete heart block at the beginning of dialysis, showed initial clinical improvement with restoration of sinus rhythm despite failure to extract fluid.