Peritoneal ultrafiltration for chronic congestive heart failure: rationale, evidence and future

Utilization of Peritoneal Dialysis in the Acute Setting

Peritoneal dialysis (PD), although classically described and utilized in the treatment of patients with end-stage renal disease, can also be utilized in the acute setting in different clinical situations. Recent studies showed that, in patients with acute renal failure, it is possible to obtain reasonable dialysis doses with adequate metabolic and electrolytic control and low incidence of complications by utilizing continuous PD through a cycler at high volume. In patients with congestive heart failure without end-stage renal disease, PD is capable of promoting clinical improvement with slow removal of liquids, becoming an attractive alternative for situations of rapidly or slowly worsening cardiac function. In patients submitted to chronic hemodialysis but who have vascular access difficulties, PD can also be utilized as a “bridge,” thereby avoiding the use of central venous catheters, which can be associated with infectious complications such as bacterial endocarditis. New studies must be realized showing other indications for PD.

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.

Peritoneal dialysis in patients with refractory congestive heart failure: potential prognostic factors

BACKGROUND

Peritoneal dialysis (PD) is increasingly used for long-term management of refractory congestive heart failure (CHF). In this study, we investigated the outcome of patients with refractory CHF treated with PD, aiming to identify potential prognostic factors for long term-survival.

METHODS

This was a prospective observational study over a period of 42 months which included 37 refractory CHF patients.

RESULTS

Median survival on PD was 14 months (1-41 months). Long survivors had serum sodium >132 mEq/l (p < 0.001), serum albumin >3.2 g/dl (p < 0.001) and hospitalization rate <2 days per month a year before starting the treatment (p = 0.008). Patients in the lowest survival quartile had lower serum albumin (2.8 vs. 3.5 g/dl in longer survivors, p = 0.003) and serum sodium (126 vs. 137 mEq/l, p < 0.0001), higher serum leukocyte count (7,500 vs. 6,800/μl in long survivors, p = 0.033), higher glomerular filtration rate (39.4 vs. 29.9 ml/min/1.73 m(2), p = 0.035), had more hospitalization before starting the treatment (3.4 vs. 1.9 days per month, p = 0.003) and lower estimated left ventricular mass index (113 vs. 137 g/m(2), p = 0.035). Long-term survivors demonstrated significant improvement in the New York Heart Association functional class by a median of one class, reduced hospitalization rate by 55% and decrease in dependence on intravenous diuretics and vasoactive medications (73% drop in CHF day care visits during the first year of treatment).

CONCLUSIONS

Survival of patients with refractory CHF treated with PD is highly variable. Serum sodium, serum albumin and hospitalization rate are important prognostic factors for long-term survival. Long survivors demonstrated improved functional status, reduced hospitalization and mortality rates.

Prospective study on clinical effects of renal replacement therapy in treatment-resistant congestive heart failure

BACKGROUND/AIMS

Clinical outcome in cardiorenal syndrome (CRS) Type 2 and treatment with dialysis.

METHODS

Prospective observational non-randomized study.

RESULTS

Twenty-three patients were included, mean age 66±21 years. Twelve (52%) patients were treated with peritoneal dialysis (PD) and 11 (48%) with intermittent haemodialysis (IHD). Median survival time after start of dialysis was 16 months. Hospitalizations for cardiovascular causes were reduced (1.4±0.6 pre-dialysis versus 0.4±0.6 days/patient/month post-dialysis, P=0.000), without significant changes in hospitalization for all causes (1.8±1.6 versus 2.1±2.9 days/patient/month). New York Heart Association (NYHA) class (3.8±0.4 at start versus 2.4±0.7 after 4 months, P=0.000, versus 2.7±0.9 after 8 months, P=0.001) and quality of life tended to improve (63±21 at start, versus 41±20 after 4 months, versus 51±25 after 8 months; P=0.056). Left ventricular ejection fraction did not change. The number of technical complications associated with dialysis therapy was relatively high in this population.

CONCLUSIONS

After starting dialysis for CRS, hospitalizations for cardiovascular causes were reduced, but not hospitalizations for all causes. Functional NYHA class improved and quality of life tended to improve, without evidence for a change in cardiac function. In this small study, no differences between IHD and PD were observed.

Continuous ambulatory peritoneal dialysis as a therapeutic alternative in patients with advanced congestive heart failure

AIMS

Continuous ambulatory peritoneal dialysis (CAPD) has been proposed as an additional therapeutic resource for patients with advanced congestive heart failure (CHF). The objective of this study was to determine the therapeutic role of CAPD, in terms of surrogate endpoints, in the management of patients with advanced CHF and renal dysfunction.

METHODS AND RESULTS

A total of 57 candidates with New York Heart Association (NYHA) class III/IV CHF, renal dysfunction (glomerular filtration rate < 60 mL/min/1.73 m(2)), persistent fluid congestion despite loop diuretic treatment, and at least two previous hospitalizations for acute heart failure (AHF) were invited to be included in the CAPD programme; however, 25 patients were finally included. The primary outcome was evaluated by the change at 6 and 24 weeks for the Minnesota Living With Heart Failure Questionnaire (MLWHFQ), the 6 min walk test (6MWT), NYHA class, serum natriuretic peptides [brain natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP)], serum carbohydrate antigen 125 (CA125), and hospitalization rates for AHF. CAPD was associated with a substantial improvement in the MLWHFQ (-21.3, P < 0.001; and -20.4, P < 0.001), the 6MWT (54.0, P < 0.001; and 45.6, P = 0.023), and NYHA class (-1.0, P < 0.001; and -1.4, P < 0.001) at 6 and 24 weeks, respectively. The Ln(CA125) decreased markedly (-0.8, P = 0.003; and -0.98, P = 0.003), with no effect on BNP and NT-proBNP. There was a marked reduction in the number of days hospitalized for AHF (6 month post-CAPD vs. 6 months pre-CAPD: -84%; P < 0.001).

CONCLUSIONS

In advanced CHF and renal dysfunction, CAPD was associated with short/mid-term improvement in severity parameters, with an acceptable rate of side effects.

Decongestive treatment of acute decompensated heart failure: cardiorenal implications of ultrafiltration and diuretics

In patients with acute decompensated heart failure (ADHF), treatment aimed at adequate decongestion of the volume overloaded state is essential. Despite diuretic therapy, many patients remain volume overloaded and symptomatic. In addition, adverse effects related to diuretic treatment are common, including worsening kidney function and electrolyte disturbances. The development of decreased kidney function during treatment affects the response to diuretic therapy and is associated with important clinical outcomes, including mortality. The occurrence of diuretic resistance and the morbidity and mortality associated with diuretic therapy has stimulated interest to develop effective and safe treatment strategies that maximize decongestion and minimize decreased kidney function. During the last few decades, extracorporeal ultrafiltration has been used to remove fluid from diuretic-refractory hypervolemic patients. Recent clinical studies using user-friendly machines have suggested that ultrafiltration may be highly effective for decongesting patients with ADHF. Many questions remain regarding the comparative impact of diuretics and ultrafiltration on important clinical outcomes and adverse effects, including decreased kidney function. This article serves as a summary of key clinical studies addressing these points. The overall goal is to assist practicing clinicians who are contemplating the use of ultrafiltration for a patient with ADHF.

Peritoneal Dialysis in Acute Renal Failure

The definition of adequate dialysis in acute renal failure (ARF) is complex and involves the time of referral to dialysis, dose, and dialytic method. Nephrologist experience with a specific procedure and the availability of different dialysis modalities play an important role in these choices. There is no consensus in literature on the best method or ideal dialysis dose in ARF. Peritoneal dialysis (PD) is used less and less in ARF patients, and is being replaced by continuous venovenous therapies. However, it should not be discarded as a worthless therapeutic option for ARF patients. PD offers several advantages over hemodialysis, such as its technical simplicity, excellent cardiovascular tolerance, absence of an extracorporeal circuit, lack of bleeding risk, and low risk of hydro-electrolyte imbalance. PD also has some limitations, though: it needs an intact peritoneal cavity, carries risks of peritoneal infection and protein losses, and has an overall lower effectiveness. Because daily solute clearance is lower with PD than with daily HD, there have been concerns that PD cannot control uremia in ARF patients. Controversies exist concerning its use in patients with severe hypercatabolism; in these cases, daily hemodialysis or continuous venovenous therapy have been preferred. There is little literature on PD in ARF patients, and what exists does not address fundamental parameters such as adequate quantification of dialysis and patient catabolism. Given these limitations, there is a pressing need to re-evaluate the adequacy of PD in ARF using accepted standards. Therefore, new studies should be undertaken to resolve these problems.

Contemporary trends in the pharmacological and extracorporeal management of heart failure: a nephrologic perspective

Heart failure and chronic kidney disease share a number of risk factors and pathophysiological pathways. These 2 pathological processes coexist in large numbers of patients. Whereas the presence of chronic kidney disease in patients with heart failure adversely influences their survival, cardiovascular disease is the major cause of mortality in individuals with chronic kidney disease. The management of heart failure by cardiologists has recently expanded from pharmacological treatment to extracorporeal strategies; the interaction between (and concurrent use of) these approaches traditionally has been part of nephrology care and training. The purpose of this review is to explore these management strategies from a nephrologic standpoint and cover the pathophysiology of diuretic resistance, new pharmaceutical strategies to induce natriuresis or aquaresis, and the physiological basis and theoretical advantages of fluid removal by nontraditional peritoneal or hemofiltration approaches. This review also focuses on the technical features, safety, and potential risks of dedicated ultrafiltration devices that do not require dialysis staff or facilities and that are now readily available to nonnephrologists.

Canadian Cardiovascular Society Consensus Conference recommendations on heart failure update 2007: Prevention, management during intercurrent illness or acute decompensation, and use of biomarkers

Heart failure is common, yet it is difficult to treat. It presents in many different guises and circumstances in which therapy needs to be individualized. The Canadian Cardiovascular Society published a comprehensive set of recommendations in January 2006 on the diagnosis and management of heart failure, and the present update builds on those core recommendations. Based on feedback obtained through a national program of heart failure workshops during 2006, several topics were identified as priorities because of the challenges they pose to health care professionals. New evidence-based recommendations were developed using the structured approach for the review and assessment of evidence adopted and previously described by the Society. Specific recommendations and practical tips were written for the prevention of heart failure, the management of heart failure during intercurrent illness, the treatment of acute heart failure, and the current and future roles of biomarkers in heart failure care. Specific clinical questions that are addressed include: which patients should be identified as being at high risk of developing heart failure and which interventions should be used? What complications can occur in heart failure patients during an intercurrent illness, how should these patients be monitored and which medications may require a dose adjustment or discontinuation? What are the best therapeutic, both drug and nondrug, strategies for patients with acute heart failure? How can new biomarkers help in the treatment of heart failure, and when and how should BNP be measured in heart failure patients? The goals of the present update are to translate best evidence into practice, to apply clinical wisdom where evidence for specific strategies is weaker, and to aid physicians and other health care providers to optimally treat heart failure patients to result in a measurable impact on patient health and clinical outcomes in Canada.

The role of peritoneal dialysis in the management of treatment-resistant congestive heart failure: A European perspective

Patients with congestive heart failure (CHF) resistant to conventional treatment have a poor prognosis. Extracorporeal ultrafiltration (UF) appears to be the therapy of choice for short-term management of such patients with severe fluid overload, whereas peritoneal dialysis (PD) may be the therapy of choice for the long-term treatment. Fluid removal results in reduction of plasma volume, improvement of hyponatremia, reduction in pulmonary capillary wedge pressure, improvement of New York Heart Association functional heart failure class, improvement of functional rehabilitation and quality of life, reduction of hospitalizations and readmissions, as well as improvement in diuretic responsiveness. Whether extracorporeal UF and/or PD modifies the survival rate of patients with refractory CHF needs to be determined in prospective randomized controlled trials.

Intermittent outpatient ultrafiltration for the treatment of severe refractory congestive heart failure

BACKGROUND

Patients with severe congestive heart failure (CHF) become refractory to conventional medical therapy, leading to recurrent rehospitalizations. We examined the impact of intermittent outpatient ultrafiltration (UF), using either peritoneal dialysis or hemofiltration, on long-term clinical outcomes in patients with refractory CHF.

METHODS AND RESULTS

We analyzed clinical and hemodynamic data in 19 consecutive patients with refractory CHF who received intermittent outpatient UF for at least 1 year between July 1998 and November 2002. The mean left ventricular ejection fraction of all 19 patients was 30.2 +/- 19.0%. All patients (100.0%) were New York Heart Association (NYHA) class IV. Only 5 patients (26.3%) received peritoneal dialysis; the remaining 14 (73.7%) received hemofiltration. There were 6 patients with a normal left ventricular ejection fraction (45%). After UF was started, the number of patients that were considered inotrope-dependent was reduced from 86.4% to 36.8% (P < .005). Compared with the year before UF was initiated, the number of CHF hospitalizations during follow-up was reduced from 2.6 to 0.3 (P < .005), and the NYHA class was improved from 4 to 3.1 (P < .005). Among all patients, 2 deaths were related to complications of UF, and cumulative 1-year survival was 63.2%.

CONCLUSION

Our study suggests that UF is a safe, feasible therapy, but it needs further evaluation in carefully designed, prospective, randomized clinical trials. UF has the potential for offering another important therapeutic option for patients with severe and refractory CHF.

Nonpharmacologic care of heart failure: counseling, dietary restriction, rehabilitation, treatment of sleep apnea, and ultrafiltration

The prognosis of patients with chronic congestive heart failure (CHF) depends not only on pharmacologic therapy but also on nonpharmacologic aspects. A complete and ongoing education program for treating CHF includes an understanding of the causes of CHF, symptoms, diet, salt and fluid restriction, drug regimen, compliance, physical and work activities, lifestyle changes, and measures of self-control. Moreover, the nonpharmacologic treatment (dietary modifications, lifestyle, physical exercise, and health care education) must be inserted in a multidisciplinary program organized by the physician in conjunction with the health system, the nurses, and, especially, the patients themselves, who must understand their disease and the many therapeutic options. Cardiologists should treat patients in a clear and comprehensible way, and other specialists (dietitians, physiotherapists, psychologists, nurses, and social workers), together with the patient's family, should strive for the best living conditions for the patient. In this way, the treatment of CHF can improve the quantity and quality of life and save a significant amount in health care costs.

Ultrafiltration and dry weight-what are the cardiovascular effects?

Long-term prognosis in dialysis is poor compared to that in healthy control persons. A worsening of the prognosis is noted especially for patients who at initiation of dialysis have congestive heart failure, ischemic heart disease, or left ventricular dysfunction or hypertrophy. This is the main reason that cardiovascular causes are the most common for morbidity in these patients. The weight obtained when normal urine output is present is the dry weight. With reduced ability to excrete the volume by the kidneys in end-stage renal disease (ESRD), the body will retain water and the patient will gain weight. This extra weight is due to volume overload. While volume overload may induce a rise in blood pressure, if the heart is in acceptable condition, a fast removal of fluid by ultrafiltration (UF) during dialysis may instead cause hypotension. Ultrafiltration failure in peritoneal dialysis (PD) patients may lead to successive water retention and overhydration with subsequent cardiac failure, while volume overload may occur over a few days in hemodialysis (HD) patients. Anemia or even too-high hematocrit may impair cardiac function further and worsen conditions caused by wrong dry weight. Thus, during long-term and sustained volume overload, left ventricular (LV) hypertrophy will occur in an eccentric manner. A sustained overload then may lead to cell death and LV dilatation and, eventually, systolic dysfunction. Once a severe left ventricular dilatation has developed, the blood pressure may decrease during volume overload. A worsened prognosis is seen if malnutrition and low albumin levels are present. Volume overload necessitates ultrafiltration to achieve dry weight. Thereby, volume contraction contributes to exaggerated stimulation of or response to activation of the RAS and alpha-adrenergic sympathetic systems. If ultrafiltration goes beyond these compensatory mechanisms, hypotension will occur and increase the risk for hypoperfusion of vital organs. Such episodes may cause cardiac morbidity, aspiration pneumonia, vascular access closure, or neurological complications (seizures, cerebral infarction), besides a more rapid lowering of residual renal function. Preventive measures are, first, finding the right dry weight; second, minimizing interdialytic weight gain; third, optimizing the target for hemoglobin (110-120 g/l); fourth, lowering dialysate calcium (1.25 mmol/l); and fifth, eventually using higher dialysate potassium if long dialyses are performed.