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

Management of patients with heart failure and chronic kidney disease

Chronic kidney disease (CKD) and heart failure are often co-existing conditions due to a shared pathophysiological process involving neurohormonal activation and hemodynamic maladaptation. A wide range of pharmaceutical and interventional tools are available to patients with CKD, consisting of traditional ones with decades of experience and newer emerging therapies that are rapidly reshaping the landscape of medical care for this population. Management of patients with heart failure and CKD requires a stepwise approach based on renal function and the clinical phenotype of heart failure. This is often challenging due to altered drug pharmacokinetics interactions with various degrees of kidney function and frequent adverse effects from the therapy that lead to poor patient tolerance. Despite a great body of clinical evidence and guidelines that have offered various treatment options for patients with heart failure and CKD, respectively, patients with CKD are still underrepresented in heart failure clinical trials, especially for those with advanced CKD and end-stage renal disease (ESRD). Future studies are needed to better understand the generalizability of these therapeutic options among heart failures with different stages of CKD.

Lower-Dosage Acute Peritoneal Dialysis versus Acute Intermittent Hemodialysis in Acute Kidney Injury: A Randomized Controlled Trial

Key Points

The efficacy of acute peritoneal dialysis is still controversial. There was no significant difference in 28-day mortality between acute peritoneal dialysis and intermittent hemodialysis.

Background

Lower delivered dose of acute peritoneal dialysis (PD) in AKI requires less resources but raises concerns regarding adequate solute and water clearance. The relative merits of lower-dose PD versus intermittent hemodialysis remain uncertain.

Methods

A multicenter randomized controlled trial compared the outcomes between acute lower-dosage PD (18–24 L per day) and intermittent hemodialysis (three times per week) from May 2018 to January 2021 in patients with AKI. The primary outcome was 28-day mortality rate. Secondary outcomes included 28-day dialysis-free survival and kidney recovery, metabolic profile, and procedure-related complications. Noninferiority of PD to hemodialysis would be demonstrated if the upper bound of the 95% confidence interval ( CI) on risk difference (PD-hemodialysis) in 28-day mortality rates between the two groups was <20%.

Results

We included 157 patients (80 allocated to PD and 77 to intermittent hemodialysis). Before KRT initiation, baseline clinical characteristics between groups were comparable. The overall mean age was 57±15 years. The most frequent cause of AKI was sepsis (68%). There was no difference in 28-day mortality between acute PD and intermittent hemodialysis (50% versus 49%, risk difference 0.6 [95% CI, −15.0 to 16.3]), and 28-day dialysis-free survival (42% versus 37%, risk difference 4.6 [95% CI, −11.1 to 20.3]). Mean weekly Kt/V urea was 2.11±1.14 and 2.55±1.11 in the PD and intermittent hemodialysis groups, respectively. The 7-day fluid balance of PD and intermittent hemodialysis patients was not significantly different. There was more frequent intradialytic hypotension in the intermittent hemodialysis group and more frequent hypokalemia in the PD group.

Conclusions

In this study of patients with AKI, there was no significant difference in 28-day mortality between acute PD and intermittent hemodialysis.

Exploring the Therapeutic Potential of Peritoneal Dialysis (PD) in the Treatment of Neurological Disorders

Peritoneal dialysis (PD) is a well-established renal replacement therapy commonly employed in clinical practice. While its primary application is in the treatment of kidney disease, its potential in addressing other systemic disorders, including neurological diseases, has garnered increasing interest. This study provides a comprehensive overview of the related technologies, unique advantages, and clinical applications of PD in the context of neurological disorders. By exploring the mechanism underlying PD, its application in neurological diseases, and associated complications, we addressed the feasibility and benefits of PD as an adjunct therapy for various neurological conditions. Our study aims to highlight its role in detoxification and symptom management, as well as its advantages over other universally accepted methods of renal replacement therapy. Our goal is to bring to the spotlight the therapeutic potential of PD in neurological diseases, such as stroke, stimulate further research, and broaden the scope of its application in the clinical setting.

Efficacy of peritoneal dialysis in patients with refractory congestive heart failure: a systematic review and meta-analysis

Refractory congestive heart failure (RCHF) is a common complication in the natural history of advanced heart failure. Peritoneal dialysis (PD) is a possible alternative in those patients, but studies are scarce, and mostly with small samples. We conducted this meta-analysis to evaluate the effects of PD in patients with RCHF. Articles published before July 2020 in the following databases: PubMed, Web of Science, and CENTRAL. Mean differences (MD) and 95% confidence intervals (CIs) were computed to generate a pooled effect size with a random effects model. We also assessed heterogeneity, risk of bias, publication bias, and quality of evidence. Twenty observational studies (n = 769) were included, with a "before and after intervention" design. PD was associated with a significant reduction in NYHA functional class (MD -1.37, 95% CI -0.78 to -1.96) and length of hospitalisation (MD -34.8, 95% CI -20.6 to -48.9 days/patient/year), a small but significant increase in left ventricular ejection fraction (MD 4.3, 95%CI 1.9 to 6.8%) and a non-significant change in glomerular filtration rate (MD -3.0, 95% CI -6.0 to 0 mL/min/1.73m2). Heterogeneity among studies was significant and overall risk of bias was rated from moderate to critical. No significant publication bias was found, and the overall quality of evidence was very low for all outcomes. PD in patients with RCHF improved functional class, length of hospitalisation, and ventricular functional, and had no impact in renal function. Further randomised clinical trials are warranted to confirm our results that showed some limitations.

The Importance of the Nephrologist in the Treatment of the Diuretic-Resistant Heart Failure

Heart failure is not only a global problem but also significantly limits the life prospects of these patients. The epidemiology and presentation of heart failure are intensively researched topics in cardiology. The risk factors leading to heart failure are well known; however, the real challenge is to provide effective treatments. A vicious cycle develops in heart failure of all etiologies, sooner or later compromising both cardiac and kidney functions simultaneously. This can explain the repeated hospital admissions due to decompensation and the significantly reduced quality of life. Moreover, diuretic-refractory heart failure represents a distinct challenge due to repeated hospital admissions and increased mortality. In our narrative review, we wanted to draw attention to nephrology treatment options for severe diuretic-resistant heart failure. The incremental value of peritoneal dialysis in severe heart failure and the feasibility of percutaneous peritoneal dialysis catheter insertion have been well known for many years. In contrast, the science and narrative of acute peritoneal dialysis in diuretic-resistant heart failure remains underrepresented. We believe that nephrologists are uniquely positioned to help these patients by providing acute peritoneal dialysis to reduce hospitalization dependency and increase their quality of life.

Managing Heart Failure in Patients on Dialysis: State-of-the-Art Review

Heart failure (HF) and end-stage kidney disease (ESKD) frequently coexist; 1 comorbidity worsens the prognosis of the other. HF is responsible for almost half the deaths of patients on dialysis. Despite patients' with ESKD composing an extremely high-risk population, they have been largely excluded from landmark clinical trials of HF, and there is, thus, a paucity of data regarding the management of HF in patients on dialysis, and most of the available evidence is observational. Likewise, in clinical practice, guideline-directed medical therapy for HF is often down-titrated or discontinued in patients with ESKD who are undergoing dialysis; this is due to concerns about safety and tolerability. In this state-of-the-art review, we discuss the available evidence for each of the foundational HF therapies in ESKD, review current challenges and barriers to managing patients with HF on dialysis, and outline future directions to optimize the management of HF in these high-risk patients.

New aspects in cardiorenal syndrome and HFpEF

Cardiorenal syndrome (CRS) is a complex disease in which the heart and kidneys are simultaneously affected, and subsequently, the malfunction of one organ promotes the deterioration of the other. Heart failure (HF) with preserved ejection fraction (HFpEF) is the most common form of HF. The pathophysiology of CRS is not well known and several mechanisms have been proposed. An elevation of central venous pressure seems to be one of the key points to consider, among others such as an increase in intraabdominal pressure. Several diagnostic tools have been identified to establish the diagnosis of CRS in patients with HFpEF. Currently, the availability of biomarkers of renal and cardiac injury, the use of pulmonary ultrasound, the monitoring of the size of the inferior vena cava and the study of the renal venous pattern offer a new dimension in accurately diagnosing and quantifying organ damage in CRS. Beyond the symptomatic treatment of congestion, until recently specific therapeutic tools for patients with CRS and HFpEF were not available. Interestingly, the development of new drugs such as the angiotensin/neprilysin inhibitors and sodium-glucose cotransporter-2 (SGLT-2) inhibitors offer new therapeutic strategies with potential benefits in reduction of cardiorenal adverse outcomes in this population. Randomized clinical trials that focus on patients with HFpEF are currently ongoing to delineate optimal new treatments that may be able to modify their prognosis. In addition, multidisciplinary teamwork (nephrologist, cardiologist and nurse) is expected to decrease the number of visits and the rate of hospitalizations, with a subsequent patient benefit.

Comparison of planned-start, early-start and deferred-start strategies for peritoneal dialysis initiation in end-stage kidney disease

INTRODUCTION

In patients with end-stage kidney disease (ESKD) suitable for peritoneal dialysis (PD), PD should ideally be planned and initiated electively (planned-start PD). If patients present late, some centres initiate PD immediately with an urgent-start PD strategy. However, as urgent-start PD is resource intensive, we evaluated another strategy where patients first undergo emergent haemodialysis (HD), followed by early PD catheter insertion, and switch to PD 48-72 hours after PD catheter insertion (early-start PD). Conventionally, late-presenting patients are often started on HD, followed by deferred PD catheter insertion before switching to PD≥14 days after catheter insertion (deferred start PD).

METHODS

This is a retrospective study of new ESKD patients, comparing the planned-start, early-start and deferred-start PD strategies. Outcomes within 1 year of dialysis initiation were studied.

RESULTS

Of 148 patients, 57 (38.5%) patients had planned-start, 23 (15.5%) early-start and 68 (45.9%) deferred-start PD. Baseline biochemical parameters were similar except for a lower serum urea with planned-start PD. No significant differences were seen in the primary outcomes of technique and patient survival across all 3 subgroups. Compared to planned-start PD, early-start PD had a shorter time to catheter migration (hazard ratio [HR] 14.13, 95% confidence interval [CI] 1.65-121.04, P=0.016) while deferred-start PD has a shorter time to first peritonitis (HR 2.49, 95% CI 1.03-6.01, P=0.043) and first hospital admission (HR 2.03, 95% CI 1.35-3.07, P=0.001).

CONCLUSION

Planned-start PD is the best PD initiation strategy. However, if this is not possible, early-start PD is a viable alternative. Catheter migration may be more frequent with early-start PD but does not appear to impact technique survival.

Peritoneal dialysis for refractory heart failure: A single center experience

INTRODUCTION

Heart failure is a disease associated with poor quality of life. Peritoneal dialysis can be an alternative in treatment of these patients to overcome fluid overload. The objective of this study is to observe the effects of peritoneal dialysis in refractory heart failure patients.

METHODS

We conducted an observational study including 10 patients with refractory congestive heart failure. Peritoneal dialysis started solely for fluid overload. Patients' baseline parameters were compared with follow-up parameters.

RESULTS

Median age was 57.5 (44.8-64.3) years. Median left ventricular ejection fraction was 20% (18.8-31.3) and all patients had right ventricular dysfunction. Median estimated glomerular filtration rate was 51.2 (43.8-101.3) ml/min/1.73 m² . 2 patients (20%) died during the follow-up period. NewYork Heart Association functional class decreased significantly from a median of 4 to 2,1 and 1 in the 3rd, 6th and 12th month respectively (p ≤ 0.01 for all from baseline). Number and length of hospitalization decreased significantly after treatment (number from a median of 3 to 0, p = 0.013; days from 50.5 to 0, p = 0.028).

CONCLUSION

Peritoneal dialysis significantly reduced NewYork Heart Association functional class, number and days of hospitalization for heart failure. It could be a reasonable option in chronic treatment of patients with refractory heart failure. This article is protected by copyright. All rights reserved.

Projet PRODIADOM "Promouvoir la dialyse à domicile"

PRODIADOM est une solution innovante destinée à aider les professionnels qui souhaitent développer la dialyse à domicile. Dans un premier temps disponible pour la dialyse péritonéale (bientôt disponible pour l’hémodialyse à domicile), PRODIADOM propose un site Web qui se veut simple, pratique, utile et convivial. Les praticiens pourront y trouver des formations, des guides, des fiches pratiques, des arborescences décisionnelles, des conduites à tenir face à des situations inhabituelles, des recommandations, tous les protocoles utiles pour la dialyse péritonéale, toutes les explorations fonctionnelles péritonéales courantes, avec leurs indications et leur réalisation pratique. PRODIADOM a l’ambition de devenir la référence des professionnels médicaux et paramédicaux qui souhaitent démarrer un programme de dialyse à domicile. Conçu par des experts, son accès est gratuit.

Outcomes after Acute Peritoneal Dialysis for Critical Cardiorenal Syndrome Type 1

INTRODUCTION

The aim of the study was to demonstrate the outcomes of peritoneal dialysis (PD) in critically ill cardiorenal syndrome type 1 (CRS1).

METHODS

A cohort of 147 patients with CRS1 who received PD from 2011 to 2019 in a referral hospital in Thailand was analyzed. The primary outcome was 30-day in-hospital mortality. Ultrafiltration and net fluid balance among survivors and nonsurvivors in the first 5 PD sessions were compared.

RESULTS

The 30-day mortality rate was 73.4%. Most patients were critically ill CRS1 (all patients had a respiratory failure of which 68% had cardiogenic shock). Blood urea nitrogen and creatinine at the commencement of PD were 60.1 and 4.05 mg/dL. In multivariable analysis, increasing age, unstable hemodynamics, and positive fluid balance in the first 5 PD sessions were associated with the risk of in-hospital mortality. The change of fluid balance per day during the first 5 dialysis days was significantly different among survivor and nonsurvivor groups (-353 vs. 175 mL per day, p = 0.01).

CONCLUSIONS

PD is a viable dialysis option in CRS1, especially in a resource-limited setting. PD can save up to 27% of lives among patients with critically ill CRS1.

Personalising heart failure management in CKD patients

CKD in heart failure patients is common, present in 49%, associated with higher mortality [Hazard ratio, 2.34 (95% CI2.20-2.50, P < 0.001) and multiple hospital admissions. The management of heart failure in CKD can be challenging due to drug induced electrolyte and creatinine changes; resistance to diuretics and infections related to device therapy. Evidence for improvement in mortality and heart failure hospitalisations exists in HFrEF stage 3 CKD patients from randomised controlled trials of ACE-inhibitor and mineralocorticoid receptor antagonist therapy; but not in dialysis patients where higher doses can cause hyperkalaemia. Evidence on improvement of cardiovascular death and heart failure hospitalisations has emerged with angiotensin blocker-neprilysin inhibitor, ivabradine and more recently with sodium-glucose cotransporter inhibitors in HFrEF patients with CKD stages 1,2, and 3. However these studies have excluded CKD 4,5 patients. Evidence for betablocker therapy exists in CKD stages 1,2 and 3 and separately in haemodialysis patients. Cardiac resynchronisation therapy reduces heart failure hospitalisations and mortality in patients with CKD 1,2,3 but not in CKD stages 4,5 or dialysis patients. Internal cardioverter and defibrillator therapy in HFrEF patients have been shown to be beneficial in CKD 3 patients, not in dialysis patients where it is associated with high rates of infection. For HFpEF patients with CKD therapy is symptomatic as there is no proven therapy for improvement in survival or hospitalisations. Heart failure patients with end-stage-kidney disease with fluid overload may benefit from peritoneal dialysis. A multidisciplinary, personalised approach has been associated with better care and improved patient satisfaction.

Barriers to optimal peritoneal dialysis

Peritoneal dialysis in the United States is underutilized when compared to the experience in other developed countries. The reasons for this are multifactorial and include government regulatory issues, the priority of dialysis facilities, and education and training of nephrology trainees and patients. The challenges to expanding PD in the United States are discussed and strategies to overcome the barriers are outlined.