Diálisis peritoneal ambulatoria continua y evolución clínica de pacientes con insuficiencia cardiaca congestiva refractaria

Peritoneal and Urinary Sodium Removal in Refractory Congestive Heart Failure Patients Included in an Ambulatory Peritoneal Dialysis Program: Valuable for Monitoring the Course of the Disease

INTRODUCTION

Spot urinary sodium emerged as a useful parameter for assessing decongestion in patients with congestive heart failure (CHF). Growing evidence endorses the therapeutic role of continuous ambulatory peritoneal dialysis (CAPD) in patients with refractory CHF and kidney disease. We aimed to examine the long-term trajectory of urinary, peritoneal, and total (urinary plus peritoneal) sodium removal in a cohort of patients with refractory CHF enrolled in a CAPD program. Additionally, we explored whether sodium removal was associated with the risk of long-term mortality and episodes of worsening heart failure (WHF).

METHODS

We included 66 ambulatory patients with refractory CHF enrolled in a CAPD program in a single teaching center. 24-h peritoneal, urinary, and total sodium elimination were analyzed at baseline and after CAPD initiation. Its trajectories over time were calculated using joint modeling of longitudinal and survival data. Within the framework of joint frailty models for recurrent and terminal events, we estimated its prognostic effect on recurrent episodes of WHF.

RESULTS

At the time of enrollment, the mean age and estimated glomerular filtration rate were 72.8 ± 8.4 years and 28.5 ± 14.3 mL/min/1.73 m2, respectively. The median urinary sodium at baseline was 2.34 g/day (1.40-3.55). At a median (p25%-p75%) follow-up of 2.93 (1.93-3.72) years, we registered 0.28 deaths and 0.24 episodes of WHF per 1 person-year. Compared to baseline (urinary), CAPD led to increased sodium excretion (urinary plus dialyzed) since the first follow-up visit (p < 0.001). Over the follow-up, repeated measurements of total sodium removal were associated with a lower risk of death and episodes of WHF.

CONCLUSIONS

CAPD increased sodium removal in patients with refractory CHF. Elevated sodium removal identified those patients with a lower risk of death and episodes of WHF.

Quantification and treatment of congestion in heart failure: A clinical and pathophysiological overview

Renal sodium and water retention with resulting extracellular volume expansion and redistribution are hallmark features of heart failure syndromes. However, congestion assessment, monitoring, and treatment represent a real challenge in daily clinical practice. This document reviewed historical and contemporary evidence of available methods for determining volume status and discuss pharmacological aspects and pathophysiological principles that underlie diuretic use.

Quantification and Treatment of Congestion in Heart Failure: A Clinical and Pathophysiological Overview

Renal sodium and water retention with resulting extracellular volume expansion and redistribution are hallmark features of heart failure syndromes. However, congestion assessment, monitoring, and treatment represent a real challenge in daily clinical practice. This document reviewed historical and contemporary evidence of available methods for determining volume status and discuss pharmacological aspects and pathophysiological principles that underlie diuretic use.

Favorable effects of peritoneal dialysis in patients with refractory heart failure and overhydration

BACKGROUND

Patients with refractory to optimal pharmacological treatment heart failure (HF) require frequent hospitalization. Peritoneal dialysis (PD) has been part of the management of such patients mainly for promoting ultrafiltration and management of overhydration independently of kidney function. The aim of this study was to evaluate the efficacy of PD, especially the use of icodextrin solutions and intermittent PD, in the hospitalization rate and cardiac functional status of patients with HF.

METHODS

We conducted a retrospective study involving patients with New York Heart Association (NYHA) class IV HF and preserved renal function (estimated glomerular filtration rate (eGFR) > 25 ml/min), who were refractory to conservative treatment. Clinical data on weight loss, hospitalization rate before and after PD initiation, cardiac functional status, and technique complications during a 6-month observational period were analyzed.

RESULTS

PD treatment was performed in 32 patients with a mean age of 63.8 ± 11.9 years and a follow-up of 20.78 ± 14.24 months. Hospitalizations were significantly reduced from 20.7 ± 13.7 to 7.7 ± 8.9 days/patients at 6 months. All patients showed improvement in NYHA class as well as in left ventricular ejection fraction. Overall, eGFR showed a significant decrease but only six patients reached end-stage renal disease. Complications included 18 cases of peritonitis. PD was well tolerated and no patient dropped out of the method. Survival rate reached 72% at 12 months but mortality rate was high with 23 patients dying at 16.65 ± 12.3 months after the initiation of treatment. Patients survival was not influenced by the type of PD modality or weight reduction achieved.

CONCLUSIONS

PD showed to be a viable option for the treatment of patients with refractory HF leading to a better cardiac functional status and diminishing the number of hospital admissions.

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.

Refractory congestive heart failure: when the solution is outside the heart

Refractory congestive heart failure is associated with an ominous prognosis in which the treatments strategies remain scarce and not well validated. In the last years, continuous ambulatory peritoneal dialysis (CAPD) has emerged as a therapeutic alternative in this subset of patients. So far, it has been associated with a significant improvement in functional capacity and quality of life, together with a striking reduction in the risk of readmissions. We present the case of an elderly patient with severe left ventricular dysfunction and severe mitral and tricuspid regurgitation who presents recurrent admissions for anasarca. After its inclusion in a CAPD programme, the patient experienced a marked clinical and biochemical improvement despite the persistence of cardiac abnormalities. CAPD onset translates into greater sodium removal. We want to emphasize the usefulness of this therapy in the management of volume excess in patients with refractory heart failure and renal failure promoting a greater sodium removal compared with traditional diuretic strategies.

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.

Effectiveness and Safety of Peritoneal Dialysis Treatment in Patients with Refractory Congestive Heart Failure due to Chronic Cardiorenal Syndrome

Aims

To evaluate the effectiveness and safety of peritoneal dialysis (PD) in treating refractory congestive heart failure (RCHF) with cardiorenal syndrome (CRS).

Methods

A total of 36 patients with RCHF were divided into type 2 CRS group (group A) and non-type 2 CRS group (group B) according to the patients' clinical presentations and the ratio of serum urea to creatinine and urinary analyses in this prospective study. All patients were followed up till death or discontinuation of PD. Data were collected for analysis, including patient survival time on PD, technique failure, changes of heart function, and complications associated with PD treatment and hospitalization.

Results

There were 27 deaths and 9 patients quitting PD program after a follow-up for 73 months with an average PD time of 22.8 ± 18.2 months. A significant longer PD time was found in group B as compared with that in group A (29.0 ± 19.4 versus 13.1 ± 10.6 months, p = 0.003). Kaplan–Meier curves showed a higher survival probability in group B than that in group A (p < 0.001). Multivariate regression demonstrated that type 2 CRS was an independent risk factor for short survival time on PD. The benefit of PD on the improvement of survival and LVEF was limited to group B patients, but absent from group A patients. The impairment of exercise tolerance indicated by NYHA classification was markedly improved by PD for both groups. The technique survival was high, and the hospital readmission was evidently decreased for both group A and group B patients.

Conclusions

Our data suggest that PD is a safe and feasible palliative treatment for RCHF with type 2 CRS, though the long-term survival could not be expected for patients with the type 2 CRS. Registration ID Number is ChiCTR1800015910.

Spatial Analysis of Case-Mix and Dialysis Modality Associations

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BACKGROUND

Health-care systems must attempt to provide appropriate, high-quality, and economically sustainable care that meets the needs and choices of patients with end-stage renal disease (ESRD). France offers 9 different modalities of dialysis, each characterized by dialysis technique, the extent of professional assistance, and the treatment site. The aim of this study was 1) to describe the various dialysis modalities in France and the patient characteristics associated with each of them, and 2) to analyze their regional patterns to identify possible unexpected associations between case-mixes and dialysis modalities. ♦

METHODS

The clinical characteristics of the 37,421 adult patients treated by dialysis were described according to their treatment modality. Agglomerative hierarchical cluster analysis was used to aggregate the regions into clusters according to their use of these modalities and the characteristics of their patients. ♦

RESULT

The gradient of patient characteristics was similar from home hemodialyis (HD) to in-center HD and from non-assisted automated peritoneal dialysis (APD) to assisted continuous ambulatory peritoneal dialysis (CAPD). Analyzing their spatial distribution, we found differences in the patient case-mix on dialysis across regions but also differences in the health-care provided for them. The classification of the regions into 6 different clusters allowed us to detect some unexpected associations between case-mixes and treatment modalities. ♦

CONCLUSIONS

The 9 modalities of treatment available make it theoretically possible to adapt treatment to patients' clinical characteristics and abilities. However, although we found an overall appropriate association of dialysis modalities to the case-mix, major inter-region heterogeneity and the low rate of peritoneal dialysis (PD) and home HD suggest that factors besides patients' clinical conditions impact the choice of dialysis modality. The French organization should now be evaluated in terms of patients' quality of life, satisfaction, survival, and global efficiency.

Peritoneal Dialysis for Heart Failure

Heart failure (HF) is a common and important cause of morbidity and mortality in the elderly, imposing a significant burden on healthcare systems. Better management of ischemic heart disease has resulted in increased survival and growth in the number of prevalent heart failure patients, but co-existing renal impairment complicates management and limits traditional therapeutic options. Ultrafiltration (UF) techniques have shown promise in the treatment of diuretic-resistant HF, but the early successes of extracorporeal treatments has not been confirmed by randomized trials. Peritoneal dialysis (PD) may be cheaper and provide more effective UF therapy in selected patients and this review examines the issues surrounding the use of PD for such patients. Whist many nephrologists are enthusiastic about the use of this technique, making a more cogent case for PD in this setting for cardiologists is likely to need a combined strategy of demonstrating improvement in individual cases and further study of potential medicoeconomic benefits.

Peritoneal dialysis in patients with refractory congestive heart failure: a systematic review

BACKGROUND

Refractory congestive heart failure (RCHF) is associated with a high mortality rate and is a major contributor to hospital admissions. Peritoneal dialysis (PD) is an option to control volume overload and perhaps improve outcomes in this challenging patient population. The aim of this systematic review is to describe the relative risk-benefit ratio based on data reported regarding the use of PD in RCHF. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. An electronic search of PubMed, Embase, and the Cochrane Library was performed to identify relevant studies published from January 1951 to February 2014. Eligible studies selected were prospective or retrospective adult population studies on PD in the setting of RCHF. The following clinical outcomes were used to assess PD therapy: (1) hospitalization rates; (2) heart function; (3) renal function; (4) fluid overload, and (5) adverse clinical outcomes.

SUMMARY

Of 864 citations, we excluded 843 citations and included 21 studies (n = 673 patients). After PD, hospitalization days declined significantly (p = 0.0001), and heart function improved significantly (left ventricular ejection fraction: p = 0.0013; New York Heart Association classification: p = 0.0000). There were no statistically significant differences in glomerular filtration rate after PD treatment in non-chronic kidney disease stage 5D patients (p = 0.1065). Among patients treated with PD, body weight decreased significantly (p = 0.0006). The yearly average peritonitis rate was 14.5%, and the average yearly mortality was 20.3%.

KEY MESSAGES

This systematic review suggests that PD may be an effective and safe therapeutic tool for patients with RCHF.