Extracorporeal versus peritoneal ultrafiltration in diuretic-resistant congestive heart failure – a review

Abstract

SummaryDiuretic-resistant congestive heart failure in the form of type 2 cardiorenal syndrome is a problem of growing significance in everyday clinical practice because of high morbidity and mortality. There has been scant progress in the treatment of overhydration, the main cause of symptoms in this group of patients. The aim of our review is to present recent advances in the ultrafiltration therapy of congestive heart failure, with special attention to the new dedicated device for extracorporeal isolated ultrafiltration, as well as modifications of peritoneal dialysis in the form of peritoneal ultrafiltration with icodextrin solution and incremental peritoneal dialysis. Technical and clinical features, costs and potential risks of available devices for isolated ultrafiltration are presented. This method should be reserved for patients with true diuretic resistance as part of a more complex strategy aiming at the adequate control of fluid retention. Peritoneal ultrafiltration is presented as a viable alternative to extracorporeal ultrafiltration because of medical and psychosocial benefits of home-based therapy, lower costs and more effective daily ultrafiltration. In conclusion, large, properly randomized and controlled clinical trials with long-term follow-up will be essential in assessing the logistics and cost-effectiveness of both methods. Most importantly, however, they should be able to evaluate the impact of both methods on preservation of renal function and delaying the progression of heart failure by interrupting the vicious circle of cardiorenal syndrome. Our review is supplemented with the case report of the use of peritoneal ultrafiltration with a single 12-hour nighttime icodextrin exchange as a life-saving procedure in a patient with congestive heart failure resistant to pharmacological treatment.

Ultrafiltration bei kardiorenalem Syndrom

“…Beide Verfahren scheinen bei häufigen, therapierefraktären Dekompensationen einen Stellenwert zu haben. Hierbei spielt die peritoneale Ultrafiltration vornehmlich bei chronisch herzinsuffizienten Patienten und die extrakorporale Ultrafiltration bei akut dekompensierten Patienten eine Rolle 31 .…”

Ultrafiltration for management of fluid overload in patients with heart failure

“…Free water (the ultrafiltrate) diffuses across the peritoneum through micropores. Concurrently, passage of water molecules forces a shift of sodium ions against the osmotic gradient and into the hyperosmolar dialysate in a process called sodium sieving . With the passage of sodium, the capillary beds become increasingly hypotonic, which begins a process of increasing glucose absorption, subsequently driving water and sodium reabsorption .…”

The role of technological progress vs. accidental discoveries and clinical experience

“…Hemofiltration focuses on removing water along with molecules from plasma by way of convective transport. Hemodiafiltration, on the other hand, merges convective transport in hemofiltration with diffusive transport of traditional dialysis [ 34 , 35 ].…”

“…Newest development is introduction of two ultrafiltration techniques – extracorporeal ultrafiltration (using dedicated devices) and peritoneal ultrafiltration (using slow everyday treatment) – in therapy of congestive heart failure (CHF) in stadium 3–4 of chronic kidney disease [ 34 , 35 ]. Our Center was a first polish institution to introduce peritoneal ultrafiltration in place of extracorporeal ultrafiltration as a treatment method of patients with CHF [ 35 , 55 , 56 ].…”