Peritoneal Dialysis for Chronic Congestive Heart Failure

Abstract

Maladaptive responses between a failing heart and the kidneys ultimately lead to permanent chronic kidney disease, referred to as cardiorenal syndrome type 2. In this narrative review, we discuss the pathophysiological pathways in the progression of cardiorenal failure and review the current evidence on peritoneal dialysis as a treatment strategy in cardiorenal syndrome type 2. A patient with heart failure can present with clinical symptoms related to venous congestion even in the absence of end-stage renal disease. Diuretics remain the cornerstone for the treatment of fluid overload related to heart failure. However, with chronic use, diuretic resistance can supervene. When medical therapy is no longer able to relieve congestive symptoms, ultrafiltration might be needed. Patients with heart failure tolerate well the gentle rate of fluid removal through peritoneal dialysis. Recent publications suggest a positive impact of starting peritoneal dialysis in patients with cardiorenal syndrome type 2 on the hospitalisation rate, functional status and quality of life.

Impact of an in-Hospital Patient Education Program on Choice of Renal Replacement Modality in Unplanned Dialysis Initiation

“…Regarding ESRD etiology, cardiorenal syndrome ( p = 0.04) and glomerulonephritis ( p = 0.0007) were significantly associated with PD modality choice. Especially in cardiorenal syndrome, studies describe beneficial effects regarding hospitalization rate, functional status and quality of life when pharmacological therapy has failed [42]. This could be an explanation for the influence on PD choice and we cannot exclude the influence of any physician advice on the decision.…”

Dialysis in the Elderly and Impact of Institutionalization in the United States Renal Data System

“…These issues should be discussed with older patients with advanced kidney disease and their families to allow them choose the most appropriate therapy [28]. Recent reports suggest peritoneal dialysis to be a beneficial treatment strategy for fluid status control in patients with refractory congestive heart failure in terms of hospitalization rates and duration [29,30]. …”

Ultrafiltration for management of fluid overload in patients with heart failure

“…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 . Prior to this phase change, the intraperitoneal fluid is drained, typically on a schedule as the process occurs with relatively fixed timing.…”

“…Additionally, catheter use is typically delayed for two to four weeks after placement to allow adequate wound healing. Unlike hemofiltration, PF does not require systemic anticoagulation, and does not require hospitalization . The ultrafiltrate capacity of any patient, however, is not known; no ultrafiltrate goal can be set, and the process cannot be titrated minute by minute.…”