Parameters associated with therapeutic response using peritoneal dialysis for therapy refractory heart failure and congestive right ventricular dysfunction

Abstract

BackgroundIn patients with refractory heart failure (HF) peritoneal dialysis (PD) is associated with improved functional status and decrease in hospitalization. However, previous studies did not focus on right ventricular dysfunction as an important pathophysiologic component of cardiorenal syndrome.MethodsIn a prospective cohort study PD was started in 40 patients with refractory right HF (with/without left HF). Refractoriness to conservative therapy was defined as persistent right heart congestion/ascites with intensified diuretic treatment and/or ≥2 hospitalizations within 6 months because of cardiac decompensation despite optimal medical treatment, and/or acute renal failure during intensified conservative treatment of cardiac decompensations.ResultsPatient survival was 55.0% at 1 year, 35.0% at 2 years and 27.5% at 3 years. The number of hospitalization days declined after initiation of PD for both cardiac [13 (IQR 1–53) days before vs. 1 (IQR 0–12) days after start of PD, p<0.001] and unplanned reasons [12 (IQR 3–44) days before vs. 1 (IQR 0–33) days after start of PD, p = 0.007]. Using a combined endpoint including survival time of ≥1 year and either improvement in quality of life or decline in hospitalizations we found that patients with extended ascites, higher systolic pulmonary artery pressure, more marked impairment of right ventricular function and tricuspid valve insufficiency, higher residual renal function as well as those who could perform PD without assistance have benefited most from this therapy.ConclusionsPatients with more pronounced backward failure, less marked residual renal functional impairment and those not depending on assistance for therapy are likely to profit most from PD.

Peritoneal dialysis in heart failure: focus on kidney and ventricular dysfunction

“…Only one PD study has focused on patients with right ventricular failure with and without left ventricular dysfunction. In this particular study, patients with extended ascites, higher systolic pulmonary artery pressure, more marked impairment of right ventricular function and tricuspid valve insufficiency, higher residual renal function, and those who could perform PD without assistance benefited most from this therapy [63].…”

“…Two studies have found a relationship between renal dysfunction at baseline and positive outcomes, yet with conflicting results. In the study by Pavo et al [63], patients with treatment success predefined as survival of at least 12 months combined with improved quality of life, a decline in hospitalization days, or both had better kidney function determined by 24-h-GFR and higher urinary volume. However, an association with eGFR was not found.…”

Usefulness of Peritoneal Ultrafiltration in Patients with Diuretic Resistant Heart Failure without End-Stage Renal Disease

“…In a study by Pavo et al [39], patients who had massive ascites, high PAPs, right-sided cardiac failure, tricuspid valve insufficiency, better residual renal function, and who were able to perform PD independently benefited more from PD treatment.…”

Heart failure management in dialysis patients: Many treatment options with no clear evidence

“…There was no comparator hemodialysis group in either study. Similarly, in a prospective Austrian study of 40 patients initiating PD in the setting of refractory right‐sided heart failure with or without left‐sided heart failure, the one‐year survival rate was 55% and patients reported improved quality of life and/or fewer hospitalization days 19 . Additionally, 4 patients who were initially deemed ineligible for a left ventricular assist device (LVAD) due to severe right heart failure improved sufficiently following PD initiation to qualify for LVAD implantation 19 .…”

“…Similarly, in a prospective Austrian study of 40 patients initiating PD in the setting of refractory right‐sided heart failure with or without left‐sided heart failure, the one‐year survival rate was 55% and patients reported improved quality of life and/or fewer hospitalization days 19 . Additionally, 4 patients who were initially deemed ineligible for a left ventricular assist device (LVAD) due to severe right heart failure improved sufficiently following PD initiation to qualify for LVAD implantation 19 . A propensity‐matched retrospective cohort study of dialysis‐dependent HFrEF patients in Taiwan found a lower incidence of hospitalization for heart failure with PD as compared to hemodialysis (19.7 vs 27.6 events per 1,000 patients‐years, respectively), 20 while a recent systematic review summarizing results in 673 patients from 21 observation studies reinforced that peritoneal dialysis is a reasonable option in diuretic‐resistant HFrEF patients with kidney failure, with an annual mortality of approximately 20% across studies 21 …”