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

Abstract

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.

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

“…The mechanisms behind the effectiveness of this treatment remain not fully elucidated but appear multiple. Among them, the removal of water, sodium, and other substances such as cytokines, uremic toxins, and even light-chain amyloid protein seem highly attractive [8, 10, 11, 19, 20].…”

“…However, the results in most cases are heterogeneous and sometimes discouraging [5]. In this regard, continuous ambulatory peritoneal dialysis (CAPD) has emerged as a promising alternative for decongestion in patients with refractory congestive HF [6][7][8][9][10][11]. However, beyond increasing water elimination, the pathophysiological mechanisms behind the benefit of CAPD in refractory congestive HF remain to be elucidated.…”

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

“…The first reported case of treating a congestive HF patient with PD dates back to 1949 [37], but its use has gained progressive interest over the last two decades. Case reports, case series, and small cohort studies have reported favorable outcomes in different patient settings, from severely reduced to preserved ejection fraction and in various types of cardiomyopathies [10,[37][38][39][40][41][42][43][44][45][46][47][48][49][50][51][52][53][54]. PD constitutes a home-based therapeutic modality that offers the possibility of continuous and gentle removal of excess water and solutes with minimal hemodynamic impact, allows easing the renal venous and intraabdominal pressure while draining ascites and interstitial edema, and has a high capacity of customization to the patient's clinical requirements and daily life.…”

Overhydration: A cause or an effect of kidney damage and how to treat it

“…Recently, both nephrologist and cardiologist appreciate this modality in CRS. 33,34 For CRS type 1, tidal PD was found to be a safe and effective mean of removing toxins and large quantities of excess fluid. In a small randomized study, it was superior to UF therapy when the preservation of renal function, improvement of cardiac function and net fluid loss was considered.…”

“…A systematic review prepared by Ronco group assessed the efficacy of PD in patients with refractory CHF. 34 Twenty-one studies encompassed 673 patients; the authors suggested that in patients with refractory CHF, PD can be an effective and safe treatment option, leading to heart function improvement and better weight control.…”