Peritoneal ultrafiltration in refractory heart failure: a cohort study.

INTRODUCTION: Acutely decompensated heart failure (HF) in patients with diuretic resistance is often treated with extracorporeal ultrafiltration. Peritoneal ultrafiltration (PUF) has been proposed for the long-term management of severe HF after resolution of the acute episode. The aim of the present study was to evaluate the use of PUF in the treatment of chronic refractory HF in patients without end-stage renal disease. ♢ METHODS: This multicenter (10 nephrology departments throughout Italy) retrospective observational study included patients with severe HF refractory to maximized drug treatment. The patients were proposed for PUF because they had experienced at least 3 hospital admissions in the preceding year for acutely decompensated HF requiring extracorporeal ultrafiltration. ♢ RESULTS: Of the 48 study patients (39 men, 9 women; mean age 74 ± 9 years), 30 received 1 nocturnal icodextrin exchange, 5 required 2 daily exchanges, and 13 received 2 - 4 sessions per week of automated peritoneal dialysis. During the first year, renal function remained stable (initial: 20.8 ± 10.0 mL/min/1.73 m(2); end: 22.0 ± 13.6 mL/min/1.73 m(2)), while pulmonary artery systolic pressure declined to 40 ± 6.09 mmHg from 45.5 ± 9.18 mmHg (p = 0.03), with a significant concomitant improvement in New York Heart Association functional status. Hospitalizations decreased to 11 ± 17 days/patient-year from 43 ± 33 days/patient-year before the start of PUF (p < 0.001). The incidence of peritonitis was 1 episode in 45 patient-months. Patient survival was 85% at 1 year and 56% at 2 years. ♢ CONCLUSIONS: This study confirms the satisfactory results of using PUF for chronic HF in elderly patients.

Incidence and relevance of acute kidney injury in patients hospitalized with acute coronary syndromes.

Acute kidney injury (AKI) occurs frequently in patients with acute coronary syndromes (ACS) and is associated with adverse short- and long-term outcomes. To date, however, no standardized definition of AKI has been used for patients with ACS. As a result, information on its true incidence and the clinical and prognostic relevance according to the severity of renal function deterioration are still lacking. We retrospectively studied 3,210 patients with ACS. AKI was identified on the basis of the changes in serum creatinine during hospitalization according to the AKI Network criteria. Overall, 409 patients (13%) developed AKI: 262 (64%) had stage 1, 25 (6%) stage 2, and 122 (30%) stage 3 AKI. In-hospital mortality was greater in patients with AKI than in those without AKI (21% vs 1%; p <0.001). The adjusted risk of death increased with increasing AKI severity. Compared to no AKI, the adjusted odds ratio for death was 3.5 (95% confidence interval 1.79 to 6.83) with stage 1 AKI and 31.2 (95% confidence interval 16.96 to 57.45) with stage 2 to 3 AKI. A significant parallel increase in major adverse cardiac events was also observed comparing patients without AKI and those with stage 2 to 3 AKI. In conclusion, in patients with ACS, AKI is a frequent complication, and the graded increase of its severity, as assessed using the AKI Network classification, is associated with a progressive increased risk of in-hospital morbidity and mortality.

[Peritoneal dialysis: a time-limited therapy because of encapsulating peritoneal sclerosis?]. / La dialisi peritoneale: una metodica ''a termine'' a causa della peritonite sclerosante incapsulante?

Encapsulating peritoneal sclerosis (EPS) is a rare but severe disease with a mortality rate of 24%-54%, whose main risk factor is peritoneal dialysis (PD) (cumulative incidence 0.5%-7.3%). Although the role of the time spent on peritoneal dialysis is not completely clear, the available evidence suggests that peritoneal dialysis should not be discontinued early for the sake of reducing the EPS risk. We proposed a ''pro-con'' debate which confirmed that PD is not a time-limited technique. Nevertheless, in patients on long-term PD, surveillance of the peritoneal membrane is crucial. The development of EPS requires two ''hits'': first a chronic, inflammatory stimulus, which is typical of peritoneal dialysis, then a second event like PD interruption or kidney transplant. The main pharmacological and dialysis strategies that have been used as primary prevention did not show any significant results, and benefits are more likely to be achieved by reducing the peritoneal inflammation and better preservation of the membrane integrity, for example by means of more biocompatible PD solutions. Among the main surveillance and early diagnosis procedures other than the peritoneal equilibration test, the Ca-125 appearance rate and new tests that evaluate the peritoneal water transport seem to be promising.

[Incremental peritoneal dialysis: a common solution for different types of patients]. / La dialisi peritoneale incrementale: una soluzione comune per pazienti diversi.

It is still a matter of debate whether peritoneal dialysis should be initiated with a full dose regimen or with incremental doses. The use of low-dose dialysis is not always feasible, but it may have the advantages of improved quality of life and lower infective and metabolic complication rates. However, incremental peritoneal dialysis has to meet the minimal suggested adequacy targets in terms of depuration (Kt/V, creatinine clearance), ultrafiltration, and electrolyte balance. Incremental peritoneal dialysis has been proved feasible and safe in asymptomatic patients with a glomerular filtration rate (GFR)<6 mL/min, but the residual renal function has to be monitored strictly. A second population is composed of asymptomatic, mostly older patients with GFR between 6 and 10 mL/min, in whom a low-dose start may preserve the residual renal function and favor a more gradual training. Lastly, patients with severe, terminal, chronic cardiomyopathy who are not candidates for a heart transplant may experience beneficial effects on cardiac function and hospitalization with low-dose peritoneal dialysis treatment even when they have GFR>10 mL/min. In conclusion, incremental peritoneal dialysis is a feasible therapeutic option that the nephrologist should know and be able to perform in those patients who may benefit from it.

Experience of 70-cm-long femoral tunnelled twin Tesio catheters for chronic haemodialysis.

BACKGROUND: Tunnelled femoral catheters with their tip in the lower inferior vena cava (IVC) are proposed only in few cases, but they often provide less than optimal blood flows and frequently have complications. The aim of this prospective observational study is to evaluate the use of 70-cm-long tunnelled cuffed femoral twin Tesio catheters with their tip in the upper IVC for haemodialysis. METHODS: Between May 2007 and May 2009, 25 tunnelled femoral catheters (fCVC) have been placed in 25 patients (77.7 +/- 10.8 years) with exhausted thoracic venous accesses or old patients with several comorbidities. Two 10 Fr carbothane 70-cm-long Tesio catheters with a Dacron cuff at 45 cm from the tip were placed in the femoral vein of each patient and then tunnelled; tips were in the upper third of the IVC. fCVCs were removed for either malfunction (Qb < 200 ml/min) or infection that did not resolve with antibiotics. RESULTS: Technical success of placement was 100%. The 6- and 12-month assisted primary patency rate were respectively 67 +/- 13% and 54 +/- 17%. The mean session Kt/V was 1.45 +/- 0.19, and the blood flow was 270 +/- 17 ml/min. Six fCVCs have been removed: three for infection, one for accidental damaging and two for the making of a different vascular access. The main complications were 2 catheter tip thrombi, 3 tunnel infections and 11 fCVC-related bacteraemia (1.77 episodes per 1000 CVC-days). CONCLUSION: The placement of twin fCVCs with their tip in the high IVC can provide an adequate dialysis and can be considered for patients with no remaining thoracic accesses.

Home peritoneal ultrafiltration in patients with severe congestive heart failure without end-stage renal disease.

Congestive heart failure (CHF), mainly because of ischemic heart disease, is becoming a common medical problem. As CHF worsens and reaches New York Heart Association (NYHA) class IV, many patients can become refractory to medical therapy, especially those who are elderly or who have pre-existing non uremic chronic renal failure. For such patients, quality of life, morbidity, and mortality are expected to be bad. Our objective in the present study was to make a preliminary assessment of the usefulness of icodextrin administered in a single nocturnal peritoneal exchange to patients nonrespondent to the maximal conventional medical therapy. We studied two patients (aged 80 and 87 years), who were affected by severe dilatative cardiomyopathy and moderate-to-severe chronic renal failure. After at least 12 months of treatment, we observed a significant improvement in quality of life and a reduction in morbidity and hospitalization in both patients. Both patients also significantly increased their creatinine clearance. One patient maintained ejection fraction stability (22%-->27%); the other experienced an increase in ejection fraction to 50%from 25%. These preliminary observations suggest that a single nocturnal exchange with icodextrin can be an effective treatment in patients affected by refractory CHF and moderate-to-severe chronic renal failure.