RESUMEN
About 5% of patients with heart failure (HF) reach the end-stage of disease, becoming refractory to therapy. The clinical course of end-stage HF is characterized by repeated hospitalizations, severe symptoms, and poor quality of life. Peritoneal ultrafiltration (PUF), removing water and sodium (Na+), can benefit patients with end-stage HF. However, effects on fluid and electrolyte removal have not been fully characterized. In this pilot study in patients with chronic HF and moderate chronic renal failure, we evaluated the effects of water and sodium removal through PUF on ventricular remodeling, re-hospitalization, and quality of life. Patients with end-stage HF (NYHA class IV, ≥3 HF hospitalization/year despite optimal therapy), not eligible for heart transplantation underwent peritoneal catheter positioning and began a single-day exchange with icodextrin at night (n=6), or 1-2 daily exchanges with hypertonic solution (3.86%) for 2 hours with 1.5-2 L fill volume (n=3). At baseline, average ultrafiltration was 500±200 ml with icodextrin, and 700±100 ml with hypertonic solution. Peritoneal excretion of Na+ was greater with icodextrin (68±4 mEq/exchange) compared to hypertonic solution (45±19 mEq/exchange). After a median 12-month follow-up, rehospitalizations decreased, while NYHA class and quality of life (by Minnesota Living with HF questionnaire), improved. In end-stage HF patients, PUF reduced re-hospitalization and improved quality of life. It can be an additional treatment to control volume and sodium balance.
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Insuficiencia Cardíaca , Diálisis Peritoneal , Humanos , Icodextrina , Ultrafiltración , Sodio , Proyectos Piloto , Calidad de Vida , Insuficiencia Cardíaca/terapiaRESUMEN
BACKGROUND: Patients with refractory to optimal pharmacological treatment heart failure (HF) require frequent hospitalization. Peritoneal dialysis (PD) has been part of the management of such patients mainly for promoting ultrafiltration and management of overhydration independently of kidney function. The aim of this study was to evaluate the efficacy of PD, especially the use of icodextrin solutions and intermittent PD, in the hospitalization rate and cardiac functional status of patients with HF. METHODS: We conducted a retrospective study involving patients with New York Heart Association (NYHA) class IV HF and preserved renal function (estimated glomerular filtration rate (eGFR) > 25 ml/min), who were refractory to conservative treatment. Clinical data on weight loss, hospitalization rate before and after PD initiation, cardiac functional status, and technique complications during a 6-month observational period were analyzed. RESULTS: PD treatment was performed in 32 patients with a mean age of 63.8 ± 11.9 years and a follow-up of 20.78 ± 14.24 months. Hospitalizations were significantly reduced from 20.7 ± 13.7 to 7.7 ± 8.9 days/patients at 6 months. All patients showed improvement in NYHA class as well as in left ventricular ejection fraction. Overall, eGFR showed a significant decrease but only six patients reached end-stage renal disease. Complications included 18 cases of peritonitis. PD was well tolerated and no patient dropped out of the method. Survival rate reached 72% at 12 months but mortality rate was high with 23 patients dying at 16.65 ± 12.3 months after the initiation of treatment. Patients survival was not influenced by the type of PD modality or weight reduction achieved. CONCLUSIONS: PD showed to be a viable option for the treatment of patients with refractory HF leading to a better cardiac functional status and diminishing the number of hospital admissions.
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Insuficiencia Cardíaca , Fallo Renal Crónico , Diálisis Peritoneal , Desequilibrio Hidroelectrolítico , Anciano , Femenino , Insuficiencia Cardíaca/complicaciones , Insuficiencia Cardíaca/terapia , Humanos , Fallo Renal Crónico/complicaciones , Fallo Renal Crónico/diagnóstico , Fallo Renal Crónico/terapia , Masculino , Persona de Mediana Edad , Diálisis Peritoneal/efectos adversos , Diálisis Peritoneal/métodos , Estudios Retrospectivos , Volumen Sistólico , Función Ventricular Izquierda , Desequilibrio Hidroelectrolítico/etiologíaRESUMEN
Several reports have demonstrated that peritoneal rest (PR) is considered to preserve the peritoneal function in peritoneal dialysis (PD) patients. However, there has been no report that examines the peritoneal permeability before and after a short-term PR of two days. We examined the effect of the two-day PR on peritoneal permeability. We observed and compared the daily PD ultrafiltration changes in the four PD and hemodialysis (HD) combination patients from the start of dialysis therapy throughout the total observation period of each case. Next, 6 months after the initiation of dialysis therapy we performed a set of peritoneal equilibrium tests (PET) before and after the 2-day PR. D/P creatinine, daily urine volume, daily ultrafiltration volume in PD, weekly residual renal creatinine clearance, and weekly PD creatinine clearance were measured. The daily PD ultrafiltration volume increased significantly after the 2-day PR, and gradually decreased over the last four days throughout the observation period in each patient. In the PET results, D/P creatinine in all patients decreased after the short-term PR, and accordingly the peritoneal ultrafiltration volume increased. However, urine volume, residual renal creatinine clearance, and peritoneal creatinine clearance did not change. The peritoneal permeability clearly decreased after the short-term PR. The repeated improvement in the PD ultrafiltration volume after the short-term PR implies that the peritoneal permeability alteration might be due to a reversible functional change in the initial dialysis period. These results suggest that a short-term PR may preserve the peritoneal function.
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Fallo Renal Crónico/terapia , Peritoneo/fisiopatología , Diálisis Renal/métodos , Adulto , Terapia Combinada , Femenino , Humanos , Japón , Fallo Renal Crónico/fisiopatología , Masculino , Persona de Mediana Edad , Diálisis Peritoneal/efectos adversos , Diálisis Peritoneal/métodos , Peritoneo/metabolismo , Permeabilidad , Diálisis Renal/efectos adversos , Estudios Retrospectivos , Ultrafiltración/efectos adversos , Ultrafiltración/métodosRESUMEN
AIM: This study aimed to explore the role of peritoneal ultrafiltration (UF) in cardiorenal syndrome (CRS) patients for fluid and metabolic control. BACKGROUND: Peritoneal UF is safely and efficiently used for the management of CRS. It has been shown to provide efficient UF in hypervolemic patients. METHODS: Thirty (20 males and 10 females) CRS patients were treated by peritoneal dialysis (PD) and UF. The baseline data of the patients (demographics, causes of heart failure, the presence of pacemaker or implantable cardioverter-defibrillator, the need for extracorporeal UF or paracentesis or thoracentesis, comorbidity, drugs, left ventricular ejection fraction [LVEF] and pulmonary artery systolic pressure [PAPs], pericardial effusion, physical examination, body weight, NYHA class, dialysis regime, urine output, N-terminal pro-B-type natriuretic peptide [NT-proBNP] level, hemoglobin, estimated glomerular filtration rate [eGFR], and other routine biochemical determinations) were recorded at the onset, every 6 months, and then annually. Echocardiograms were performed at baseline and after 6 and 12 months. The time points of complications associated with PD, the need for hemodialysis, the day of death, and causes of death were documented. RESULTS: Mean age was 69 ± 8 years (range 49-84 years). The average PD duration was 18.25 ± 14.87 months. According to the CKD-EPI, initial mean GFR was 34.34 ± 11.9 mL/min/1.73 m2 (range 16.57-59.0), and this increased to 45.48 ± 26.04, 45.10 ± 28.58, and 41.10 ± 25.68 mL/min/1.73 m2 in the third, sixth, and twelfth months, respectively. There was a significant increase in the first 3 months and a significant decrease between the third and twelfth months (respectively, p = 0.018 and p = 0.043). There was no difference in eGFR levels between baseline and the end of the first year (p = 0.217). In the first 3 months, there was a significant decline in urea levels to 79.38 ± 36.65 from 109.92 ± 42.44 mg/dL and this was maintained until the end of the first year of PD therapy (after 3 months, p = 0.002; after 1 year, p = 0.024). However, there was no significant change in creatinine levels within the first year (p = 0.312). There was a significant increase in hemoglobin level up to the end of the first year of PD (after 3 months, p = 0.000; after 12 months, p = 0.013). There was a marked decrease in NT-proBNP levels in the first 6 months (p = 0.011). Functional capacity (according to NYHA classification) improved in all patients by the third month of PD treatment (p < 0.001). This early improvement was maintained in many patients during the following 12 months (p < 0.001). There was a marked decrease in NT-proBNP levels in the first 6 months (p = 0.011). At the end of the first year, there was an approximate 15% reduction in NT-proBNP levels (p = 0.647). Hospitalizations decreased to 6 ± 15 days/patient-year (range 18-122 days) from 62 ± 24 days/patient-year (p = 0.000). CONCLUSION: Peritoneal UF is a treatment method that maintains renal function and electrolyte balance, improves cardiac function, and reduces hospitalizations in CRS patients. We observed that this treatment significantly increased functional capacity and quality of life and significantly reduced hospital admissions.
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Insuficiencia Cardíaca , Fallo Renal Crónico , Anciano , Anciano de 80 o más Años , Diuréticos/uso terapéutico , Femenino , Insuficiencia Cardíaca/complicaciones , Insuficiencia Cardíaca/terapia , Humanos , Masculino , Persona de Mediana Edad , Calidad de Vida , Volumen Sistólico , Ultrafiltración , Función Ventricular IzquierdaRESUMEN
INTRODUCTION: Despite continuous improvement in the treatment, heart failure (HF) is a growing health problem and a major cause of mortality and morbidity in the world. There is some positive experience with the removal of the fluid excess via peritoneum in those patients, regardless of their renal function. The aim of this single center pilot study was to assess the efficacy of peritoneal ultra filtration (PUF) with a nightly 12-h exchange in the long-term treatment of refractory HF. METHODS: The study included patients with chronic HF resistant to updated HF therapy (pharmacological and devices if applicable), who had experienced at least three hospitalizations due to HF during the preceding year and were disqualified from heart transplantation. All of them were treated with nightly 12-h 7.5% icodextrin exchange. RESULTS: There were 15 patients (13 men), aged 72 ± 9 years, with charlson comorbidity index (CCI) 9 ± 1.2, NYHA class IV (11 patients) or III (4 patients), and eGFR 32 ± 11 ml/min/1.73m2. They were followed up for 24 ± 8 months (range 12-43, median 26 months). During the 1st year, all patients improved their NYHA functional class from 3.7 ± 0.5 to 2.6 ± 0.5; P = 0.0005, with stable (34.3 ± 12.4, and 35.6 ± 16.5%, respectively) left ventricular ejection fraction (LVEF), and inferior vena cava (IVC) diameter decreased from 27.8 ± 2.7 to 24.4 ± 3.4 mm; P = 0.09. Daily diuresis increased from 867 ± 413 to 1221 ± 680 ml; P = 0.25, while the dose of furosemide could be reduced from 620 ± 256 to 360 ± 110 mg/d; P = 0.0005, however, the kidney function deteriorated, with eGFR drop from 32 ± 11 to 25.6 ± 13 ml/min/1.73m2; P = 0.01). HF-related hospitalizations decreased from 8.9 ± 2.8 days/month to 1.5 ± 1.2 days/month (P = 0.003). Mechanical peritoneal dialysis complications occurred in five patients and infectious complications in four (peritonitis rate 1 per 72 patient-month). Patient survival was 93% at 1 year and 73% at 2 year. Technique survival was 100%. CONCLUSION: In patients with refractory HF, PUF with one overnight icodextrin exchange appears to be a promising therapeutic option as an adjunct to pharmacological management of those who are not transplant candidates. It should be emphasized that the treatment can have a great impact on the quality of life and the total costs of treating these patients.
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Diuretics are the mainstay of treatment of refractory heart failure. There is a high incidence of dyselectrolytemia and suboptimal response due to diuretic resistance. Ultrafiltration by peritoneal route can be a safe and effective alternative. This study aims to study the ultrafiltration by peritoneal route in refractory heart failure patients with respect to change in functional status, renal parameters, left ventricular ejection fraction, number of days of hospitalization, and level of myocardial depressant factors. This was a prospective observational study conducted in Nephrology Department of tertiary care hospital. We studied patients with refractory heart failure who had persistent symptoms requiring frequent admissions despite optimal medical decongestion or had dyselectrolytemia with worsening renal parameters. The data were collected at baseline and then after 6 months of starting ultrafiltration. A total of 30 participants were studied. All the patients were in NYHA functional status Class IV before peritoneal ultrafiltration. There was a significant improvement in functional status and only 14 patients (46%) had Class III to Class IV status after application of ultrafiltration. (P < 0.001) There was a significant improvement in duration of hospital stay (75.8 ± 43.3 days to 7.8 ± 12.4, P > 0.001), serum creatinine (3.18 ± 0.98 to 2.16 ± 0.79 mg/dl, P < 0.001), and left ventricular ejection fraction [29.3 ± 7.4 (%) to 48.5 ± 11.8 (%), P < 0.0001] post ultrafiltration. There was also significant improvement in level of myocardial depressant factors (IL-1, IL-6, TNF alpha). Ultrafiltration by peritoneal route seems to be an effective alternative and should be offered to patients with chronic heart failure who are symptomatic despite maximal medical treatment.
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In Italy, the congestive heart failure is the leading cause of hospitalization and despite advances in therapy, the long-term prognosis is poor. Congestive heart failure is associated with advanced varying degrees of chronic renal disease that identify the cardio-renal syndrome type 2. High-dose diuretic therapy often fail to solve the water overload that is frequently the cause of death. The resistance to diuretics aggravates the state of the patient's edema and consequently morbidity and mortality. In the acute stage, the extracorporeal ultrafiltration unable to repair over hydration but needs frequent access weekly or midweek at the dialysis center. In addition, the significant changes of the fluid overload induce the risk of intradialytic hypotension and consequent renal hypoperfusion can cause a gradual loss of kidney function. The ultrafiltration can also be obtained using a method similar to the peritoneal dialysis (peritoneal ultrafiltration -PUF) but with a limited daily commitment both manual and automated modalities because the indication is not the correction of end stage renal disease. PUF is a home treatment and is indicated for chronic congestive heart failure with refractory hypervolemia despite optimal sequential diuretic therapy. PUF clinical results for the treatment of chronic congestive heart failure have demonstrated effectiveness in improving the clinical condition with reduction of NYHA class and improvement of FE%, the reduction of days of hospitalization, in reducing mortality, improving quality patient's life. In addition, PUF ensures a constant and continuous ultrafiltration, similar to renal function and thus allows a constant hemodynamic stability and ensures the maintenance of diuresis and the residual renal function. Therefore PUF in patients with refractory heart failure seems to be a viable integration of cardiological therapy and the encouraging results lead to the search of a multidisciplinary collaboration between cardiologist and nephrologist to ensure the patient a simple and effective "home" management for the treatment of a pathology so serious.
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Síndrome Cardiorrenal/terapia , Insuficiencia Cardíaca/complicaciones , Hemodiafiltración/métodos , Fallo Renal Crónico/complicaciones , Fallo Renal Crónico/terapia , Diálisis Peritoneal , Estudios de Seguimiento , Humanos , Guías de Práctica Clínica como AsuntoRESUMEN
⦠BACKGROUND: A modified version of automated peritoneal dialysis (APD) using not only variable dwell times but also variable fill volumes has been tested against conventional APD (cAPD) with fixed dwell volumes in a randomized controlled clinical study. The results have indicated that the modified schedule for APD, denoted adapted APD (aAPD), can lead to improved small solute clearances, and, above all, a markedly increased sodium removal (NaR). To theoretically test these results, we have modeled aAPD vs cAPD in computer simulations using the 3-pore model (TPM). ⦠METHODS: The TPM, modified by including a transient, initial inflation of small solute mass transfer area coefficients (PS values), was employed. For simulations of osmotic ultrafiltration (UF), the TPM uses a constantly inflated value for PS for glucose and also a reduced value for PS for Na+, setting the peritoneal lymphatic reabsorption term at 0.3 mL/min. The simulations were performed by assuming that increases in intraperitoneal hydrostatic pressure (IPP) are transmitted to the capillary level (via vein compression) and therefore do not significantly affect the Starling balance. Furthermore, the effective peritoneal surface area (A) was set to be variable as a function of intraperitoneal volume (IPV). ⦠RESULTS: The simulations demonstrated a minor improvement of small solute clearances (~0.7 - 1.6%) and a very small improvement of UF and NaR in aAPD compared to cAPD. ⦠CONCLUSIONS: Due mainly to the increased fill volumes in 3 out of 5 dwells in aAPD, this modality caused minor increases in small solute clearances and marginal effects on UF and NaR. The computer simulations point to a need for accurate sodium determinations in aAPD, considering all the methodological problems and pitfalls relevant to determining dialysate Na+ concentrations and peritoneal sodium mass balance.
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Automatización/métodos , Permeabilidad Capilar/efectos de los fármacos , Simulación por Computador , Soluciones para Diálisis/administración & dosificación , Diálisis Peritoneal/métodos , Permeabilidad Capilar/fisiología , Soluciones para Diálisis/metabolismo , Humanos , Mejoramiento de la Calidad , Valores de Referencia , UltrafiltraciónRESUMEN
This case offers a starting point for a literature review on peritoneal ultrafiltration in refractory heart failure.
RESUMEN
BACKGROUND: Cardiorenal syndrome type 2 (CRS-2) is common in end-stage chronic heart failure (CHF). Peritoneal ultrafiltration (pUF) may entail clinical functional improvement and a reduction in hospitalizations. METHODS: Thirty-nine consecutive end-stage CHF patients with stable CRS-2 were initiated on ambulatory pUF after interdisciplinary cardiological/nephrological evaluation and prospectively followed for 1 year. All-cause hospitalization was the primary end point. Secondary end points included mortality, treatment alteration and change in weight, NYHA functional class or quality of life (QoL). Outcomes were compared both within the pUF cohort (365 prior to initiation) and with 39 matched CHF patients receiving standard medical treatment. RESULTS: Compared with pretreatment, there was a trend to a reduction in 1-year hospitalization days in the pUF group (P = 0.07). One-year mortality was 33% in the pUF group and 23% in the matched control cohort. pUF was stopped in eight patients (18%) due to recurrent peritonitis (n = 3), insufficient ultrafiltration (n = 3) or cardiac recompensation (n = 1). Compared with standard medical treatment, pUF significantly improved volume overload (P < 0.05), NYHA functional class (P < 0.001) and mental health (P < 0.05). Moreover, hospitalization days for all causes as well as cardiovascular hospitalization days were significantly reduced during the interim periods in the pUF group (P < 0.05 and P < 0.001, respectively). CONCLUSIONS: pUF is effective in improving the clinical condition of end-stage CHF patients suffering from CRS-2. Randomized controlled trials are needed to clarify the effects of pUF on hospitalization and mortality in these patients.
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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.