Peritoneal dialysis in refractory end-stage congestive heart failure: a challenge facing a no-win situation
Better is what the eyes can see than what can be imagined.Ecclesiastes VI
1 Center for Experimental Nephrology, Ha'Emek Medical Center, Afula, Israel and 2 Fresenius Medical Care, Bad-Homburg, Germany
Correspondence and offprint requests to: Lazaro Gotloib, MD, Center for Experimental Nephrology, Ha'Emek Medical Center, Afula 18101, Israel. Email: gotloib{at}012.net.il
Background. Current medical therapeutic strategies for refractory congestive heart failure (CHF) in the population of 65 years and older with contraindications for heart transplantation are limited. Peritoneal dialysis applied to CHF patients with or without renal impairment showed clinical functional improvement.
Methods. A single centre, prospective but non-randomized study in 20 patients with severe congestive heart failure refractory to optimal pharmacological therapy [New York Heart Association (NYHA), class IV] was performed between 2000 and 2003. The mean age was 65.71±7.66 years. The patients had a baseline glomerular filtration rate of 14.84±3.8 ml/min. Fifteen patients were diabetics (type I, 10; type II, five). For all patients, the baseline ejection fraction was <35% (31.2±4.7%). The mean Charlson's co-morbidity index was 7.8±1.8. Patients were treated initially by 2–5 sessions of continuous veno-venous haemofiltration (CVVH) or sequential haemofiltration (SHF). Automated peritoneal dialysis (APD) was started after implantation of a Tenckhoff catheter. Three APD sessions/week (8 h each), with 15–20 l of dialysis fluid (PDF) per session (10.35±3.05 l of 1.5% lactated glucose and 8.95 ±2.95 l of 4.25% glucose PDF), were performed. Total follow-up ranged between 7 and 35 months (mean 19.80±7.37).
Results. After 1 year of follow-up, all patients showed haemodynamic improvement: significant improvement of left cardiac work index (2.33±0.69 to 2.59±0.47 kg min/m2), reduction of the systolic times ratio (61.14±12.57 to 39.18±13.44%), lower thoracic fluid contents (0.04±0.005 to 0.003±0.0001 
) as well as a regression from NYHA class IV to class I. Need for hospitalization for CHF decreased from 157 to 13 days.
Conclusions. Peritoneal dialysis appears to be a promising therapeutic tool for patients affected by refractory CHF. Clinical improvement of cardiac function may be related to clearing blood from middle molecular weight myocardial depressant substances, including atrial natriuretic peptide. Prospective multicentre trials are needed to confirm these encouraging results.
Keywords: apoptosis; atrial natriuretic peptide; cytokines; haemofiltration; heart failure; peritoneal dialysis
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