NDT Advance Access published online on September 25, 2009
Nephrology Dialysis Transplantation, doi:10.1093/ndt/gfp484
Efficacy of peritoneal ultrafiltration in the treatment of refractory congestive heart failure
1 Nephrology Service 2 Health Outcomes Research Unit 3 Cardiology Service, Hospital Universitario Central de Asturias, Oviedo, Spain
Correspondence and offprint requests to: Jose E. Sánchez; E-mail: jesastur{at}hotmail.com
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Abstract |
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Background. Heart failure (HF) is a major health problem in developed countries. HF is a progressive, lethal disorder, even with adequate treatment. There exists a vicious circle in the pathophysiology of HF that perpetuates and magnifies the problem. Concomitant fluid accumulation may worsen the congestive HF, it is responsible for numerous hospitalizations and it is an important cause of mortality. In this situation, any means of fluid removal may aid in the management of these patients.
The objective of this study was to evaluate the efficacy of peritoneal dialysis (PD) in the treatment of refractory HF in terms of functional status, hospitalization and mortality. We also determined the improvement in health-related quality of life with the use of PD, and examined the economic consequences of its use.
Methods. We conducted a single centre, prospective, non-randomized study involving patients showing symptoms and signs of congestive HF refractory to maximum tolerable drug treatment. All of them were treated with PD. We analysed physical and biochemical determinations, functional status (according to the NYHA classification) and echocardiogram parameters. Also, to determine the efficacy of the technique we compared the perceived state of health (measured by the EQ5D) to PD patients respect to those reported with conservative therapies. Finally, we carried out a cost-utility evaluation measured by the incremental cost-utility ratio between these two options.
Results. Seventeen patients (65% men, 64 ± 9 years) were included in the study, and 12 were still undergoing PD treatment at the end of the follow-up period (15 ± 9 months). All patients improved their NYHA functional status (65% two classes; the rest, one; P < 0.001), with an important improvement in their pulmonary artery systolic pressure (44 ± 12 versus 27 ± 9 mmHg; P = 0.007), but no changes in left ventricular ejection fraction. Hospitalization rates underwent a dramatic reduction (from 62 ± 16 to 11 ± 5 days/patient/year; P = 0.003) before and after PD treatment. PD treatment raised life expectancy of 82% after 12 months of treatment, and 70% and 56% after 18 and 24 months, respectively, much better outcomes than those reported about conservative therapies, which only use diverse diuretic regimens. PD was associated with a higher perception state of health than the conservative therapy (0.6727 versus 0.4305; P < 0.01). Finally, we found that PD is cost-effective compared with the conservative therapy.
Conclusions. We demonstrate that congestive HF programmes should consider offering PD in hope of seeing better functional status, reduced morbidity and mortality, better quality of life as well as reduced health care costs.
Keywords: congestive heart failure; costs; peritoneal dialysis; quality of life; ultrafiltration
Received for publication: 23. 2.09
Accepted in revised form: 20. 8.09