Congestive Heart Failure Complicates Peritoneal Dialysis Treatment

By Peter Laird, MD

Chronic renal patients face difficult decisions in how to apply renal replacement therapies (RRT) to maximize individual survival. Many patients that seek the independence of home therapies consider peritoneal dialysis in the comfort of their own home their ideal solution. Survival data reveals equal outcomes between conventional in-center hemodialysis and peritoneal dialysis making the decision between home based therapy a decided advantage as far as retaining independence. However, patients with congestive heart failure prior to the onset of RRT may have worse outcomes than those patients treated in-center. In addition, a large percentage of patients will develop congestive heart failure with peritoneal dialysis after 4 years of treatment:

Heart Failure in Long-Term Peritoneal Dialysis Patients: A 4-Year Prospective Analysis

Results Eighty-six patients had a previous history of heart failure at study entry. The cumulative 4-year survival probability was 37.4% and 64.7% for patients with and without previous heart failure, respectively (P < 0.0001). During follow-up, 87 patients (40.9%) developed heart failure, of which 53 were recurrence and 34 were new-onset heart failure. Diabetes, background atherosclerotic vascular disease, systolic hypertension, left ventricular (LV) mass index, systolic dysfunction, and hypoalbuminemia were significant risk factors predicting heart failure in the entire cohort. Diabetes and LV mass and volume index were significant predictors of new-onset heart failure. Systolic hypertension, LV volume index, and hypoalbuminemia were significant predictors of recurrent heart failure.

Conclusions Heart failure is a highly prevalent complication in long-term PD patients and predicts adverse clinical outcomes. More attention should be focused on improving BP and volume control and identifying treatment strategies that effectively lower atherosclerotic burden and reverse LV hypertrophy, remodeling, and systolic dysfunction in PD patients.

Many people utilize the convenience of peritoneal dialysis as a bridge to transplant when the wait for a living donor is less than two years quite successfully. However, anyone considering long term usage of peritoneal dialysis must closely follow their volume status. We do know that the primary complications of peritoneal dialysis follow closely the patients residual renal function (RRF). As RRF declines, the benefits of PD likewise falls as well. Considering the best strategy for renal replacement treatments at times combines the use of modalities such as PD First, followed by either transplant or by short daily or nocturnal dialysis.

The outcomes between PD FIrst vs nocturnal dialysis first are unknown at present, but we do know that daily nocturnal dialysis rivals cadaveric transplant outcomes, while PD is comparable to conventional in-center therapy. Further trials are warranted to delineate the best strategy at the onset of RRT.

http://www.hemodoc.com/2011/04/congestive-heart-failure-complicates-peritoneal-dialysis-treatment.html