Original articleContinuous Ambulatory Peritoneal Dialysis and Clinical Outcomes in Patients With Refractory Congestive Heart FailureDiálisis peritoneal ambulatoria continua y evolución clínica de pacientes con insuficiencia cardiaca congestiva refractaria
Introduction
Systemic congestion commonly occurs in patients with advanced heart failure (HF) and is considered a hallmark in those with acute heart failure (AHF).1 In addition, there is strong evidence suggesting that congestion may play an important role in progression of the disease.2, 3, 4 Indeed, recent data support the role of fluid retention in the pathogenesis of renal dysfunction (cardiorenal syndrome) and subsequent diuretic resistance,5, 6 which are associated with limited therapeutic options7, 8 and poor prognosis.9, 10, 11 In this context, 2 related procedures have been proposed for the management of these patients: a) intermittent ultrafiltration, which is particularly useful during episodes of acute decompensation,12, 13 and b) continuous ambulatory peritoneal dialysis (CAPD), which has been considered an attractive alternative for the treatment of refractory congestive heart failure (CHF) by offering a continuous and more physiological ultrafiltration process.14, 15, 16, 17, 18, 19, 20, 21 Indeed, our group, as well as other groups, have described patient improvement in clinical and functional status, favorable changes in echocardiographic and hemodynamic parameters, and reduction in hospitalization rates associated with the use of CAPD with an acceptable rate of adverse effects.14, 15, 16, 17, 18, 19, 20, 21 Nevertheless, the effect of CAPD on long-term clinical outcomes is still unknown.
The aim of this study was to compare clinical outcomes between patients included in a CAPD program vs a similar cohort of CHF patients who were eligible for CAPD but who refused to be enrolled or were excluded from the program.
Section snippets
Study Group and Protocol
We prospectively studied a cohort of 62 patients, who were followed up in the HF unit of the Hospital Clínico Universitario de Valencia from August 1, 2008 to June 1, 2011, and who met the following inclusion criteria: a) at least 2 prior admissions for AHF, with the last episode being in the past 6 months; b) New York Heart Association (NYHA) functional class III/IV; c) persistent congestion despite optimal loop-diuretic therapy, and d) the presence of renal dysfunction documented at least
Results
As part of the inclusion criteria, all patients were in NYHA class III/IV, had previous admissions for AHF and showed persistent signs and symptoms of congestion (despite treatment with loop diuretics). The mean age was 73.4 (9.2) years; 75.8% were men, and 66.1% had a prior history of ischemic heart disease. The medians for Charlson comorbidity index, eFGR, left ventricular ejection fraction, plasma N-terminal pro-brain natriuretic peptide and daily furosemide dose were 4 [3-6], 30.6
Discussion
The results of this study indicate that CAPD may play a significant role in modifying the natural history of patients with refractory CHF, in which persistent fluid overload (despite intensive diuretic therapy) and the coexistence of renal failure is also present. Indeed, the magnitude of the mortality reduction attributed to CAPD was striking in terms of relative and absolute risk reductions. A relative risk reduction of more than 50% was observed for all of the clinical endpoints, findings
Conclusions
In this observational study, we found that the risk of major outcomes was significantly reduced in patients with advanced and refractory CHF and concomitant renal dysfunction who underwent CAPD. Additional studies, hopefully in more controlled scenarios, are needed to confirm these results and to define the clinical utility of this technique in this challenging subset of HF patients.
Funding
This study was supported by unrestricted grants from the Ministerio de Sanidad y Consumo, Instituto de Salud Carlos III, RED HERACLES RD06/0009/1001 (Madrid, Spain), help for projects of emerging groups in 2010 of the Conselleria de Sanitat de Valencia (DOCV 6.175, 30/12/2009-Annex III), Spanish Society of Cardiology (Beca Esteve 2009) and Fresenius Medical Care.
Conflicts of interest
None declared.
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