Original article
Continuous 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

https://doi.org/10.1016/j.rec.2012.05.010Get rights and content

Abstract

Introduction and objectives

Peritoneal dialysis has been proposed as a therapeutic alternative for patients with refractory congestive heart failure. The objective of this study was to assess its effect on long-term clinical outcomes in patients with advanced heart failure and renal dysfunction.

Methods

A total of 62 patients with advanced heart failure (class III/IV), renal dysfunction (glomerular filtration<60 mL/min/1.73 m2), persistent fluid congestion despite loop diuretic treatment and at least 2 previous hospitalizations for heart failure were invited to participate in a continuous ambulatory peritoneal dialysis program. Of these, 34 patients were excluded and adjudicated as controls. The most important reasons for exclusion were refusal to participate, inability to perform the technique and abdominal wall defects. The primary endpoint was all-cause mortality and the composite of death/readmission for heart failure. To account for baseline imbalance, a propensity score was estimated and used as a weight in all analyses.

Results

The peritoneal dialysis (n=28) and control groups (n=34) were alike in all baseline covariates. During a median follow-up of 16 months, 39 (62.9%) died, 21 (33.9%) patients were rehospitalization for heart failure, and 42 (67.8%) experienced the composite endpoint. In the propensity score-adjusted models, peritoneal dialysis (vs control group) was associated with a substantial reduction in the risk of mortality using complete follow-up (hazard ratio=0.40; 95% confidence interval, 0.21-0.75; P=.005), mortality using days alive and out of hospital (hazard ratio=0.39; 95% confidence interval, 0.21-0.74; P=.004) and the composite endpoint (hazard ratio=0.32; 95% confidence interval, 0.17-0.61; P=.001).

Conclusions

In refractory congestive heart failure with concomitant renal dysfunction, peritoneal dialysis was associated with long-term improvement in clinical outcomes.

Resumen

Introducción y objetivos

Se ha propuesto el empleo de la diálisis peritoneal como alternativa para los pacientes con insuficiencia cardiaca congestiva refractaria. El objetivo de este estudio es evaluar su efecto en la evolución clínica a largo plazo de los pacientes con insuficiencia cardiaca avanzada y disfunción renal.

Métodos

Se invitó a un total de 62 pacientes, con insuficiencia cardiaca avanzada (clase III/IV), disfunción renal (filtrado glomerular < 60 ml/min/1,73 m2), congestión persistente por exceso de líquidos a pesar del tratamiento con diuréticos de asa y al menos dos hospitalizaciones previas por insuficiencia cardiaca, a participar en un programa de diálisis peritoneal ambulatoria continua. De ellos, se excluyó a 34 y se los asignó al grupo control. Las razones de exclusión más importantes fueron la negativa a participar, la incapacidad de aplicar la técnica y la presencia de defectos de la pared abdominal. El objetivo primario fue la mortalidad por cualquier causa y la combinación de mortalidad y reingreso por insuficiencia cardiaca. Para tener en cuenta el desequilibrio existente en la situación basal, se estimó una puntuación de propensión que se utilizó como ponderación en todos los análisis.

Resultados

Los grupos de diálisis peritoneal (n = 28) y de control (n = 34) eran similares respecto a todas las covariables basales. Durante una mediana de seguimiento de 16 meses, 39 (62,9%) fallecieron, 21 (33,9%) pacientes fueron rehospitalizados por insuficiencia cardiaca y 42 (67,8%) presentaron el objetivo combinado. En los modelos ajustados según la puntuación de propensión, la diálisis peritoneal, comparada con el grupo control, se asoció a una reducción sustancial del riesgo de mortalidad en el seguimiento completo (razón de riesgos = 0,40; intervalo de confianza del 95%, 0,21-0,75; p = 0,005), la mortalidad evaluada con los días de vida fuera del hospital (razón de riesgos = 0,39; intervalo de confianza del 95%, 0,21-0,74; p = 0,004) y el objetivo combinado (razón de riesgos = 0,32; intervalo de confianza del 95%, 0,17-0,61; p = 0,001).

Conclusiones

En la insuficiencia cardiaca congestiva refractaria con disfunción renal concomitante, la diálisis peritoneal se asoció a una mejoría de la evolución clínica a largo plazo.

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.

References (33)

  • M.R. Costanzo et al.

    Ultrafiltration versus intravenous diuretics for patients hospitalized for acute decompensated heart failure

    J Am Coll Cardiol

    (2007)
  • J. Núñez et al.

    Antigen carbohydrate 125 in heart failure: not just a surrogate for serosal effusions?

    Int J Cardiol

    (2011)
  • D. Zemel et al.

    Appearance of tumor necrosis factor-alpha and soluble TNF-receptors I and II in peritoneal effluent of CAPD

    Kidney Int

    (1994)
  • L.E. Miller et al.

    The blind leading the blind: use and misuse of blinding in randomized controlled trials

    Contemp Clin Trials

    (2011)
  • M. Gheorghiade et al.

    Assessing and grading congestion in acute heart failure: a scientific statement from the Acute Heart Failure Committee of the Heart Failure Association of the European Society of Cardiology and endorsed by the European Society of Intensive Care Medicine

    Eur J Heart Fail

    (2010)
  • M. Dupont et al.

    Impact of systemic venous congestion in heart failure

    Curr Heart Fail Rep

    (2011)
  • Cited by (0)

    View full text