Defining the role of peritoneal dialysis in management of congestive heart failure

ABSTRACT

Introduction: Congestion is an integral component of heart failure (HF) pathophysiology and portends an adverse impact on outcome. Peritoneal dialysis (PD) is a home-based therapeutic modality that has been used in the setting of refractory congestive HF to help optimize volume status. Not only does PD allow for customized sodium and water removal, but it also provides the opportunity for the patients to fully benefit from guideline-directed medical therapy for HF that could have otherwise been challenging to use.

Areas covered: Authors provide an overview of the pathophysiologic basis for the use of PD in HF, followed by a review of the findings of the main clinical trials such as the salutary impact on HF re-admissions and quality of life. Since the goals of therapy in this setting differ from those for patients with end-stage renal disease, pertinent practical considerations in the use of this modality are then discussed as well as potential barriers.

Expert opinion: For patients with chronic refractory HF, PD represents an alternative to medical therapy alone. Identification of patients that would benefit most from this modality and detection of major enablers and obstacles for the implementation of this therapy should be the focus of future studies.

KEYWORDS:

• Cardiorenal syndrome
• congestion
• heart failure
• peritoneal dialysis
• ultrafiltration

Article highlights box

• Congestion is the primary reason for hospitalization of patients with acute heart failure and is a key driver of adverse outcomes.

• Renal dysfunction and diuretic resistance are common findings in advanced heart failure.

• Peritoneal dialysis, a home-based therapeutic modality, has the ability for efficient removal of salt and water to treat congestion while sparing the kidneys.

• Several clinical trials have confirmed the feasibility of peritoneal dialysis for management of refractory heart failure.

• Reduction in hospital readmission, improvement of functional status, and quality of life are among beneficial impacts of peritoneal dialysis in this setting.

• Peritoneal dialysis is a highly flexible modality and can easily be adjusted to the patients’ characteristics and clinical needs that might vary over time.

• Peritoneal dialysis can provide patients with the opportunity to fully benefit from the established therapies of heart failure that would otherwise be challenging to use (e.g. risk of hyperkalemia with renin-angiotensin-aldosterone inhibition).

• Future studies are needed to explore whether peritoneal dialysis can have a role in the reduction of heart failure-associated health-care expenditure and patient survival.

• Designing interdisciplinary collaborative programs with the involvement of cardiologists and nephrologists would be crucial for the implementation and success of this initiative.

Declaration of interest

J Bargman is a consultant and speaker for Baxter Canada and DaVita Healthcare Partners. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.