Division of Cardiology, Kashima Hospital, 22-1 Kashimamachi, Shimokuramochi, Aza-Nakasawame, Iwaki, Fukushima 971-8143, Japan.
J Cardiol. 2010 Jan;55(1):49-54. doi: 10.1016/j.jjcc.2009.08.003. Epub 2009 Sep 26.
Heart failure (HF) often accompanies chronic kidney disease (CKD) in the elderly. This clinical condition is a critical socio-medical issue, because high-dose diuretic therapy stimulates the renin-angiotensin-aldosterone axis and sympathetic nervous system outflow, and may thus result in vicious cycles of cardio-renal deterioration, leading to excess hospitalization and death. Peritoneal dialysis (PD) is a renal replacement therapy used for maintenance dialysis, and is characterized by the continuous removal of fluid. The present study examined the clinical feasibility and effects of a novel style of PD for elderly CKD patients with refractory HF.
Twelve elderly CKD patients (stages 3-5) with refractory HF [New York Heart Association (NYHA) class III, n=9; IV, n=3; mean age, 81+/-6 years] received PD treatment. Patients had episodes of >3 hospitalizations in the previous year, and were initially treated with < or =19 sessions of sequential hemofiltration, followed by incremental PD, with 3 PD sessions/week (8h each) at the start, increasing in frequency and dwelling time as clinically indicated.
During follow-up (median, 26.5 months), PD was well tolerated by all patients, and no patients required hospitalization for HF. Three patients died due to non-HF-related events. All patients showed improvements in NYHA functional class (class I, n=9; class II, n=3) and significant decreases in the dose of diuretics prescribed (P<0.05). Kidney function stabilized, while significant improvements in end-diastolic left ventricular diameter (-5%, P<0.05) and hemoglobin count (+15%, P<0.05) were achieved. Brain natriuretic peptide (-46%) and aldosterone (-13%) levels tended to decrease.
Incremental PD could represent a novel therapeutic option for elderly patients with refractory HF. In addition to fluid removal by PD, correction of renal anemia, preservation of kidney function, and avoidance of high-dose diuretic therapy may play a role in maximizing clinical benefits.
心力衰竭（HF）常伴有老年人慢性肾病（CKD）。这种临床情况是一个关键的社会医学问题，因为大剂量利尿剂治疗会刺激肾素-血管紧张素-醛固酮轴和交感神经系统输出，从而可能导致心脏-肾脏恶化的恶性循环，导致过度住院和死亡。腹膜透析（PD）是一种用于维持透析的肾脏替代疗法，其特点是连续去除液体。本研究探讨了一种新的 PD 治疗方案对老年 CKD 合并难治性 HF 患者的临床可行性和疗效。
12 名老年 CKD 合并难治性 HF 患者（3-5 期）[纽约心脏协会（NYHA）心功能分级 III 级，n=9；IV 级，n=3；平均年龄 81+/-6 岁]接受 PD 治疗。患者在过去一年中有>3 次住院发作，最初接受<或=19 次序贯血液滤过治疗，然后逐步增加 PD，开始时每周 3 次 PD（每次 8 小时），根据临床需要增加频率和居住时间。
在随访期间（中位数 26.5 个月），所有患者均能耐受 PD，无 HF 住院患者。3 名患者因非 HF 相关事件死亡。所有患者 NYHA 心功能分级均有改善（I 级，n=9；II 级，n=3），利尿剂剂量显著减少（P<0.05）。肾功能稳定，舒张末期左心室直径（-5%，P<0.05）和血红蛋白计数（+15%，P<0.05）显著改善。脑钠肽（-46%）和醛固酮（-13%）水平趋于下降。
递增 PD 可能是老年难治性 HF 患者的一种新的治疗选择。除了 PD 去除液体外，纠正肾性贫血、保护肾功能和避免大剂量利尿剂治疗可能在最大限度地提高临床获益方面发挥作用。
