Novel therapeutic option for refractory heart failure in elderly patients with chronic kidney disease by incremental peritoneal dialysis.

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.