Successful Use of Continuous Ambulatory Peritoneal Dialysis in Refractory Heart Failure

Abstract

Four patients with end-stage heart failure, massive ascites refractory to medical interventions and a variable degree of renal failure were treated successfuly with CAPD for eight to 24 months. The New York Heart Association functional class improved in all four. In two patients, who presented initially with signs and symptoms mainly of right-sided heart failure, ejection fraction improved. Each day dialysis achieved a significant degree of ultrafiltration and a negative sodium balance. We propose that CAPD is an alternative therapeutic modality in patients with severe heart failure refractory to the conventional medical treatment. The advent of potent diuretics and preload and afterload reducing agents has had a major impact in the treatment of refractory congestive heart failure. Recently, captopril, an angiotensinconverting enzyme inhibitor, has been used with major benefit in some patients (I). However, some patients still do not respond to these treatments and their management presents a major therapeutic challenge. Furthermore, overzealous therapy with diuretics may lead to intravascular volume depletion resulting in hypotension, azotemia and electrolyte disturbances which further complicate their management. In the past, intermittent peritoneal dialysis (IPD) or hemodialysis (HD) has been used to remove fluid from patients with intractable edema due to heart failure (2 7). But the benefit is only transient and fluid accumulates again, requiring repeated sessions of acute dialysis. However, hypotension is a frequent complication during either form of acute dialysis especially in hemodynamically unstable patients due to rapid removal of large amounts of fluid from intravascular space. Continuous ambulatory peritoneal dialysis (CAPD), whose main characteristic is the slow continuous removal of sodium and water, offers obvious advantages in patients with intractable heart failure. This paper describes our experience of four patients with intractable heart failure who have been treated with CAPD for eight to 24 months.