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Heart failure is a clinical syndrome that occurs when abnormalities in the structure and function of the myocardium impair cardiac debt or reduce ventricular filling. It is a disease with high morbidity-mortality, specially increasing the incidence among older patients. One major complication of this pathology is volume overload, affecting approximately 80% of patients. This mechanism is triggered by reduced cardiac output associated with increased peripheral vascular resistance, leading to water and sodium retention and resulting in a state of hypovolemia. These factors contribute to the progression of both kidney and cardiac diseases.
This is a case report
A 63-year-old male patient with undetermined etiology chronic kidney disease (CKD) and ischemic heart failure (HF) underwent angioplasty in 2013, initiating hemodialysis (HD) and later transitioning to continuous ambulatory peritoneal dialysis (CAPD), in March 2017. Despite optimized pharmacological therapy, including low-dose enalapril, initial echocardiogram in March 2017 revealed an ejection fraction (EF) of 20%, left ventricular hypertrophy with moderate enlargement, and moderate mitral insufficiency. A follow-up echocardiogram after nine months on CAPD showed an improved EF of 37.3%, maintaining other previous findings. At that time, the patient was classified as NYHA class III, experiencing frequent episodes of paroxysmal nocturnal dyspnea.
After five years of CAPD (five exchanges with 1.5% and 2.3% bags), the latest echocardiogram showed an increased EF to 69%. Symptoms related to HF improved, leading to reclassification as NYHA class I. HF is a common condition in CKD patients, significantly impacting morbidity and mortality. Peritoneal dialysis (PD) has been recognized as a therapeutic intervention for heart failure since 1949 and has gained prominence in recent years for this population.
PD in these patients offers slow ultrafiltration, has less association with the stunned myocardium syndrome, preserves residual kidney function, reduces intra-abdominal and renal venous pressure, and removes substances harmful to the myocardium without the potential negative cardiac effects of arteriovenous fistulas. Studies have demonstrated an improvement in the functional class of HF patients, such as Núñez et al.'s prospective study, where NYHA decreased from 3 ± 0.3 to 2 ± 0.5 after six weeks of treatment. Additionally, lower rates of hospitalization for both cardiovascular and general causes were observed, along with shorter hospital stays. Patients also reported an improvement in quality of life after starting PD.
The patient above, after initiating PD, showed increased EF, improved functional class, and no new hospitalizations for cardiac decompensation. In addition to the mentioned advantages, the therapy also enhanced sensitivity to HF treatment, decreasing resistance to diuretics and achieving the target dose of mineralocorticoid antagonists and renin-angiotensin system inhibitors without causing severe hyperkalemia. Thus, the importance of PD in the population with HF and CKD requiring dialysis is affirmed.
Therefore, PD emerges as a promising alternative in managing patients facing the dual challenge of heart failure and renal insufficiency. Intrinsic benefits, such as reducing cardiovascular stress, flexibility in fluid control, preserving residual kidney function, and promoting patient autonomy, stand out as crucial elements in the therapeutic approach. However, recognizing the importance of a personalized approach in choosing the dialytic method, considering each patient's specific characteristics and the nuances of the relationship between HF and CKD, is imperative. Furthermore, close collaboration among multidisciplinary teams, including nephrologists, cardiologists, and specialized healthcare professionals, is essential to ensure treatment efficacy and maximize benefits for the patient. Ultimately, PD emerges not only as a therapeutic response to CKD but also as a strategic tool in the integrated management of complex medical conditions, offering an optimistic outlook for improving the quality of life and survival of these patients. Ongoing understanding of its benefits and advancements in patient-centered clinical approaches will contribute to significant progress in caring for individuals facing the challenging complications of the analyzed renal and cardiac conditions.