1. Prof. Dr. med. Vedat Schwenger
CAPD in heart failure
Prof. Dr. med. Vedat Schwenger
Nephrologist – University of Heidelberg
Nierenzentrum, Heidelberg, Germany

2. PD in CHF patients – is there a need for nephrological care?
V. Schwenger, Heidelberg 2012

3. Congestive Heart Failure
one of the most cost intensive chronic illnesses
30-60% of CHF patients suffer from renal failure
renal failure patients = high risk patients
renal failure is a strong predictor of mortality

4. Smith: JACC 2006

5. cardio-renal syndrome
risk factors:
albuminuria hypertension dyslipidemia chron. Inflammation anemia calcium-phosphate malnutrition uremia
etiology: genetics low-output syndrome maintained output, venous congestion
renal hypoperfusion renal fibrosis
renal embolism atherosclerosis
SNS
RAAS
reno-cardial syndrome
mod. Breidthardt T, Mebazza A, Mueller CE, 2009

6. Classifikation of the CRS
Parfrey: Nature Rev. Nephrol 2009

8. Renal failure in CHF patients additional „nephrological“ care
diagnosis and specific treatment
refractory hypervolemia
electrolyte disorders
drug dosing
sHPT – Vit. D
metabolic acidosis

9. Refractory hypervolemia in CHF patients therapeutic options
Aquaresis
Hemodialysis
Peritoneal dialysis

10. UF: NYHA III: n=52 NYHA IV: n=45
Design:
multizentric prospective randomised trial (diuretics vs. UF), n=200, 63±15 J., 138 ♂
Prim. EP:
weigth loss, dyspnea
Cohort:
UF: NYHA III: n=52 NYHA IV: n=45
EF≤40%: 71% BNP1256±1203 pg/ml
Diuretic: NYHA III: n=48 NYHA IV: n=45 EF≤40%: 70% BNP1309±1494 pg/ml
Costanzo: JACC 2007

12. Unload Trial
Costanzo: JACC 2007

13. Aquadex®
easy to perform
without evidence
costs
central venous line

14. cardiorenal syndrome - hemodialysis
3x/week volume control !
high incidence of pulmonary hypertension (~40% in patients with AV-fistula)
after creation of AV-fistula: BNP ↑, cardiac output und Endothelin ↑ (?) NO ↓
PA-P and cardiac output decreased after RTX by mmHg and >1,5 L/min, resp.
hemodynamics
Ori: NDT 1996, Iwashima: AJKD 2002 Yigla: Chest 2003 Nakhoul: NDT 2005

15. dialysis modality – association to heart failure
incident patients
USRDS 2007

16. dialysis related morbidity
USRDS 2009

17. PD in CHF – potential advantages
continuous modality
no additional hemodynamic burden
removal of ascites
quality of life
flexibility – self determination of life
lower potassium values (-/+)
better preservation of residual renal function (?)

18. 500 – 1000 cc 5% glucose solution/hour
Continuous peritoneal irrigation in the treatment of intractable edema of cardiac origin
Female patient, age 47 a, severe right and left congestive heart failure, No. 24 Mushroom catheter + sump drain,
500 – 1000 cc 5% glucose solution/hour
Schneierson SJ: Am J Med Sci 218: 76-79, 1949

19. “incremental peritoneal dialysis”
n=12, 81 ± 6 J.
HF prior PD (0-19)
follow-up 26.5 Mo
Nakayama: J Cardiol 2010

20. UF in patients with CRS n= 17; after 15 months n=12
hospitalisation 62 ± 16 d prior PD vs. 11 ± 5 d with PD
QoL and survival improved (82% after 12 Mo)
Size of bubbles: cost-utility
total health care cost
€/ quality adjusted life-year
Sanchez: NDT 2010

21. PD in refratory CHF patients
75.1 J., 72% ♂, NYHA III-IV (LV 40 ± 14 %)
hospitalization after 6 mo: 0 d (12 mo prior PD 16 d)
Nunez: Eur J Heart Failure 2012

22. reduced hospitalization for CV causes
(not for all causes)
NYHA class improved
QoL tended to improve
no difference between IHD (n=11) and PD (n=12)
Cnossen: NDT 2012

23. incident ESRD patients (REIN registry 2002-2008) n=4401 (3468 HD)
1/3 CHF (1173 HD, 490 PD)
RR mortality90: 1.48
Sens: KI 2011

24. registry „Herz-Niere.de“*
* P<0.0001

25. registry „Herz-Niere.de“* *
* P=0.0002
* P<0.0001

26. summary renal failure is one of the most important RF
frequently underdiagnosed
integrated care
indications have to be clearly defined
evidence?