Peritoneal Dialysis for Patients with refractory Heart Failure and Liver Cirrhosis

The prevalence of chronic heart failure (CHF) and liver cirrhosis continue to increase worldwide. Concomitant chronic kidney disease (CKD) is reported in 50% and 30% of patients, respectively, which limits treatment options and predisposes to recurrent volume overload in both conditions, especially when found in combination with advanced stages of CKD. Peritoneal dialysis (PD) has long been established as a therapeutic option for CHF patients with end-stage renal disease because of its better hemodynamic stability compared with hemodialysis. Recent studies also reported beneficial effects for peritoneal ultrafiltration (pUF) in CHF patients with stage 4 CKD and recurrent volume overload refractory to diuretics. In these patients pUF was able to significantly reduce the number and duration of hospitalizations due to decompensated CHF as well as improve the severity of dyspnea. Further advantages include a more liberal use of antagonists of the renin-angiotensin-aldosterone as well as an effective drainage of CHF-induced ascites. However, PD and pUF cannot be offered to frail patients without appropriate support in the domestic environment as there are currently no nursing services and reimbursement plans for ambulatory PD/pUF care. As a treatment procedure PD can also be considered for patients with liver cirrhosis and end-stage kidney disease as it enables continuous and thus hemodynamically stable UF without the need for extra anticoagulation. Additionally, it provides permanent drainage of ascites which makes serial therapeutic paracentesis unnecessary. Importantly, studies have also shown no elevated risk of peritonitis and no excessive loss of protein due to PD.