To the Editor,

The term cardiorenal syndrome (CRS) describes the clinical situation in which heart and kidney function are simultaneously compromised, which perpetuates the progression of damage in both organs1.

In type II CRS, chronic heart failure (HF) may accelerate the chronic deterioration of renal function, which itself may cause fluid overload, resistance to the effect of diuretics and, lastly, refractory HF (RHF) with normal treatment. When patients are not candidates for cardiac transplantation (CT), they have the option of palliative treatment2 or newer alternatives, amongst them ultrafiltration (UF) techniques with the nephrologist having an active role2. UF by peritoneal dialysis (PD) may provide some advantages over haemodialysis (HD), such as a better preservation of residual renal function, better haemodynamic stability, continuous UF, etc.3-5. The best solution would be CT. Furthermore, there are previous conditions that increase post-transplant morbidity and mortality and may make it contraindicated, such as systemic diseases with poor prognosis (e.g. advanced renal failure) and severe pulmonary hypertension.

Our approach is that since it improves the clinical and functional status of patients, PD may be an instrument that contributes to a better condition before CT and facilitates its implementation and a better outcome.

CASE REPORT

Before the start of PD (Table 1): male, 47 years old, severe HF (New York Heart Association class III-IV) secondary to dilated cardiomyopathy of ischaemic aetiology, revascularised and without a possibility of further revascularisation, optimal treatment-resistant, with a poor quality of life (a score of 16 in the SF-36 questionnaire), continuous admissions and prolonged hospitalisation (more than 150 days accumulated in one year). The diuretic doses displayed in the Table refer to chronic home treatment. During admissions and flare-ups the patient received high doses of intravenous furosemide (>500mg), thiazides and they were even combined with potassium-sparing diuretics. Systolic and diastolic dysfunction. Severe pulmonary hypertension (PH), resistant to medical treatment (sildenafil and iloprost). Severe mitral insufficiency. Stage III chronic kidney disease (CKD).

The possibility of CT was studied, but because of the multiple admissions due to episodes of CHF and severe PH, the indication and definitive inclusion time was delayed.

The decision was made to include him in the UF programme with PD: manual PD (continuous ambulatory peritoneal dialysis [CAPD]) of only one exchange per day of 10-12 hours (nocturnal) with icodextrin solution, without daytime dialysis or exchanges, every day.

Three months after starting PD, the patient was clinically and haemodynamically stable, with a good clinical course (Table 1): improvement of the functional HF class, no admissions, reduction of oedema, an improvement of echocardiographic parameters without a deterioration of renal function (glomerular filtration rate >60ml/min) and with restored response to diuretics, without PD-related complications and with a considerable improvement in his quality of life (60 points in the SF-36).

He received a CT four months after the start of PD. He has remained haemodynamically stable during the post-operative period. Diuresis has been maintained without deterioration of renal function. No signs of HF. Good cardiac graft evolution without rejection. Two months after CT, the peritoneal catheter was removed, with no reintroduction of peritoneal UF being necessary to date (Table 1).

DISCUSSION AND CONCLUSIONS

The nephrologist and UF techniques are taking on a priority and key role in RHF, being proposed as an alternative level of treatment, with a priori promising results. It has shown an improvement in symptoms, a decrease in re-admissions, pulmonary and peripheral oedema, an improvement in functional class, renewed response to diuretics, a decrease in circulating proinflammatory cytokines, and even an improved glomerular filtration rate2,3. UF with PD may provide, as has been mentioned, advantages over HD2,6, and its different methods can be used (CAPD, automated peritoneal dialysis) as well as new solutions, as is the case of icodextrin7. The latest studies reinforce the beneficial effect of PD in this type of patient (Table 2), expressed as an improvement in cardiac function, hospitalisation, symptoms and even mortality, even in patients with CKD not at end-stage, and it is also a cost-effective treatment against RHF with many hospitalisations and conventional treatments5,8-10.

Taking into account that these patients have relatively complex situations, such as prolonged hospitalisation or the difficulty in accessing CT, including PD as the last option in their treatment may be the key to allowing them a more viable future, and more time at home and even access to interventional cardiac techniques (valvuloplasty, surgery, etc.) or even CT, as in our case.

Conflicts of interest

The authors declare that they have no conflicts of interest related to the contents of this article.

12570_19157_65747_en_ref.1257033601_12570_19115_60155_es_12570_tabla1_en.doc

Table 1. Evolution of clinical, functional, laboratory, volume and complementary parameters before peritoneal dialysis, one month after the introduction of the technique and one month after cardiac transplantation

12570_19157_65748_en_ref.1257033601_12570_19115_61335_es_12570_tabla2_en.doc

Table 2. Clinical experiences since 2010