Peritoneal Ultrafiltration to Treat Congestive Heart Failure
Peritoneal Ultrafiltration to Treat Congestive Heart Failure
The purpose of this study is to determine whether the treatment of peritoneal ultrafiltration
 can improve survival and quality of life of refractory congestive heart failure with special
 accent on preserving residual renal function and peritoneal membrane characteristics/
Congestive heart failure (CHF) is the leading cause of acute hospital admissions. The
 morbidity associated with this condition presents a major health and economic challenge,
 which is anticipated to increase in the aging of population especially in developed
 countries.

 Peritoneal dialysis (PD) in patients with diuretic resistant cardio-renal syndrome type 2
 enables low-molecular weight solute clearance and ultrafiltration (UF) without serious
 hemodynamic changes, which makes this modality attractive for chronic CHF treatment . The key
 practical advantage of PD is that the patient can be treated at home, with treatment
 adjustment in accordance with his current condition. The additional advantages are:
 continuous UF, flexible schedule, no need for devices or anticoagulation, no need for medical
 staff.

 Despite the fact that there was no significant improvement of survival in CHF patients
 treated by PD, as compared to regular treatment, improvement of symptoms, physical
 performance, quality of life , biochemical profile, and significant decrease in
 hospitalization rate have been reported.

 PD has a number of both theoretical and practical advantages for extending treatment in CHF
 patients, but there is little experience in this field and limited knowledge regarding its
 influence on peritoneal membrane and renal function in patients with moderate renal failure.

 Aims of the study:

 1. primary aim - to find out if there is survival benefit on PD treatment, reduced
 hospitalization rate and improved QOL, to compare the functional outcomes of CHF
 patients 1 year before dialysis treatment and on PD treatment with different types of PD
 fluids

 2. secondary aim - to choose the optimal type of dialysis treatment in term of effective
 UF, preservation of peritoneal membrane and residual renal function.

 Research question: Whether UF improves survival and QOL in patients with severe CHF. What are
 the modes of PD and HD treatment ensuring the least possible negative impact on peritoneal
 membrane and residual renal function? Research hypothesis: UF improves survival and QOL in
 patients with severe CHF. Low glucose dialysis solutions are preferable treatment for CHF
 patient on PD for preservation of residual renal function and peritoneal membrane
 characteristics.

 Possible risks preventing: early peritoneal membrane failure and deterioration of renal
 function, symptoms of fluid overload and need for inpatient treatment.

 Type of study: observational prospective Population: CHF patients referred to nephrologist
 for home-based UF (PD) or medical or hemodialysis treatment

 Inclusion criteria:

 -  diagnosis of heart failure NYHA 3-4 on maximal treatment with evidence of diuretic
 resistance and repeated hospital admissions due to fluid overload (at least 2 in
 previous 3 months)

 -  evidence of CKD stage 3-4

 -  agreement to place dialysis catheter in the peritoneal cavity for PD treatment or IV
 access for hemodialysis

 -  available medical records 1 year before dialysis treatment

 Exclusion criteria:

 -  unstable hemodynamic or respiratory condition

 -  need for vasopressor support

 -  patient refusal

 -  lack of family support or housing conditions needed for PD treatment

 -  evidence of active kidney disease (obstructive uropathy, glomerulonephritis, vasculitis
 etc.) at recruitment to the study Accrual rate: 10 -20 patients per year, 40-80 patient
 overall Enrolment mode: The patients will be referred to peritoneal dialysis center by
 treating nephrologist or cardiologist. After identification and approval of candidate by
 dialysis nurse, the incident patients who meet the inclusion criteria, will be referred
 for peritoneal catheter insertion.

 Intervention: PD catheter insertion by nephrologist or surgeon and PD treatment by dialysis
 fluids in according to clinical needs of the patient. Monitoring of clinical symptoms of
 fluid overload, hospital admissions, UF rate, peritoneal membrane damage parameters
 (cell-free DNA in peritoneal effluent, peritoneal equilibration test) and residual renal
 function markers (eGFR creatinine based , KT/V, urinary markers , PET) at the start of the
 treatment, each 3 months during the treatment and at each change of prescription.
 Complications of all kinds will be recorded.

 Comparison group: CHF patients referred to nephrologist for home-based UF (PD) treatment and
 who preferred to continue conventional treatment.
Inclusion Criteria:

 -  diagnosis of heart failure NYHA 3-4 on maximal treatment with evidence of diuretic
 resistance and repeated hospital admissions due to fluid overload (at least 2 in
 previous 3 months)

 -  evidence of CKD stage 3-4

 -  agreement to place dialysis catheter in the peritoneal cavity for PD treatment or IV
 access for hemodialysis

 -  available medical records 1 year before dialysis treatment

 Exclusion Criteria:

 -  unstable hemodynamic or respiratory condition

 -  need for vasopressor support

 -  patient refusal

 -  lack of family support or housing conditions needed for PD treatment

 -  evidence of active kidney disease (obstructive uropathy, glomerulonephritis,
 vasculitis etc.) at recruitment to the study

 -  contraindications for peritoneal ultrafiltration treatment (active intraabdominal or
 abdominal wall inflammatory process, morbid obesity, multiple abdominal surgery in the
 past)

 -  non compliance with treatment protocol