title: Novel therapeutic option for refractory heart failure in elderly patients with chronic kidney disease by incremental peritoneal dialysis.
abstract: BACKGROUND
  Heart failure (HF) often accompanies chronic kidney disease (CKD) in the elderly. This clinical condition is a critical socio-medical issue, because high-dose diuretic therapy stimulates the renin-angiotensin-aldosterone axis and sympathetic nervous system outflow, and may thus result in vicious cycles of cardio-renal deterioration, leading to excess hospitalization and death. Peritoneal dialysis (PD) is a renal replacement therapy used for maintenance dialysis, and is characterized by the continuous removal of fluid. The present study examined the clinical feasibility and effects of a novel style of PD for elderly CKD patients with refractory HF.
  
  
  METHODS
  Twelve elderly CKD patients (stages 3-5) with refractory HF [New York Heart Association (NYHA) class III, n=9; IV, n=3; mean age, 81+/-6 years] received PD treatment. Patients had episodes of >3 hospitalizations in the previous year, and were initially treated with < or =19 sessions of sequential hemofiltration, followed by incremental PD, with 3 PD sessions/week (8h each) at the start, increasing in frequency and dwelling time as clinically indicated.
  
  
  RESULTS
  During follow-up (median, 26.5 months), PD was well tolerated by all patients, and no patients required hospitalization for HF. Three patients died due to non-HF-related events. All patients showed improvements in NYHA functional class (class I, n=9; class II, n=3) and significant decreases in the dose of diuretics prescribed (P<0.05). Kidney function stabilized, while significant improvements in end-diastolic left ventricular diameter (-5%, P<0.05) and hemoglobin count (+15%, P<0.05) were achieved. Brain natriuretic peptide (-46%) and aldosterone (-13%) levels tended to decrease.
  
  
  CONCLUSIONS
  Incremental PD could represent a novel therapeutic option for elderly patients with refractory HF. In addition to fluid removal by PD, correction of renal anemia, preservation of kidney function, and avoidance of high-dose diuretic therapy may play a role in maximizing clinical benefits.
authors.affiliation: Division of Cardiology, Kashima Hospital, 22-1 Kashimamachi, Shimokuramochi, Aza-Nakasawame, Iwaki, Fukushima 971-8143, Japan. ms-nakayama@kashima.jp
authors.forename: Masaru
authors.initials: M
authors.lastname: Nakayama
authors.forename: Hirofumi
authors.initials: H
authors.lastname: Nakano
authors.forename: Masaaki
authors.initials: M
authors.lastname: Nakayama
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000450:Aldosterone / Q000097:blood; D004232:Diuretics / Q000008:administration & dosage; D005260:Female; D005665:Furosemide / Q000008:administration & dosage; D006333:Heart Failure / Q000150:complications* / Q000628:therapy*; D006440:Hemofiltration; D006454:Hemoglobins / Q000032:analysis; D006801:Humans; D007676:Kidney Failure, Chronic / Q000150:complications* / Q000628:therapy*; D008297:Male; D020097:Natriuretic Peptide, Brain / Q000097:blood; D010530:Peritoneal Dialysis / Q000379:methods*
chemical_list: D004232:Diuretics; D006454:Hemoglobins; D020097:Natriuretic Peptide, Brain; D000450:Aldosterone; D005665:Furosemide