title: Arteriovenous renal replacement therapy in end-stage left-sided heart failure patients has a detrimental effect on patients with impaired right ventricular function.
abstract: OBJECTIVE
  Chronic intermittent renal replacement therapy(RRT) is an alternate method of decongestion for patients presenting with diuretic-resistant, end-stage heart failure(HF) and cardiorenal syndrome. The optimal method of vascular access has not been confirmed. This study investigated the 6-month outcomes of patients with end-stage HF after the creation of arteriovenous communications (AVC) compared with other means of RRT.
  
  
  METHODS
  We treated 40 patients with chronic, intermittent, ambulatory RRT, of whom 15 (37.5%; Group A) underwent creation of AVC, and 25 (62.5%; Group B) received intraperitoneal (n=6) or internal jugular catheters (n=19) with the goal of achieving body weight stabilization and relief from congestion.
  
  
  RESULTS
  The characteristics of the two groups were similar. According to Cox regression analysis, the 6-month rate of death or re-hospitalization for HF was significantly higher in Group A (73%) than in Group B (44%); hazard ratio (HR): 2.58; 95% confidence interval (CI) 1.2-6.2; P=0.02. Over a 6-month follow-up, the cumulative survival was significantly shorter (P=0.03) in Group A (13.8±10 weeks) than in Group B (20.7±7 weeks). In the 15 patients who received AVC, the only independent predictor of adverse outcome at 6 months was serum total bilirubin concentration (HR 2.5; 95% CI 1.1-5.7, p=0.02), whereas in the 25 patients who underwent other means of RRT, pulmonary vascular resistance (PVR) was identified as a risk factor for hospitalization or death at 1-year follow-up (HR 1.26; 95% CI 1.1-1.57, p=0.04).
  
  
  CONCLUSIONS
  In patients with end-stage HF, the creation of AVC for intermittent RRT was followed by a significant increase in morbidity and mortality in comparison to the safe and effective placement of permanent central venous catheters. Patients with elevated PVR seem to comprise a group at high risk for adverse outcomes after central catheter insertion.
authors.affiliation: Third Department of Cardiology, Athens University School of Medicine, Athens, Greece. Electronic address: v_repasos@hotmail.com.
authors.forename: Evangelos
authors.initials: E
authors.lastname: Repasos
authors.affiliation: Third Department of Cardiology, Athens University School of Medicine, Athens, Greece.
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Kaldara
authors.affiliation: Third Department of Cardiology, Athens University School of Medicine, Athens, Greece.
authors.forename: Christos
authors.initials: C
authors.lastname: Pantsios
authors.affiliation: Third Department of Cardiology, Athens University School of Medicine, Athens, Greece.
authors.forename: Chris
authors.initials: C
authors.lastname: Kapelios
authors.affiliation: Third Department of Cardiology, Athens University School of Medicine, Athens, Greece.
authors.forename: Emmeleia
authors.initials: E
authors.lastname: Nana
authors.affiliation: Transplantation Unit, Athens University School of Medicine, Laiko General Hospital, Athens, Greece.
authors.forename: Spiridon
authors.initials: S
authors.lastname: Vernadakis
authors.affiliation: Department of Nephrology and Renal Transplantation, Athens University School of Medicine, Laiko General Hospital, Athens, Greece.
authors.forename: Christina
authors.initials: C
authors.lastname: Melexopoulou
authors.affiliation: Third Department of Cardiology, Athens University School of Medicine, Athens, Greece.
authors.forename: Konstantinos
authors.initials: K
authors.lastname: Malliaras
authors.affiliation: Department of Nephrology and Renal Transplantation, Athens University School of Medicine, Laiko General Hospital, Athens, Greece.
authors.forename: John
authors.initials: J
authors.lastname: Boletis
authors.affiliation: Third Department of Cardiology, Athens University School of Medicine, Athens, Greece.
authors.forename: John N
authors.initials: JN
authors.lastname: Nanas
mesh_terms: D000368:Aged; D059347:Cardio-Renal Syndrome / Q000628:therapy; D062905:Central Venous Catheters / Q000592:standards* / Q000706:statistics & numerical data; D006333:Heart Failure / Q000401:mortality / Q000628:therapy*; D006440:Hemofiltration / Q000379:methods*; D006801:Humans; D008875:Middle Aged; D009026:Mortality / Q000639:trends; D065228:Non-Randomized Controlled Trials as Topic / Q000379:methods; D010359:Patient Readmission / Q000706:statistics & numerical data; D017582:Renal Replacement Therapy / Q000009:adverse effects*; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate; D014655:Vascular Resistance / Q000502:physiology; D018497:Ventricular Dysfunction, Right / Q000150:complications / Q000503:physiopathology*
keywords: arteriovenous communication; cardiorenal syndrome; congestive heart failure; high-output heart failure; renal replacement therapy