Guglielmi, Anthony A.; Guglielmi, Kelly E.; Bhat, Geetha; Siemeck, Roxanne; Tatooles, Antone J.
From the Center for Heart Transplant and Assist Devices, Advocate Christ Medical Center, Oak Lawn, Illinois.
Submitted for consideration July 2013; accepted for publication in revised form September 2013.
Disclosure: Drs. Bhat and Tatooles are consultants for Thoratec Corp, and R. Siemeck is a paid speaker for Thoratec Corp. The remaining authors declare no conflicts of interest.
Reprint Requests: Geetha Bhat, PhD, MD, Center for Heart Transplant and Assist Devices, Advocate Christ Medical Center, 4400 W. 95th St., Suite 407, Oak Lawn, IL 60453. Email: firstname.lastname@example.org.
Patients with refractory congestive heart failure may be considered for implantation of a left ventricular assist device (LVAD). Renal failure after LVAD placement can occur to varying degrees from cardiorenal syndrome (CRS) or due to intrinsic renal disease. Patients with severely impaired renal function after LVAD may require renal replacement therapy (RRT) as a temporary or permanent means of support. We present a unique case of a patient who initiated peritoneal dialysis (PD) 1 year after placement of an LVAD for destination therapy (DT). One year later, PD continues to be successfully utilized by this patient for RRT. There are several proven and theoretical benefits to PD in LVAD patients. Peritoneal dialysis can provide sustained daily ultrafiltration offering greater hemodynamic stability, preservation of residual renal function, and a lower risk of systemic infection. Conversely, limitations to PD include nutritional risks due to peritoneal albumin losses, hyperglycemia, and potential limitations to successful catheter placement. Considering our patient’s successful outcome and the potential benefits associated with PD, despite the limitations, we conclude that PD should strongly be considered in patients with LVADs that require RRT.
A 78-year-old Caucasian man with a history of class IV (New York Heart Association) heart failure secondary to ischemic cardiomyopathy with concurrent stage III chronic kidney disease underwent placement of a continuous flow left ventricular assist device (LVAD) for worsening heart failure. Before placement of the LVAD, the patient’s blood urea nitrogen (BUN) was 29 mg/dl, serum creatinine was 1.7 mg/dl, and estimated glomerular filtration rate was 42 ml/min/1.73 m2. Nephrologic evaluation revealed preserved renal size and echogenicity with no proteinuria. Patient’s abnormal renal function preoperatively was felt to be primarily because of cardiorenal syndrome (CRS). After LVAD placement, the patient was ultimately discharged home with a BUN of 22 mg/dl and a serum creatinine of 1.46 mg/dl.
Almost 1 year later, patient was noted to demonstrate an increase in serum creatinine level to 2.1 mg/dl. The patient was rehospitalized 10 days later after gaining nearly 18 lbs in 3 weeks with a rise in creatinine to a level of 2.48 mg/dl. Cholesterol embolic disease was diagnosed based on progressive deterioration in renal function concurrent with petechial lesions, hypocomplementemia, and eosinophiluria on chronic coumadin therapy. Hemodialysis (HD) was initiated via a temporary HD catheter. During HD, the patient had intermittent episodes of hypotension and decreased pulsatility and suction events. Several days after the start of HD, bacteremia developed in the patient, prompting the removal of all lines.
After initiation of treatment for bacteremia and an extensive discussion with the patient and family, the patient underwent peritoneal dialysis (PD) catheter placement. Because the LVAD driveline exited in the left lower quadrant of the patient’s abdomen, the peritoneal dialysis catheter was placed in the right lower quadrant as far from the driveline as feasible. Several days after catheter placement, low-volume supine peritoneal dialysis was initiated with subsequent transition to standard peritoneal dialysis. While hospitalized, the patient’s wife and daughter were trained in peritoneal dialysis, and the patient was discharged 3 weeks later. At discharge, patient was transitioned to automated peritoneal dialysis (APD).
One year after initiation of peritoneal dialysis, the patient is functionally independent and continues to perform APD at home with family support. He has had no episodes of peritonitis and no hospitalizations for cardiac congestive failure.
Peritoneal Dialysis in LVADs
Patients with refractory congestive heart failure may be considered for implantation of an LVAD. Renal failure after LVAD placement can occur to varying degrees from CRS or due to intrinsic renal disease. Patients with severely impaired renal function after LVAD may require renal replacement therapy (RRT) as a temporary or permanent means of support. Acute kidney injury (AKI) requiring the need for RRT after LVAD placement is common, having been reported to be as high as one-third of LVAD patients, and is associated with a high mortality.1
Peritoneal dialysis has been extensively reviewed as a therapeutic modality for treatment of CRS with advanced renal failure. There are a number of potential benefits of PD as a therapeutic modality in LVAD patients (Table 1). Potential benefits include sustained daily ultrafiltration that offers greater hemodynamic stability, as well as preservation of residual renal function.2 Because of the fixed speed setting of all continuous flow pumps, an LVAD will not automatically adjust speed to accommodate volume shifts or reduced preload to the heart as can occur in HD. Some pumps may temporarily decrease speed in the setting of decreased preload, but this temporary speed drop may not be sufficient to prevent sequelae of volume shifts. Pump speeds may be decreased for hypotension and increased suction events while the patient is hospitalized. Outpatient dialysis units and intermittent home dialysis may not provide access to the clinical screen for adjustment of LVAD speed. Although outpatient HD is feasible in patients with stable volume status, volume shifts during HD could pose a problem.
Peritoneal dialysis is a well-established longstanding home-based therapy. Furthermore, when an individual with an LVAD develops renal failure requiring RRT, transitioning the patient to an outpatient unit is often problematic as many outpatient HD units are not able to safely accommodate an LVAD patient because of their lack of a pulsatile blood pressure and potentially unstable hemodynamics with rapid ultrafiltration.3 Difficulties placing a patient with an LVAD in an outpatient HD center not uncommonly results in a prolonged hospitalization and subsequent increase in hospitalization costs.3
Driveline infection may be a relative contraindication for PD. Systemic infection is a serious complication and poses an increased risk of mortality after LVAD.4 Hemodialysis catheter placement is well-known to carry a significant risk for bloodstream infection. Topkara et al.5 demonstrated that LVAD patients who required postoperative continuous venovenous HD had a higher rate of sepsis and shorter post-LVAD survival.
Peritoneal dialysis catheter-related peritonitis rarely leads to bacteremia.3 In patients with CRS, complications related to PD such as peritonitis are minimal.6 The patient has not experienced leaking of any fluid from the driveline since starting PD. The LVAD driveline is placed retroperitoneally, and the peritoneum is not entered. Thus, the placement of a PD catheter will not result in peritoneal fluid leakage from the driveline. Based on these observations, we suggest that PD may result in a lower incidence of systemic infection and potentially improve morbidity and mortality in LVAD patients receiving RRT when compared with HD.
Peritoneal dialysis can be a cost-effective therapeutic modality in patients with CRS and advanced renal failure. Cnossen et al.7 reviewed patients with treatment-resistant congestive heart failure complicated by severe renal failure who were treated with PD. A reduction in hospitalizations for cardiovascular causes was noted after the initiation of peritoneal dialysis.7 Moreover, PD is approximately 25% less costly than HD.8
There are limitations to successful PD in LVAD patients (Table 1). These include nutritional risks as PD does result in peritoneal albumin losses.2 As the peritoneal fluid contains dextrose, hyperglycemia may be problematic in patients with poorly controlled diabetes. An appropriate home environment and support system are necessary, although all are also necessary in individuals who undergo LVAD placement. In addition, multiple previous abdominal surgeries with extensive adhesions or hernias may limit catheter placement and function. Certainly, tunnel or exit site infections can occur, but the likelihood of cross-contamination with the driveline site is minimized by placing the catheter as far as possible away from exit site as was done in our reported case.
Our reported case is the first case identified in the literature where PD has been successfully used chronically in an LVAD patient. The incidence of AKI after LVAD requiring RRT is significant. There are potential benefits as well as limitations associated with the use of PD in LVAD patients. Additional cases where PD is used chronically in LVAD patients are needed to confirm our findings and to assess the efficacy of PD use in this unique patient population. Given our patient’s successful outcome and the potential benefits associated with PD in LVAD patients, notwithstanding the limitations, we conclude that PD should be considered in patients with LVADs that require RRT.
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3. Thomas BA, Logar CM, Anderson AE. Renal replacement therapy in congestive heart failure requiring left ventricular assist device augmentation. Perit Dial Int. 2012;32:386–392
4. Hannan MM, Husain S, Mattner F, et al.International Society for Heart and Lung Transplantation. Working formulation for the standardization of definitions of infections in patients using ventricular assist devices. J Heart Lung Transplant. 2011;30:375–384
5. Topkara VK, Dang NC, Barili F, et al. Predictors and outcomes of continuous veno-venous hemodialysis use after implantation of a left ventricular assist device. J Heart Lung Transplant. 2006;25:404–408
6. Nakayama M. Nonuremic indication for peritoneal dialysis for refractory heart failure in cardiorenal syndrome type II: Review and perspective. Perit Dial Int. 2013;33:8–14
7. Cnossen TT, Kooman JP, Krepel HP, et al. Prospective study on clinical effects of renal replacement therapy in treatment-resistant congestive heart failure. Nephrol Dial Transplant. 2012;27:2794–2799
8. USRDS. U.S. Renal Data System, 2012 Annual Data Report: Atlas of End-Stage Renal Disease in the United States. 2012 Bethesda, MD National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases
left ventricular assist device; peritoneal dialysis renal failure; renal replacement therapy