Peritonealdialyse – Behandlung bei Herzinsuffizienz

Herzinsuffizienz hat eine steigende Inzidenz und Mortalität in den westlichen Industrienationen. Infolgedessen nimmt auch die Bedeutung des kardiorenalen Syndroms weiter zu. Die rezidivierenden Dekompensationen bei therapierefraktärer Herzinsuffizienz sind ein wachsendes klinisches und gesundheitsökonomisches Problem. Nach einer ausführlichen kardiologischen und nephrologischen Diagnostik und Ausreizung aller konservativen Therapieoptionen kann bei betroffenen Patienten, auch wenn formal noch keine terminale Niereninsuffizienz vorliegt, eine additive Nierenersatztherapie mit Peritonealdialyse eine zusätzliche therapeutische Option sein. Eine Peritonealdialyse bei therapierefraktärer Herzinsuffizienz hat den Vorteil einer vergleichsweise geringeren hämodynamischen Belastung und kann durch den intrakorporalen und kontinuierlichen Volumenentzug die Hypervolämie und die Anzahl der Krankenhausaufenthalte reduzieren sowie die NYHA-Stadien verbessern. Um mit diesem Therapieansatz jedoch nachhaltigen Erfolg zu erzielen, ist eine enge Kooperation zwischen Kardiologen und Nephrologen eine unabdingbare Voraussetzung.

Severe congestive heart failure (CHF) is one of the fastest growing morbidities and a major cause of mortality in western countries. Consequently, cardiorenal syndrome is of increasing importance. Recurrent volume overload in patients with severe CHF, refractory to conventional therapy, is still an unresolved clinical and health economical problem. After careful cardial and renal diagnostics and optimization of CHF therapy, an additional intracorporal ultrafiltration therapy using peritoneal dialysis might be an effective option, even if patients are not dialysis-dependent. Peritoneal dialysis has the advantage of less hemodynamical stress and can be beneficial in terms of volume control due to the continuous and intracorporal volume removal. Therefore, peritoneal dialysis is associated with a lower rate of rehospitalizations as well as an improvement of NYHA functional class. However, to achieve sustained success, a close cooperation between cardiologist and nephrologist is essential.

Key words

refractory heart failure - cardiorenal syndrome - renal replacement therapy - peritoneal dialysis

• Literatur

• 1 Ronco C, McCullough P, Anker SD et al. Acute Dialysis Quality Initiative (ADQI) consensus group. Cardio-renal syndromes: report from the consensus conference of the acute dialysis quality initiative. Eur Heart J 2008; 31: 703-711
• 2 Heywood JT, Fonarow GC, Costanzo MR et al. ADHERE Scientific Advisory Committee and Investigators. High prevalence of renal dysfunction and its impact on outcome in 118,465 patients hospitalized with acute decompensated heart failure: a report from the ADHERE database. J Card Fail 2007; 13: 422-430
• 3 Coca SG, Krumholz HM, Garg AX, Parikh CR. Underrepresentation of renal disease in randomized controlled trials of cardiovascular disease. JAMA 2006; 296: 1377-1384
• 4 Anavekar NS, McMurray JJ, Velazquez EJ et al. Relation between renal dysfunction and cardiovascular outcomes after myocardial infarction. N Engl J Med 2004; 351: 1285-1295
• 5 McAlister FA, Ezekowitz J, Tonelli M, Armstrong PW. Renal insufficiency and heart failure: prognostic and therapeutic implications from a prospective cohort study. Circulation 2004; 109: 1004-1009
• 6 Parfrey PS, Foley RN, Harnett JD et al. Outcome and risk factors for left ventricular disorders in chronic uraemia. Nephrol Dial Transplant 1996; 11: 1277-1285
• 7 NHLBI Working Group. Cardio-Renal Connections in Heart Failure and Cardiovascular Disease. 20.08.2004. Im Internet: http://www.nhlbi.nih.gov/meetings/workshops/cardiorenal-hf-hd.htm Stand 27.05.2013
• 8 Neumann T, Biermann J, Erbel R et al. Heart failure: the commonest reason for hospital admission in Germany: medical and economic perspectives. Dtsch Arztebl Int 2009; 106: 269-275
• 9 Hoppe U, Böhm M, Dietz R et al. Vorstand der Deutschen Gesellschaft fur Kardiologie--Herz- und Kreislaufforschung e.V. Leitlinien zur Therapie der chronischen Herzinsuffizienz. Z Kardiol 2005; 94: 488-509
• 10 Felker GM et al. Diuretic strategies in patients with acute decompensated heart failure. N Engl J Med 2011; 364: 797-805
• 11 Nationale VersorgungsLeitlinie Chronische Herzinsuffizienz – Langfassung. Version 1.5, März 2012. Im Internet: http://www.herzinsuffizienz.versorgungs leitlinien.de Stand 27.05.2013
• 12 Nakayama M, Nakano H, Nakayama M. Novel therapeutic option for refractory heart failure in elderly patients with chronic kidney disease by incremental peritoneal dialysis. J Cardiol 2010; 55: 49-54
• 13 Nakhoul F, Yigla M, Gilman R et al. The pathogenesis of pulmonary hypertension in haemodialysis patients via arterio-venous access. Nephrol Dial Transplant 2005; 20: 1686-1692
• 14 Selby NM, McIntyre CW. Peritoneal dialysis is not associated with myocardial stunning. Perit Dial Int 2011; 31: 27-33
• 15 Yigla M, Nakhoul F, Sabag A et al. Pulmonary hypertension in patients with end-stage renal disease. Chest 2003; 123: 1577-1582
• 16 Moist LM, Port FK, Orzol SM et al. Predictors of loss of residual renal function among new dialysis patients. J Am Soc Nephrol 2000; 11: 556-564
• 17 Wang AY, Wang M, Woo J et al. Inflammation, residual kidney function, and cardiac hypertrophy are interrelated and combine adversely to enhance mortality and cardiovascular death risk of peritoneal dialysis patients. J Am Soc Nephrol 2004; 15: 2186-2194
• 18 Sánchez JE, Ortega T, Rodríguez C et al. Efficacy of peritoneal ultrafiltration in the treatment of refractory congestive heart failure. Nephrol Dial Transplant 2009; 25: 605-610
• 19 Elahi M, Asopa S, Pflueger A et al. Acute kidney injury following cardiac surgery: impact of early versus late haemofiltration on morbidity and mortality. Eur J Cardiothorac Surg 2009; 35: 854-863
• 20 Bart BA, Boyle A, Bank AJ et al. Ultrafiltration versus usual care for hospitalized patients with heart failure: the Relief for Acutely Fluid-Overloaded Patients With Decompensated Congestive Heart Failure (RAPID-CHF) trial. J Am Coll Cardiol 2005; 46: 2043-2046
• 21 Costanzo MR, Guglin ME, Saltzberg MT et al. UNLOAD Trial Investigators. Ultrafiltration versus intravenous diuretics for patients hospitalized for acute decompensated heart failure. J Am Coll Cardiol 2007; 49: 675-683
• 22 Marenzi G, Lauri G, Grazi M et al. Circulatory response to fluid overload removal by extracorporeal ultrafiltration in refractory congestive heart failure. J Am Coll Cardiol 2001; 38: 963-968
• 23 Bart BA, Goldsmith SR, Lee KL et al. Heart Failure Clinical Research Network. Ultrafiltration in decompensated heart failure with cardiorenal syndrome. N Engl J Med 2012; 367: 2296-2304
• 24 Bleyer AJ, Hartman J, Brannon PC et al. Characteristics of sudden death in hemodialysis patients. Kidney Int 2006; 69: 2268-2273
• 25 Dasselaar JJ, Slart RH, Knip M et al. Haemodialysis is associated with a pronounced fall in myocardial perfusion. Nephrol Dial Transplant 2009; 24: 604-610
• 26 Flythe JE, Kimmel SE, Brunelli SM. Rapid fluid removal during dialysis is associated with cardiovascular morbidity and mortality. Kidney Int 2010; 79: 250-257
• 27 Jefferies HJ, Virk B, Schiller B et al. Frequent hemodialysis schedules are associated with reduced levels of dialysis-induced cardiac injury (myocardial stunning). Clin J Am Soc Nephrol 2011; 6: 1326-1332
• 28 Ryckelynck JP, Lobbedez T, Valette B et al. Peritoneal ultrafiltration and treatment-resistant heart failure. Nephrol Dial Transplant 1998; 13: 56-59
• 29 Núñez J, González M, Miñana G et al. Continuous ambulatory peritoneal dialysis as a therapeutic alternative in patients with advanced congestive heart failure. Eur J Heart Fail 2012; 14: 540-548
• 30 Hunt SA, Baker DW, Chin MH et al. American College of Cardiology, American Heart Association. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary. J Heart Lung Transplant 2002; 21: 189-203