Continuous ambulatory peritoneal dialysis for patients with severe left ventricular systolic dysfunction and end-stage renal disease

Continuous Ambulatory Peritoneal Dialysis for Patients With Severe Left Ventricular Systolic Dysfunction and End-Stage Renal Disease Marie-Jo&e

Hkbert, MD, Madeleine Falardeau, RN, Vincent Pichette, MD, Marc Houde, MD, Linda Nolin, MD, Jean Cardinal, MD, and Denis Ouimet, MD

0 To better define the survival and quality of life of patients with major left ventricular systolic dysfunction and end-stage renal disease treated by continuous ambulatory peritoneal dialysis (CAPD), we reviewed all cases who started CAPD between May 1984 and March 1993 who had an isotopic left ventricular ejection fraction (LVEF) ~35%. Seventeen patients (12 men and five women with a mean age of 51.6 5 14.9 years) met the inclusion criteria. Mean isotopic LVEF before initiation of CAPD was 24.8% + 6.2%. All patients were symptomatic from congestive heart failure. Thirteen patients were classified as New York Heart Association grade Ill or IV. Continuous ambulatory peritoneal dialysis was associated with a significant improvement of isotopic LVEF, of functional status, and of blood pressure control. In 10 patients with a second measurement on CAPD, LVEF increased from a mean value of 23.2% 2 9.1% to a mean value of 30.3% 2 8.1% (P < 0.01). This represents a 30% increase of LVEF. After 6 months on CAPD, 94% of patients were classified as New York Heart Association grade I or II. Actuarial survival rates were 94%, 30%, and 04% at 12, 18, and 24 months, respectively. The mean duration of CAPD was 24 ? 17 months. These results suggest that current CAPD treatment is an elective modality of treatment in patients with concomitant heart and renal failure. 0 1995 by the National Kidney Foundation, Inc. INDEX WORDS: Left ventricular systolic dysfunction; ysis; radionuclide ventriculogram.

S

chronic

EVERE left ventricular systolic dysfunction (LVSD) in patients with end-stage renal disease (ESRD) represents a therapeutic dilemma. Aggressive treatment of preload and afterload may jeopardize residual renal function, whereas resistance to diuretic therapy’ may lead to recurrent episodes of pulmonary edema. Relatively early renal replacement therapy may therefore be considered to treat both conditions. Intermittent hemodialysis may be poorly tolerated in such patients because of cyclic fluid overload and rapid fluid removal. Continuous ambulatory peritoneal dialysis (CAPD) has been proposed as an advantageous option because of continuous ultrafiltration and, hence, a more stable hemodynamic status.2-6 However, initiating renal replacement therapy in patients with a relatively short expected length of survival may imply significant morbidity and a possible deterioration in the quality of their residual life. Few studies have examined the effectiveness of CAPD as longterm therapy of concomitant heart and renal failure. 2*7-L1How CAPD alters the natural evolution of congestive heart failure (CHF) and modifies the quality of life of these patients needs to be more precisely evaluated. We therefore retrospectively studied the evolution of all patients with severe LVSD diagnosed by radionuclide ventriculogram (RVG) who started CAPD in our center. American

Journal

of Kidney

Diseases,

renal failure; continuous PATIENTS

ambulatory

peritoneal

dial-

AND METHODS

From May 1984 to March 1993, 154 patients were successfully trained and followed up at our CAPD unit. Before initiation of renal replacement therapy, RVG was part of a routine evaluation of cardiac function in 109 of these patients. Patients with an isotopic left ventricular ejection fraction (LVEF) 535% at initiation of CAPD were selected for the study. Radionuclide ventriculogram had not been performed because of the absence of clinical evidence of CHF in five nondiabetic patients younger than 30 years, because of a normal echocardiogram in 11 patients, and because of unspecified reasons in 29 patients. The following information was collected from the records of the study group: cause of heart and renal failure; presence of diabetes mellitus; initial echocardiographic results if available; isotopic LVEF at initiation of CAPD and while on CAPD; medication at initiation of CAPD and after 6, 12, and 24 months of evolution; functional status as defined by the

From the Service de Nephrologie, H6pital MaisonneuveRosemont, Universite’ de Montreal, Montreal, Quebec, Canada. Received December 15, 1993; accepted in revised form January 23, 1995. Supported in pan by a grant from Baxter Corporation, Toronto, Canada. Preliminary results from this work have been presented at the Thirteenth Annual Conference on Peritoneal Dialysis, San Diego, CA, March 1993. Address reprint requests to Denis Ouimet, MD, Service de Nephrologie, Hopital Maisonneuve-Rosemont, 5415 Boulevard de I’Assomption, Montreal, Quebec, Canada HIT 2M4. 0 1995 by the National Kidney Foundation, Inc. 0272-6386/95/2505-0012$3.00/O

Vol 25, No 5 (May), 1995: pp 761-768

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New York Heart Association; presence of CHF by history of dyspnea or peripheral edema and cardiomegaly along with two of the following signs: raised jugular venous pressure, basal crepitations, peripheral edema, pulmonary venous hypertension on chest x-ray film, or interstitial edema on chest x-ray film”; body weight, blood pressure, and blood biochemistry at initiation of CAPD and every 6 months thereafter; reasons for a second RVG; reasons and duration of hospitalizations; reason for stopping CAPD; and, finally, cause of death. Duration of initial and terminal hospitalizations is reported in days. Initial admission started with catheter insertion and included (not exclusively) a break-in period of 9 to 11 days and training for CAPD. Terminal hospitalization was defined as a hospitalization in which dialysis was withdrawn. Hospitalization rate on CAPD was calculated as days per patientmonth exposure. after discharge from initial hospitalization until terminal admission or drop-out from CAPD. Admission rate was analyzed expressing the frequency per patient-month exposure. Patients with an isotopic LVEF of more than 35% at initiation of CAPD served as a comparative group for survival. The comparative group was subdivided in two subgroups: one with minor LVSD (LVEF between 35% and 55%) and one with normal systolic function (LVEF ~55%). Continuous ambulatory peritoneal dialysis was carried out using four daily 1.5- to 2.5-L exchanges. Dialysis fluid was a 1.5%, 2.58, or 4.25% dextrose Dianeal solution (Baxter Corporation, Toronto, Canada). Tonicity of dialysate and ‘dry” weight were adjusted to achieve the best functional status. From May 1984 to May 1987, a conventional system (System II; Baxter Corporation) was used. Thereafter, the O-Set Y-connector system (Baxter Corporation) was used exclusively from May 1987 to May 1992 and the Ultraset Yconnector system (Baxter Corporation) was used exclusively from May 1992 until the end of the study. The only exceptions were 14 patients, all in the comparative group, using a sterilizing device for visual handicap. Treatment of ESRD also included daily oral calcitriol, calcium supplements, and magaldrate as phosphate binder. Erythropoietin therapy for the control of ESRD-associated anemia was used from May 1990. Radionuclide ventriculogrsm was performed with 99”technetium pertechnetate-labeled red blood cells. The first-pass technique was used from 1984 to 1987 and the equilibrium method was used thereafter. Data arc reported as mean values + SD. Paired and unpaired Student’s f-tests were used when appropriate. Nonparametric variables were analyzed by the use of &i-squared tests. The cumulative survival rate was calculated using the actuarial survival rate method. Transplantation, recovery of renal function, and transfer to hemodialysis or to another CAPD center were treated as censored observations. The actuarial survival rates of the study group and the two comparative subgroups were compared using the Mantel-Cox, TaroneWare, and Breslow tests. The Mantel-Cox and Tarone-Ware tests were used to evaluate differences in survival rates throughout the study period. The Breslow test was used to more specifically screen differences between survival rates at the beginning of the study period. To evaluate how other covariates could influence the survival rates, a survival analy-

ET AL

sis with stepwise selection of covariates (Cox model) was used to investigate the relationship between survival and sex, age, diabetes mellitus, and LVEF status within all three groups.

RESULTS

Initial Characteristics Seventeen patients (five women and 12 men) with a mean age of 5 1.6 + 14.9 years (age range, 25 to 75 years) met the inclusion criteria, representing 11% of all patients treated in our CAPD unit. The mean LVEF was 24.8% + 8.2% and ranged from 8% to 35%. Left ventricular ejection fraction had been measured 3.7 t 4.2 months before initiation of renal replacement therapy. Ten patients (58.8%) were diabetic. Before initiation of CAPD, mean serum urea, creatinine, and creatinine clearance (calculated from Cockcroft and Gault’s formula13) were 109.1 2 33.3 mg/ dL, 10.6 t 5.4 mg/dL, and 7.67 t 3.3 mL/min, respectively. Fourteen patients had a serum creatinine of less than 10 mg/dL when CAPD was started. The mean serum albumin was 3.4 + 0.4 g/dL. Renal failure was secondary to diabetic nephropathy in nine patients, to glomerulopathy in three, to hypertensive nephrosclerosis in two, to ischemic nephropathy in one, and to polycystic kidney disease in one; it was of undetermined origin in one patient. Continuous ambulatory peritoneal dialysis was the initial long-term treatment of ESRD in all but four patients: three patients were transferred from chronic hemodialysis for intractable angina pectoris and recurrent hypotension during hemodialysis sessions, and one diabetic patient was transferred from the transplantation program after acute myocardial infarction and CHF following an unsuccessful kidney transplantation. Before insertion of a long-term peritoneal catheter could be feasible, eight patients had to be treated with other acute modalities of dialysis: five patients needed acute hemodialysis with a central venous access, two patients were treated with acute peritoneal dialysis followed by a few hemodialysis sessions, and one patient presented with anasarca that had to be controlled by continuous arteriovenous hemofiltration. Ultrafiltration through renal replacement therapy was associated with a highly significant decrease of body weight from 63.9 + 8.4 kg to 57.1 ? 6.6 kg (P < 0.001). Fluid

CAPD FOR SEVERE SYSTOLIC DYSFUNCTION AND ESRD

overload was thus estimated at 11.17% + 5.38% of “dry” weight. Before initiation of CAPD, all patients in the study group were clinically in CHF. Thirteen patients (76.5%) were severely symptomatic, being classified as New York Heart Association grade III or IV, and four patients were classified as New York Heart Association grade II. Review of our hospital records revealed 20 episodes of acute pulmonary edema in 12 patients. Heart failure was deemed secondary to ischemic heart disease in nine patients, to diabetic cardiomyopathy in three, and to chronic hypertension in three; it was of unknown origin in two patients. Five patients were treated for angina pectoris and eight patients had suffered a myocardial infarction. Fourteen patients were treated for hypertension. Systolic, diastolic, and mean blood pressures were 146 ? 17 mm Hg, 88 2 9 mm Hg, and 108 + 11 mm Hg, respectively. Echocardiography results were available for 10 patients and showed a mean end-diastolic left ventricle diameter of 60.1 2 7.9 mm (normal, ~55 mm). The comparative group comprised the 92 patients with an isotopic LVEF greater than 35% before initiation of CAPD. Twenty-eight patients had a minor systolic dysfunction with an LVEF between 35% and 55%. The mean age in this subgroup was 51.7 + 14.4 years (20 men and eight women); 32% of these patients were diabetic. Sixty-four patients had a normal LVEF (~55%). The mean age in the second subgroup was 52.8 ? 13.6 years (39 men and 25 women): 23% of these patients were diabetic. Evolution and Clinical Outcome Continuous ambulatory peritoneal dialysis was associated with significant improvement of functional status, as summarized in Table 1. After 6 months of evolution, 12 patients had improvement in their functional status, four patients were stable as grade II, and only one patient had died. Fifteen patients were stabilized in a satisfactory status, being classified as grade I or II, and no patients were clinically in CHF. After 1 year of evolution, two patients had received a kidney transplant and all others were in a stable functional status. During the second year of evolution, a third patient received a kidney transplant, five patients died, and three patients’ functional status deteriorated, changing from grade II to

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grade III; two patients were clinically in CHF. These two patients accounted for the only three episodes of acute pulmonary edema during the follow-up period. Functional improvement was associated with statistically significant improvement of LVEF in 10 patients with a second RVG after 11.3 + 6.7 months of evolution. The reasons for a second RVG were as follows: pretransplantation workup in three patients, objective evaluation of myocardial dysfunction on CAPD in four, unsatisfactory hemodynamic status in one, and unspecified in two. Left ventricular ejection fraction increased from a mean value of 23.2% + 9.1% to a mean value of 30.3% t 8.1% (P < 0.01). This represents a 30% increase of LVEF. Nevertheless, LVEF remained below 35% in all but one patient. We have found no correlation between the delay in acquiring a control LVEF and the degree of LVEF improvement. After 6 months of CAPD treatment, there was a significant decrease of diastolic blood pressure (from 88 + 9 mm Hg to 77 + 9 mm Hg; P < 0.01) and of mean blood pressure (from 107 + llmmHgto98+ 15mmHg;P<0.02), with a concomitant reduction of antihypertensive medication (Table 2). Mean blood pressure was stable at 1 and 2 years of evolution with values of 97 + 18 mm Hg and 96 ? 13 mm Hg, respectively, without further modification of antihypertensive regimen. Mean serum albumin was 3.7 + 0.5 g/dL, 3.5 t 0.4 g/dL, and 3.3 ? 0.5 g/dL at 6 months, 1 year, and 2 years, respectively. There was no significant change of “dry” weight after 6,12, and 24 months of CAPD. Mean hemoglobin level was maintained above 10 g/dL at each point. Treatment of ESRD was associated with a significant increase of total serum calcium from a mean value of 8.4 2 1.2 mg/dL to 9.2 2 1.2 mg/ dL, 9.6 + 0.8 mg/dL, and 10.0 t 0.4 mg/dL at 6 months, 1 year, and 2 years, respectively. Treatment of ESRD also was associated with a significant decrease of serum phosphorus from a mean value of 8.4 + 3.1 mg/dL to 6.2 + 2.7 mg/ dL, 6.8 ? 3.1 mg/dL, and 5.7 f 1.5 mg/dL at 6 months, 1 year, and 2 years, respectively. However, there was no significant change of serum parathyroid hormone with dialysis treatment. The cumulative survival rates of the study group were compared with survival rates of pa-

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Table 1. Functional Peritoneal

Status According to the New York Heart Association Dialysis and After 6, 12, and 24 Months of Evolution, at the End of the Study Period Functional

Patient No.

Before Continuous Ambulatory and Clinical Outcome

Status (NYHA)

0 mo

6 mo

12 mo

24 mo

Clinical Outcome

II II Ill IV II Ill IV IV IV Ill II Ill IV Ill IV Ill Ill

II II II II II II

II II II II II

Ill II II

II II II II II II I Ill II II

II

Withdrawal from dialysis at 33.75 mo Withdrawal from dialysis at 66 mo Sudden death at 30.25 mo Kidney transplantation at 15 mo Transfer to hemodialysis at 24.25 mo Kidney transplantation at 9.75 mo Sudden death at 1.5 mo Sudden death at 21 mo Kidney transplantation at 8.75 mo Sudden death at 13.75 mo Withdrawal from dialysis at 23.25 mo Still on CAPD at 62.5 mo Withdrawal from dialysis at 27.25 mo Kidney transplantation at 27.75 mo Withdrawal from dialysis at 34.75 mo Sudden death at 13.25 mo Still on CAPD at 17.25 mo

1 2 3 4 5 6 7

8 9 10 11 12 13 14 15 16 17 Abbreviation:

ET AL

NYHA,

New

York

Heart

II II II II I Ill II II

II Ill I Ill

Association.

tients from the comparative group with minor or no LVSD, as shown in Fig 1. In the study group, the survival rates were 94%, 94%, 80%, and 64% at 6, 12, 18, and 24 months, respectively. In the first comparative subgroup with minor LVSD, the survival rates were 96%, 91%, 86%, and 79% at 6, 12, 18, and 24 months, respectively. Finally, the second comparative subgroup with normal

Table 2. Cardiovascular Drugs Used Before Initiation of Continuous Ambulatory Peritoneal Dialysis and After 6 Months of Evolution No. of Patients

Diuretic Beta-blocker Centrally acting adrenergic agonist Alpha-adrenergic blocker Direct-acting vasodilator Angiotensin-converting enzyme inhibitor Calcium channel blocker Nitrates Digoxin

Ill

left ventricular systolic function showed cumulative survival rates of 98%, 96%, 90%, and 90% at 6, 12, 18 and 24 months, respectively. The Mantel-Cox and Tarone-Ware tests showed that the cumulative survival rates were significantly different within the three groups (P = 0.009 and 0.005, respectively). The Breslow test also showed statistically significant different cumulative survival rates (P = 0.02). Analysis with the Cox model of the influence of covariates, such as age, sex, presence or absence of diabetes, and LVEF, on survival rates revealed only LVEF as a covariate attaining statistical significance (improvement chi-squared

= 8.77,P = 0.002).

Before CAPD

On CAPD

8 1

1 0

3 2 1

0 0 0

The mean duration of initial hospitalization in the study group was 26.7 + 14.1 days. The mean duration of CAPD treatment was 24.01 + 17.20 months and ranged from 0.25 to 67.75 months. The hospitalization rate was 1.25 days per patientmonth. The admission rate was one per 8.3 patient-months. Sixty-one percent of the admissions were associated with peritonitis, exit site infection, or other CAPD-related problems. In five patients withdrawn from dialysis, the mean duration of terminal hospitalization was 49.6 5 34.7 days.

CAPD FOR SEVERE SYSTOLIC DYSFUNCTION AND ESRD

L-i01 0

6

12

18

24

30

36

42

48

64

60

MONTHS

Fig 1. The cumulative survival rate from the time of peritoneal catheter insertion in patients with LVEF less than 36% (solid circles, N = 17), in patients with LVEF between 35% and 66% (open triangles, N = 26), and in patients with LVEF ~55% (open squares, N = 64). The numbers indicate the number of patients at risk. Cumulative survival rates were statistically different within the three groups (Breslow, P = 0.02; Mantel-Cox, P = 0.009; Tarone-Ware, P = 0.005).

The total CAPD experience was 408.25 patient-months. Eight patients had 25 episodes of peritonitis, whereas nine patients remained peritonitis free during the study period. Introduction of the Y-connector was associated with an important decrease in the peritonitis rate, the admission rate (P < 0.05), and the hospitalization rate. Morbidity associated with different connecting systems is summarized in Table 3. As shown in Table 1, four patients discontinued CAPD because of kidney transplantation. There were five sudden deaths. Five patients died after withdrawal from dialysis. Two patients were withdrawn from renal replacement therapy because of severe peripheral vascular disease (patients no. 1 and 2), two were withdrawn because of intractable low-output cardiac failure (patients no. 13 and 15), and one was withdrawn because of severe organic brain disease (patient no. 11). One patient was transferred to hemodialysis because of ultrafiltration failure related to an episode of surgically treated diverticulitis. The remaining patients were still on CAPD at the end of the study period. DISCUSSION

In the present study, 11% of our CAPD patients presented with major LVSD, as diagnosed

765

by RVG, and CHF. This finding correlates with a previous study that showed a 10% prevalence of CHF in the dialysis population.” The use of RVG for the measurement of LVEF is a well-standardized, safe, reproducible, and reliable method for the assessment of myocardial function.‘4-16 Not surprisingly, the mean end-diastolic left ventricle diameter measured by echocardiography in 10 of these patients suggests a high prevalence of dilated cardiomyopathy in patients with major LVSD. Congestive heart failure diagnosed using clinical criteria is known to be a strong negative predictive factor for survival. In men, the survival rates after the first occurrence of CHF are 80% and 55% at 1 and 3 years, respectively.” The lyear survival rate of New York Heart Association class IV patients with a mean serum creatinine of 1.4 mg/dL may be as low as 54%.18 The 2year survival rate of less symptomatic patients with a mean LVEF of 30% is 66%.19 Finally, the survival rates of patients with a LVEF 135% and a serum creatinine of less than 1.9 mg/dL are 85% and 74% at 1 and 2 years, respectively.20 These survival rates, however, may be favorably altered by treatment with direct vasodilators” or an angiotensin-converting enzyme inhibitor.‘9.20 On the other hand, ESRD treated with CAPD is equally associated with significant mortality. The US CAPD Registry has reported cumulative survival rates of 84% and 77% at 1 and 2 years, respectively.2’ The European Dialysis and Transplant Association has reported survival rates of 85% and 73% at 1 and 2 years, respectively, in patients between 15 and 64 years of age.22 The Canadian Registry has reported survival rates of 83% and 66% at 1 and 2 years, respectively, in patients between 45 and 64 years of age.23 Therefore, a very poor survival rate could have been expected in our patients with the association of two morbid conditions. Such has not been the case, at least during the first 2 years. The survival rates in the study group are 94% and 64% at 1 and 2 years, respectively (Fig 1). These shortterm results are similar to those published in the literature for patients with only one of the comorbid conditions. This is an unexpected finding which suggests that peritoneal dialysis is an efficient treatment of CHF associated with ESRD. Nonetheless, over 5 years, systolic dysfunction proved to be a very significant factor affecting

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Table 3. Morbidity Associated With Continuous Ambulatory Peritoneal Dialysis Using Standard and Y-Connector Systems in Patients With Severe Systolic Dysfunction

Period Experience (patient-months) No. of EOPs Peritonitis rate ESI (% catheters) Admission rate Reason for admission (%) Peritonitis ESI CAPD-related CHF Other reasons Total Hospitalization rate Abbreviations:

Standard System

Y-Connector System

May 1964-May 1987 161.75 19 l/8.5 patient-months 42.8 l/4.4 patient-months

May 1987-March 1993 246.50 6 l/41 .l patient-months 33.3 l/20.5 patient-months

14 (37.8) 9 (24.3) 2 (5.4) 1 (2.7) 11 (39.7) 37 (100) 2.38 d/patient-month

0 0 5 (41.7) 1 (8.3) 6 (50.0) 12 (100) 0.44 d/patient-month

EOP, episode of peritonitis; ESI, exit site infection.

survival in CAPD patients. The survival rate of patients with major systolic dysfunction was found to be significantly lower than in patients with minor LVSD or normal systolic function (Fig 1). In the comparative subgroup with LVEF greater than 55%, the survival rates were 96% an 90% at 1 and 2 years, respectively. The relative risk of death at 2 years of patients with LVEF 535% is therefore more than three times that of patients with normal LVEF. This correlates with the previous observation that in patients with ESRD, the relative risk of death is doubled in those with concomitant left-sided heart failure.24 The difference in survival rate could not be explained by covariates such as age, sex, and, particularly, diabetes mellitus, which was increasingly more prevalent with decreasing LVEF. Only LVEF was found to significantly influence survival within the study group and the two comparative subgroups. This suggests that left ventricular systolic function is an important predictive factor with regard to survival on CAPD. However, poorer long-term survival in patients with major cardiac dysfunction frequently associated with other vascular problems is not an unexpected finding. Our experience with the use of CAPD for the treatment of refractory CHF in patients with moderate to severe renal insufficiency is in agreement with previous favorable long-term survival in four patients reported by Kim et al* and one patient reported by McKinnie et a1.9Sur-

vival in the present study, however, is much better than what has been previously reported for several patients with severe (grade IV) CHF and renal insufficiency.7~8*25This discrepancy is probably related to differences in the populations studied; the latter reports addressed the issue of the use of CAPD in patients with end-stage cardiopathy in association with functional or mild to moderate renal insufficiency. Even more so than crude survival rates, the functional status on CAPD of patients with major LVSD and CHF is an important estimate of their quality of life. Continuous ambulatory peritoneal dialysis was associated with significant and sustained improvement of functional status over an appreciable length of time (Table 1). We concomitantly found a significant improvement of isotopic LVEF. The improvement of cardiac performance on CAPD may be related to the treatment of uremia26 or to normalization of serum calcium levels.27 Although hyperparathyroidism has been mentioned as an important factor in the genesis of ventricular dysfunction in uremic patients, 28the improvement in clinical status and LVEF occurred without any significant change of serum parathyroid hormone. The most important factor is probably the correction of fluid overload by ultrafiltration,’ with favorable displacement on cardiac Starling’s curve and significant improvement of blood pressure control. Obviously, severe intrinsic renal dysfunction with fluid overload may deteriorate cardiac per-

CAPD FOR SNERE

SYSTOLIC DYSFUNCTION AND ESRD

formance and functional grade of patients with moderate cardiac dysfunction. Clinical presentation may falsely suggest severe irreversible CHF. Hence, with a similar LVEF inclusion criteria but no significant renal dysfunction, patients of the SOLVD study*’ had a better functional status. In the latter study, 67% of the patients were classified as grade I or II, whereas 76% of our patients were classified initially as grade III or IV. On the other hand, after 6 months of CAPD, 94% of our patients were classified as grade I or II. This optimization of cardiac performance with improvement of functional status is, in our opinion, the important factor in the maintenance of quality of life in these patients. However, even though functional status and LVEF improved on CAPD, systolic function remained severely diminished. Nevertheless, this was not associated with a prohibitive increased probability of death on CAPD. Continuous ambulatory peritoneal dialysis is known to be associated with a nonnegligible morbidity in relation to CAPD-related technical, infectious, or nutritional problems. These problems may have a significant negative impact on the quality of life of these patients starting dialysis in a poor physical condition. Previous report suggested that in a context of concomitant heart and renal failure, the incidence of peritonitis may be prohibitive and preclude a successful treatment.” During the last 10 years, however, a major development in CAPD connection systems, namely, the introduction of Y-shaped systems, has helped to significantly reduce the morbidity associated with peritonitis.29 This improvement is equally reflected in our group of patients with major cardiac dysfunction treated with CAPD. The peritonitis rate and the number of admissions for peritonitis have decreased drastically with the use of Y-connectors (Table 3); this was associated with a fivefold reduction in the hospitalization rate. Although no formal nutritional evaluation could be obtained from the records, it is noteworthy that mean serum albumin was stable during CAPD treatment. This occurred in spite of obligatory protein loss from the peritoneal cavity.2 Serum albumin is a general but well-recognized indicator of nutritional status and a powerful predictor of morbidity and mortality in patients on dialysis.30 Nutrition and protein intake therefore

767

seemed adequate, which may have played a positive role in the quality and length of survival. In conclusion, even though major LVSD is a strong negative predictor of survival in patients on CAPD, considering the improved functional status, the reduction of antihypertensive medication, the stable and adequate nutritional status, and the acceptable current level of CAPD-related morbidity, we believe that quality of life of patients with severe LVSD and renal failure can be substantially improved by CAPD, with an appreciable survival rate regarding the natural evolution of patients with isolated major LVSD or ESRD. ACKNOWLEDGMENT The authors thank Ginette Lemay, RN, Gidle Pelletier, RN, and Francine Deschenes, RN, from the peritoneal dialysis unit of the HBpital Maisonneuve-Rosemont for excellent collaboration. REFERENCES 1. Agnostini P, Marenzi G, Lauri G, Perego G, Schianm M, Sganzerla P: Sustained improvement in functional capacity after removal of body fluid with isolated ultrafiltration in chronic cardiac insufficiency: Failure of furosemide to provide the same result. Am J Med 96:191-199, 1994 2. Rim D, Khanna R, Wu G, Fountas P, Druck M, Greopoulos D: Successful use of continuous ambulatory peritoneal dialysis in refractory heart failure. Petit Dial Bull 5:127-130, 1985 3. Maiorca R, Cancarini G, Brunori G, Camerini C, Manili L: Morbidity and mortality of CAPD and hemodialysis. Kidney Int 43:S-4-S-15, 1993 (suppl 40) 4. Wizemann V, Timio M, Alpert M, Kramer W: Options in dialysis therapy: Significance of cardiovascular findings. Kidney Int 43:+%85-S-91, 1993 (suppl 40) 5. Rottembourg JB: Which dialytic therapy is best for the patient with an unstable cardiovascular system? CAPD is more advantageous than hemodialysis. Semin Dial 5:212214, 1992 6. Hamburger RJ, Mattem WD, Schreiber MJ Jr, Soderblom R, Sorkin M, Zimmerman SW: A dialysis modality decision guide based on the experience of six dialysis centers. Dial Transplant 19:66-70, 1990 7. Mousson C, Tanter Y, Chalopin JM, Rebibou JM, Dentan G, Morelon P, Rifle G: Traitement de l’insuftisance cardiaque congestive au stade terminal par dialyse p&on&ale continue. Presse Med 17:1617-1620, 1988 8. Rubin J, Ball R: Continuous ambulatory peritoneal dialysis as treatment of severe congestive heart failure in the face of chronic renal failure. Arch Intern Med 146:1533-1535, 1986 9. Mckinnie JJ, Bourgeois RJ, Husserl FE: Long-term therapy for heart failure with continuous ambulatory peritoneal dialysis. Arch Intern Med 145:1128-l 129, 1985 10. Page D, Hierlihy PJ, Couture RA, Levine DZ: CAPD

768 in the treatment of severe congestive heart failure. Petit Dial Bull 456-57, 1984 11. Robson M, Arie B, Boleswar K, Schai G, Ravid M: Peritoneal dialysis in refractory congestive heart failure part 11: Continuous ambulatory peritoneal dialysis (CAPD). Petit Dial Bull 3:133-134, 1983 12. Parfrey PS, Ham&t JD, Griffiths SM, Gault MH, Barre PE: Congestive heart failure in dialysis patients. Arch Intern Med 148:1519-1525, 1988 13. Cockcroft DW, Gault MM: Prediction of creatinine clearance from serum creatinine. Nephron 16:31-34, 1976 14. Fouad-tarazi FM, MacIntyre WJ: Radionuclide methods for cardiac output determination. Eur Heart J 11:33-40, 1990 15. Folland AD, Hamilton GW, Larson SM, Kennedy JW, Williams DL, Ritchie JL: The radionuclide ejection fraction: A comparison of three radionuclide techniques with contrast angiography. J Nucl Med 18:1159-l 166, 1977 16. Dymond D, Elliott A, Stone D, Hendrix G, Spurrell R: Factors that affect the reproducibility of measurements of left ventricular function from first-pass radionuclide ventriculograms. Circulation 65:31 l-322, 1982 17. McKee P, Castelli W, McNamara P, Kannel W: The natural history of congestive heart failure: The Framingham study. N Engl J Med 285:1441-1446, 1971 18. The CONSENSUS Trial Study Group: Effects of enalapril on mortality in severe congestive heart failure: Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). N Engl J Med 316:1429-1435, 1987 19. Cohn JN, Archibald DG, Ziesche S, Cobb F, Francis G, Tristani F, Smith R, Dunkman WB, Loeb H, Wong M, Bhat G, Goldman S, Fletcher RS, Doherty J, Hugues CV, Carson P, Cintron G, Shabetai R, Haakenson C: Effect of vasodilator therapy on mortality in chronic congestive heart failure: Results of a Veterans Administration Cooperative Study. N Engl J Med 314:1547-1552, 1986 20. The SOLVD investigators: Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med 325:293302, 1991

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