The Role of PD in

Cardio-Renal
Syndrome
Berlene Villanueva, R.N., B.N.,
CNeph(c) Manitoba Health

Objectives
Discuss the definition of cardiorenal
syndrome
Discuss the rationale of utilization of
PD for management of cardiorenal
syndrome
Review clinical experience and
challenges of PD for cardiorenal
syndrome (St. Boniface Hospital
perspective)

Epidemiology

Heart failure is a common chronic

condition affecting 1% of adult
population in Canada and is the
common cause of hospitalization in
those aged 65 and above (Heart and Stroke
Foundation)

Direct and indirect costs were

estimated at $18.4 billion in 1998
(Canadian Public Health Association 1998)

Number of Hospitalizations for CHF (actual and

projected) for Canada 1980-2025

Heart and Stroke Foundation,

1999

One third to one half of patients with

heart failure develop renal
insufficiency
AKI may further complicate these
admissions resulting in: an increase in
length of stay, greater likelihood for
hospital readmission and a higher
mortality rate (Forman DE, Bulter J., Wang Y. et.

al. J Am Coll Cardiol 2004; 147:331-338)

Pathophysiology

Heart failure characterized by sodium and

H20 retention by kidneys
HF impairs sufficient blood flow to organs,
kidneys retain salt and water that leads to
congestion and clinical s+s of HF
Understanding the cardiorenal axis
(relationship btw the heart and kidney)
Successfully managing HF lies in navigating
btw fluid overload and deteriorating renal
function

What is CardioRenal Syndrome?

Definition of Cardio-Renal
Syndrome

Pathophysiologic condition in which

combined cardiac and renal
dysfunction amplifies progression of
failure of the individual organ to lead
to astounding morbidity and mortality
(Eur Heart J 2005:26:11)

At its extreme, cardio-dsyregulation

leads to what is termed cardiorenal
syndrome; in which therapy to relieve
congestive symptoms of HF is limited
by further decline in renal function
(NHLBI Working Group April30,2005)

Definition of Cardio-Renal
Syndrome

2008 Ronco: attempted to further

define the syndrome by including a
variety of acute or chronic conditions,
where the primary failing organ can be
either the heart or the kidney

Cardio-Renal Syndrome
Classification (ADQI)
The Cardiorenal Syndrome (CRS)
was officially defined at a consensus
conference of the Acute Dialysis
Quality Initiative in 2009
Conference defined 5 forms of heartkidney interaction
Recognition that communication
between the heart and kidneys occurs
through a variety of pathways

Cardiorenal Type I:

Acute cardiorenal syndrome: Acute heart

failure is directly associated with acute kidney
failure (AKI)
Ronco, C. et al. J AM Coll Cardiol 2008;52:1527-1539

Cardiorenal Type II:

Chronic cardiorenal syndrome: Chronic heart

failure is associated with chronic kidney
disease (CKD)

Ronco, C. et al. J AM Coll Cardiol 2008;52:1527-1539

Cardiorenal Type III:

Acute renocardiac syndrome: Acute kidney

injury is associated with acute heart failure
Ronco, C. et al. J AM Coll Cardiol 2008;52:1527-1539

Cardiorenal Type IV:

Chronic renocardiac syndrome: Chronic kidney

disease primarily leads to chronic heart failure
Ronco, C. et al. J AM Coll Cardiol 2008;52:1527-1539

Cardiorenal Type V:

Secondary cardiorenal syndrome: Concomitant

development of both kidney and heart failure
Ronco, C. et al. J AM Coll Cardiol 2008;52:1527-1539

Where does PD fit in?

Role of PD in management of cardiorenal syndrome has not been formally
evaluated in clinical trials
Literature is restricted

Where does PD fit in?

Most individuals with CRS have been
through numerous interventions:
diuretics, drugs, extracoporeal
ultrafiltration
Symptoms can be attributed to the
retention of salt and water
Most are refractory to diuretic therapy,
and often develop hyponatremia and
hyperkalemia

Cardiorenal patients
Often suffer great morbidity, largely
from repeated hospitalizations related
to recurrent worsening of volume
overload
Extracorporeal ultrafiltration, suffers
from several limitations: requires pts
to return to health-care facilities and
fluid removal can be complicated by
hypotension

Change in Function Status with

use of Peritoneal Dialysis

Mehrotra, R. and Kathuria, P. Kidney International 2006;70:S67-S71

Effect of PD on Hospitalizations

Mehrotra, R. and Kathuria, P. Kidney International 2006;70:S67-S71

Potential Roles of Peritoneal Ultrafiltration in

Patients with Cardiorenal Syndrome

Restore diuretic responsiveness

Bridge therapy (eg. Valve
repair/replacement or cardiac
transplantation)
Palliative therapy

Improve symptoms and exercise tolerance

Preserve residual renal function
Reduce hospitalizations
Improve quality of life

Why PD?

Home based, long term therapy is usually

well established in many centers
Simple machinery, less use of hospital
resources
Associated with preservation of renal
function, gentle continuous ultrafiltration,
hemodynamic stability, better middlemolecule clearance, sodium sieving with
maintenance of normonatremia, and less
inflammation (Krishnan,A. et. Al, Advances in Peritoneal
Dialysis 2007;23:82-89)

St.Boniface Hospital History

Serve as 1 of 2 centers, located in
Winnipeg that offer PD to the
residents of Manitoba and
Northwestern Ontario
Current PD population: 180 pts
Current Cardiorenal: 8 pts
Total Cardiorenal: 12 pts

Referral
PD Assessment
PD Catheter Insertion
Training
Evaluation/Clinic Follow-Up

Our Goals:
Reduce HF risk factors
Reduce HF symptoms
Reduce hospitalizations
Improve quality of life
Prolong survival

Referral Process
Depends on cardiology/nephrology to
make an accurate and timely
diagnosis
Refer patients at a higher risk so that
treatment can be initiated

Assessments

Modified cardiorenal

All patients and/or

designated family
must be able to
manage PD cath
Assisted PD program
not eligible to drain
out ascites for
patients
Discussion of different
stages of intervention

General PD

May be eligible for

Assisted PD
program

Stages of Intervention
Stage 1 Ascities drain out only
Stage 2 Single night time exchange
with icodextran
Stage 3 1-2 dextrose twin bags for
volume management
Stage 4 Full CAPD

PD cath placement for drainage

of ascites in non ESRD patients

Criteria that need to be met:

A. Patient is on maximal diuretics and

diuretic resistant AND/OR
B. Frequent requirement for paracentesis (at
least twice monthly) AND/OR
C. Frequent hospitalizations for acute
decompensated congestive heart failure (at
least 3 times within 6 months)

Nephrologist who is assessing the patient

for PD catheter will decide if criteria are
being met

Training for Cardiorenal

Dependent on stage of intervention
required
Each stage has separate training
requirements
Change in training manuals/forms

Training for Cardiorenal

Physician:

Defines quantity of fluid to be removed

Details/clarifies criteria for adjusting fluid
removal
Establishes fluid restriction

Nurse:

Enforces requirement for that stage

Establishes recording of intake/output
Monitoring of patient
Basic troubleshooting

St. Boniface Cardio-renal

population
Stage 4
Stage 3

Full PD
1-2 Bags
Icodextran
Ascites

Stage 2
Stage 1
0

Cardiorenal Patients

Timeline/Progression of
Stages
CR (d)
GF(d)
IT (d)
SR(d)
RT
MT
PS

Stage 1
Stage 2
Stage 3
Stage 4

SM
CB
MCM
JH
TH
0

10

20

30
Months

40

50

60

Evaluation/Follow up
Any patient that requires even one
daily exchange will be followed in the
PD program as any other PD patient
Clinic: monitor GFR
Communication with Heart Failure
clinic: to assist in determining whether
pt requires different stage of
intervention

Pitfalls, Challenges and

Practicality
No established guidelines/algorithm
Draining issue/blocked catheter vs. no
ascities drainage
Maintaing bps
Infection

Effectiveness
Did we accomplish our goals?
Majority of patients report decrease in
HF symptoms, and improved quality
of life
Since commencing PD, only 2 of 8 pts
have required hospitalization (1 for
ICD replacement)

Future prospects at SBH

Looking at the development of a
Cardiorenal Clinic
New initiative to capture patients who
fall into this particular subset
primarily Type IV CRS
Benefits: Coordination of care,
Identification of risk, Facilitate
treatment if indicated

General Future prospects

Large trials with long term follow up to
look at the effects of PD on
progression of heart failure
Studies to compare PD with standard
therapy to demonstrate survival
benefits, morbidity and costs

Summary
Cardiorenal syndrome has complex
pathophysiology
Combination of renal insufficiency and
heart failure make management a
challenge, associated with poor
prognosis
PD can be used to alleviate some
symptoms of HF, but mainly used as a
palliative focus

The End