Arteriovenous renal replacement therapy in end-stage left-sided heart
failure patients has a detrimental effect on patients with impaired
right ventricular function
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).
Conclusion: 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. (C) 2016 Hellenic Society of Cardiology. Publishing services
by Elsevier B.V. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/)