Heart Failure-Focus on Kidney Replacement Therapy: Why, When, and How?

Abstract

Heart failure (HF) is a major health problem because of its high prevalence, morbidity, mortality, and cost of care. An important contributor to morbidity and mortality in patients with advanced HF is kidney dysfunction. Almost half of HF patients develop cardiorenal syndrome (CRS). The management of advanced HF complicated by CRS is challenging. Two main strategies have been widely accepted for the management of CRS, namely improving cardiac output and relieving congestion. Diuretics remain the cornerstone and first-line therapy for decongestion; however, a substantial number of CRS patients develop diuretic resistance. In the face of persistent congestion and the progressive deterioration of kidney function, the implementation of kidney replacement therapy may become the only solution. In the review the current evidence on extracorporeal and peritoneal-based kidney replacement techniques for the therapy of CRS patients are presented.

Keywords: acute kidney injury; chronic kidney disease; congestion; extracorporeal ultrafiltration; heart failure; kidney replacement therapy; peritoneal ultrafiltration.

Figure 1

Pathophysiological factors and mechanisms involved in CRS pathophysiology. RAAS—renin–angiotensin–aldosterone system, SNS—sympathetic nervous system, GFR—glomerular filtration rate, AVP—arginine vasopressin, ET-1—endothelin 1, ROS—reactive oxygen species, TNFα—tumor necrosis factor α, IL-1—interleukin 1, IL-6—interleukin 6, FGF23—fibroblast growth factor 23, ACEi—angiotensin-converting enzyme inhibitor, ARB—angiotensin receptor blocker, and ARNI—angiotensin receptor-neprilysin blocker.

Figure 2

Treatment strategies for cardiorenal syndrome.

Figure 3

Pathophysiology of cardiovascular–kidney–metabolic syndrome. Based on [47] (MASLD—metabolic dysfunction-associated steatotic liver disease).

Figure 4

Kidney replacement therapy modalities.

Figure 5

Principles of extracorporeal kidney replacement therapy modalities.

Figure 6

Principles of peritoneal dialysis; modified based on Yu et al. [93].

Figure 7

Peritoneal dialysis methods. In continuous ambulatory peritoneal dialysis (CAPD), dialysis fluid exchanges are performed manually by the patient. A typical CAPD schedule includes 2–3 exchanges during the day and 1 at night. Each time, 1.5–2.5 L of dialysis fluid is delivered into the peritoneal cavity. If the exchanges are performed using an automatic device, such as a cycler, this method is called automatic peritoneal dialysis (APD). The patient is connected to the cycler for 8–10 h overnight. Most adult patients treated with APD also require the peritoneal cavity to be filled during the day to achieve good dialysis adequacy. This type of APD is called continuous cyclic peritoneal dialysis (CCPD).

Figure 8

Peritoneal ultrafiltration and peritoneal dialysis methods depending on the degree of kidney damage. Courtesy of J Matuszkiewicz-Rowińska.

Figure 9

Algorithm for the selection of kidney replacement therapy modality in HF patients with refractory congestion and diuretic resistance.