Cardiorenal syndrome (CRS) presents a challenging interplay of cardiovascular and renal pathologies and is particularly prevalent in the concurrent development of congestive heart failure (CHF) and chronic kidney disease (CKD). This case report highlights the successful management of CRS type 2 in a 70-year-old male with severe ischaemic cardiomyopathy complicating chronic kidney disease. The patient’s deteriorating condition prompted a nuanced approach that incorporated peritoneal dialysis (PD) as a pivotal element in addressing haemodynamic instability and acute-on-chronic kidney disease.
Keywords: Cardiorenal syndrome, Peritoneal dialysis, Case report.
With a growing global population experiencing the simultaneous onset of congestive heart failure (CHF) and chronic kidney disease, the coexistence of these conditions has raised significant concerns.1-3 Decreased kidney function is often accompanied by congestive heart failure, while chronic kidney disease exacerbates pre-existing CHF. The concept of cardiorenal syndrome (CRS) categorises patients with concurrent cardiac and kidney dysfunction into four clinical types based on the fundamental mechanisms of each disorder:4
Type I: Sudden deterioration of cardiac function leading to acute kidney injury.
Type II: Chronic cardiac abnormalities cause a decline in kidney function, resulting in permanent chronic kidney damage.
Type III: Sudden worsening of kidney function leading to acute cardiac injury.
Type IV: Chronic kidney disease causing sustained cardiac load resulting in permanent chronic cardiac damage.
Irrespective of the type, CRS represents a detrimental cycle leading to the clinical deterioration of both kidney and cardiac function.
Ultrafiltration (UF) is a potent non-pharmacologic, extracorporeal intervention for diuretic-resistant CHF.5 This therapy is most effective in patients experiencing acute decompensated heart failure (ADHF) in CRS types I and III. In contrast, the role of UF as a chronic maintenance therapy is less well established in patients with CRS types II and IV, except in uraemic patients with end-stage kidney disease who fall under CRS type IV. Managing CRS types II and IV, particularly CRS type II with diuretic-resistant CHF, has been contentious.6 However, since the early 1990s, a growing body of reports has suggested the clinical utility of peritoneal dialysis (PD) as a maintenance therapy for intractable CHF in this population.
Cardiorenal syndrome (CRS) represents a complex interplay between cardiovascular and renal pathologies, posing a significant challenge in clinical management. We report a compelling case of CRS type 2 in a 70-year-old male with severe ischaemic cardiomyopathy, complicating the course of chronic kidney disease. The patient’s deteriorating condition necessitated a multifaceted approach, including peritoneal dialysis, highlighting the importance of tailored interventions in such challenging scenarios.
Our patient, a 70-year-old male with a longstanding history of diabetes mellitus, systemic hypertension, and dyslipidaemia, had previously undergone coronary artery bypass grafting for triple-vessel coronary artery disease. Despite optimal medical management, the patient developed severe ischaemic cardiomyopathy with an ejection fraction of 30%. During this presentation, he exhibited symptoms of urosepsis leading to acute-on-chronic kidney disease (CRS type 2) and decompensated heart failure.
The initial management included intravenous antibiotics, correction of acidosis, and supportive measures. Haemodynamic instability during haemodialysis has prompted a peritoneal dialysis (PD) shift. The patient underwent continuous ambulatory peritoneal dialysis, gradually progressing from 2 cycles of 5 litres each to 3 cycles over 8 h, accompanied by serial monitoring of electrolyte, calcium, amylase, and lipase levels.
As the patient’s general condition improved, renal parameters showed enhancement and urine output increased, leading to a reduction in the frequency of PD cycles over the subsequent two weeks.
This case underscores the intricate challenges encountered in managing CRS type 2 in the context of severe ischaemic cardiomyopathy. The transition from haemodialysis to PD proved pivotal in addressing haemodynamic instability while effectively managing acute-on-chronic kidney disease. The versatility of peritoneal dialysis (PD) was demonstrated in this instance, enabling a customised and incremental methodology that ultimately proved beneficial for the patient’s clinical trajectory. A cohort of 147 individuals diagnosed with CRS were administered PD, which presented a feasible dialysis solution for CRS in circumstances where clinical resources were scarce and had the potential to save the lives of up to 27% of critically ill patients.6
This case also prompts the consideration of peritoneal dialysis as a viable alternative in patients with complex cardio-renal interactions, especially when traditional haemodialysis poses challenges. However, further research and long-term follow-up studies are necessary to validate the efficacy and sustainability of this approach in similar clinical scenarios.
PD has been consistently demonstrated to be clinically effective in numerous case series of CHF patients. PD may serve as a valuable and distinctive palliative measure for severely ill patients, as suggested by reports indicating that hope among hospitalised CHF patients exceeds that among healthy subjects.7 Additionally, utilising PD may provide further advantages by preventing the progression of CHF patients to end-stage renal failure, thereby reducing the burden of excess hospitalisations and associated costs.8 Concerning the prescription of peritoneal dialysis (PD), using the icodextrin solution stands out as a long-acting osmotic agent. This solution enables a gradual increase in the patient’s ultrafiltration (UF) volume, extending over up to 12 hours.9,10
In conclusion, this case report highlights the successful management of CRS type 2 in a patient with severe ischaemic cardiomyopathy using peritoneal dialysis. Tailoring interventions to the unique challenges of cardiorenal syndromes is crucial for optimal patient outcomes. This case contributes to the growing body of evidence supporting the role of peritoneal dialysis in complex clinical scenarios; however, further research is warranted to establish its long-term efficacy and generalisability.
Dr Farhan DrNB Nephrology PG Kauvery Hospital, Chennai.
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