Renal Replacement Therapy in Congestive Heart Failure Requiring Left Ventricular Assist Device Augmentation

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Abstract

"Cardiorenal syndrome" is a term used to describe a dys-regulation of the heart affecting the kidneys, or vice versa, in an acute or chronic manner (1,2). Renal impairment can range from reversible ischemic damage to renal failure requiring short- or long-term renal replacement therapy (2). Patients who require mechanical circulatory support, such as a left ventricular assist device (LVAD), as definitive treatment for congestive heart failure or as a bridge to cardiac transplantation pose a unique challenge with respect to receiving dialysis, because they experience higher rates of morbidity and mortality from infection in the post-LVAD period (3-7). Acute dialysis access can pose an increased infection risk. In this article, we present a patient who required renal replacement therapy and a LVAD for management of acute-on-chronic cardiorenal syndrome while awaiting heart transplantation. A literature review to determine whether peritoneal dialysis or hemodialysis is superior for patients with profound hemodynamic dysfunction and the need to minimize risk of infection did not offer clear guidance about which modality is superior in patients with advanced congestive heart failure. However, there is clear evidence of the superiority of peritoneal dialysis in reducing the risk of systemic infection secondary to acute dialysis access. Given the high risk of LVAD infection, we therefore conclude that, to decrease mortality secondary to systemic infection, peritoneal dialysis should strongly be considered in patients who require renal replacement therapy before or after LVAD placement.

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