Peritoneal ultrafiltration for refractory fluid overload and ascites due to pulmonary arterial hypertension
Faeq Husain-Syed
, María-Jimena Muciño-Bermejo**,***, Claudio Ronco**, Werner Seeger****, Horst-Walter Birk*
,**,****,
Corresponding author
* Department of Internal Medicine II, Division of Nephrology, University Clinic Giessen and Marburg (UKGM), Campus Giessen, Giessen, Germany
** International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Vicenza, Italy
*** Intensive Care Unit and Liver Research Unit, Medica Sur Clinic & Foundation, Mexico City, Mexico
* Department of Internal Medicine II, University Clinic Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL) - Campus Giessen, Giessen, Germany
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Lane 1, patient sample. The LpX band is of narrower size range than VLDL and often found in the mid region (as above). The LDL species in this patient of intermediate size and very low concentration (estimate of < 0.5 mmol/L).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Dineo V. Phatlhane, Annalise E. Zemlin" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Dineo V." "apellidos" => "Phatlhane" ] 1 => array:3 [ "preGrado" => "MBChB, FCPath (SA) (Chem), MMed (Chem Path)" "nombre" => "Annalise E." 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We present the case of a recurrent hospitalized patient with refractory volume overload treated with peritoneal ultrafiltration.</p></span><span id="s0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0020">Case Report</span><p id="p0010" class="elsevierStylePara elsevierViewall">In 2007, a 51-year-old Caucasian woman was admitted to our department diagnosed with severe idiopathic PH (mPAP 59 mmHg, PVR 900 dyn x sec x cm<span class="elsevierStyleSup">-5</span>, PCWP 11 mmHg, CO 4,87 L/min). She was cyanotic, with oxygen saturation of 82%. Treated with sequential pulmonary vasoactive therapy (sildenafil, terguride, iloprost inhalation and ambrisentan), she was readmitted since 2011 every 2-3 months due to severe fluid overload (despite high doses of sequential nephrone blockade). The renal function decreased progressively with an estimated glomerularfiltration rate (eGFR using MDRD) of 41 mL/min and serum creatinine (SCr) of 140,8 <span class="elsevierStyleItalic">μ</span>mol/l. Estimation of other renal biomarkers or collection of 24 h urine specimen was not performed. She has a weight gain of 30 kg from overhydration with severe edema and ascites. The ascites was considered due to congestive hepatopathy by chronic right heart failure (HF) with a Child-Pugh-Score of 8. No alcoholic intoxication was documented, the hepatitis B and C virus serology was negative and we excluded autoimmune disease and Budd-Chiari syndrome. We refrained from performing paracentesis due to abnormal prothrombin time, BMI of 51.9 m/kg<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and caput medusae. Initially, the symptoms of hypervolemia were relieved by intravenous (IV) furosemide administration. In later stages with decreasing renal function, treatment options were bailed out.</p><p id="p0015" class="elsevierStylePara elsevierViewall">End of 2011, the oliguric patient was hospitalized on intensive care unit (despite IV furosemide and xipamide high doses), being dependent on IV iloprost and continuous extracorporal renal replacement therapy for 15 days. She lost 8 kg of fluid, resulting in a partial renal recovery. Some weeks later, staying on ICU for 3 months with the same therapeutic plan, this time without significant weight loss (<a class="elsevierStyleCrossRef" href="#f0005">Figure 1A</a>). Her Karnofsky score remained 20% over the last 8 months.</p><elsevierMultimedia ident="f0005"></elsevierMultimedia><p id="p0020" class="elsevierStylePara elsevierViewall">The placement of a peritoneal dialysis (PD) catheter to mobilize ascites was discussed in the past but refused due to an excessive risk of general anesthesia. Regarded as a “lost case” the surgical department implanted a PD catheter in local anesthesia. During 15 days, 25 L of amber-colored ascites was drained (<a class="elsevierStyleCrossRef" href="#f0010">Figure 2</a>). Laboratory testing revealed transudative ascites, rich in epithelial cells without signs of infection or malignancy. No extracorporeal treatment or diuretics (besides spironolactone because of hypokalemia) were necessary as diuresis increased. The eGFR was 38 mL/min with a SCr of 158 <span class="elsevierStyleItalic">μ</span>mol/l and urine output about 2 L/day. She was no longer bed-ridden, oxygen supply could be reduced and the assessment showed a patient in no distress and without dyspnea at rest. The Child-Pugh-Score remained the same.</p><elsevierMultimedia ident="f0010"></elsevierMultimedia><p id="p0025" class="elsevierStylePara elsevierViewall">One hallmark of PD is the variable and individualized use of its solutions. At this point, when ascites decreased below 400 mL, peritoneal ultrafiltration was started with empirically 1,000 mL/day icodextrin and a dwell time of 24 h. The underlying rationale was to achieve as much UF as possible to avoid relapse, but use as less icodextrin as necessary in order to preserve residual renal function. For that, the daily amount of 400 mL ascites seemed reasonable to start with peritoneal ultrafiltration. The recommended dwell time for icodextrin is 8- to 16 h. However, a shorter period than 24 h and a larger fill volume did not significantly increase UF, so that we continued the abovementioned PD regime with that we could mobilize additional 15 L of body fluid. Hypoalbuminemia did not occur within the next months (lowest level 3.8 g/dL). Before dismissal, diuresis was 1.5 L (torasemide 20 mg, xipamide 20 mg, spironolactone 75 mg) and a peritoneal ultrafiltration 1 L/day. We saw her first on a weekly, then on a monthly basis, and Karnofsky index of 60% was reached (<a class="elsevierStyleCrossRef" href="#f0005">Figure 1B</a>).</p><p id="p0030" class="elsevierStylePara elsevierViewall">No hospital admissions were required for 1 year. Considering the lack of interpretability of eGFR and SCr under daily use of icodextrin, all attempts failed to measure urinary creatinine clearance. In November 2012, the PD treatment regime was adjusted to nocturnal continuous cycling peritoneal dialysis (CCPD) due to decreasing renal function with end stage renal disease (ESRD) and anuria with a total UF of 1,500 mL/day.</p><p id="p0035" class="elsevierStylePara elsevierViewall">In 2013, she got hospitalized due to upper gastrointestinal bleeding based on congestive gastropathy. She was readmitted for the last time in March 2014 due to refractory terminal right HF. Clinical and hemodynamic assessments (fluid challenge and aggravation during UF, performing pulmonary arterial catheterization) revealed adequate fluid balance. The IV administration of sildenafil and epoprostenol did not lower the severity and laboratory studies showed no signs of infection or other causes. The patient died as a part of the diseases’ nature without any options left.</p></span><span id="s0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0025">Discussion</span><p id="p0040" class="elsevierStylePara elsevierViewall">Regarding the clinical scenario of both, PH and chronic liver disease, this case provides different teaching points. It underscores that refractory ascites can be successfully controlled with peritoneal ultrafiltration, even in non-ESRD. Functional renal impairment played an essential role, since renal function partially recovered. Right-sided HF and especially ascites-induced intra-abdominal hypertension can contribute to impaired kidney function.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">–</span><a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Patients with right-sided HF and hepatorenal syndrome 2 often present diuretic resistance due to venous congestion and hyperaldosteronism.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Here, the paracentesis and administration of mineralcorticoid antagonists due to PD induced hypokalemia presumably provided escape from the vicious cycle, as she lost 30 kg of fluid. Since fluid overload can lead to acute respiratory failure and worsen pulmonary hypertension, we found respiratory function improvement after peritoneal ultrafiltration a keypoint in this case report.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5</span></a><span class="elsevierStyleSup">–</span><a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The success has to be defined in terms of reduced hospitalization numbers, improved mobility and quality of life. We avoided the implantation of transjugular intrahepatic portosystemic shunts, as the hemodynamic effects could have worsened PH.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="p0045" class="elsevierStylePara elsevierViewall">Second, similar to congestive HF, peritoneal ultrafiltration seems to be a favorable modality in PH, if refractory to diuretics.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> While extracorporal UF is fast and commonly available in acute setting, HF-patient suffers from immobility, potential hemodynamic fluctuations, risk of infection, bleeding, need for hospitalization, higher hospital expense and compromised quality of life.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11</span></a><span class="elsevierStyleSup">–</span><a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Patients with PH present strong hemodynamic fluctuations having a narrow window for fluid balance, as extremes can be associated with worsened renal and right ventricular function. Although no invasive hemodynamic measurements were performed after the initiation of peritoneal ultrafiltration, we can only predict the beneficial effect of fluid management in the progression of PH, since there was a significant clinical improvement and decrease of oxygen demand. Brain natriuretic peptide and sodium did not show any correlation with the clinical course.</p><p id="p0050" class="elsevierStylePara elsevierViewall">We choose a therapeutic manoeuvre that has been reported to be useful and safe in patients with different diagnosis but similar clinical features. There are no randomized trials concerning the safety of PD catheter placement in patients with ascites due to PH, but clinical reports on its safety on cirrhotic patients.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Technical survival of PD in cirrhosis has been described as long as 2 years.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> The case thought us to be careful in judging treatment as futile when quality of life is the ultimate goal.</p><p id="p0055" class="elsevierStylePara elsevierViewall">Ours may be the first to report the application of peritoneal ultrafiltration in the treatment of refractory ascites in patient in chronic liver disease and PH. Given the lack and difficulty of randomization, this case report should help foster the notion of a multidisciplinary approach in PH.</p></span><span id="s0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0030">Support</span><p id="p0060" class="elsevierStylePara elsevierViewall">None.</p></span><span id="s0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0035">Financial Disclosure</span><p id="p0065" class="elsevierStylePara elsevierViewall">None.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:3 [ "identificador" => "xres1199887" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abs0010" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1118323" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "s0005" "titulo" => "Introduction" ] 3 => array:2 [ "identificador" => "s0010" "titulo" => "Case Report" ] 4 => array:2 [ "identificador" => "s0015" "titulo" => "Discussion" ] 5 => array:2 [ "identificador" => "s0020" "titulo" => "Support" ] 6 => array:2 [ "identificador" => "s0025" "titulo" => "Financial Disclosure" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-01-15" "fechaAceptado" => "2015-03-09" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1118323" "palabras" => array:4 [ 0 => "Chronic right heart failure" 1 => "Congestive hepatopathy" 2 => "Diuretic resistance" 3 => "Hepatorenal syndrome" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abs0010" class="elsevierStyleSection elsevierViewall"><p id="sp0015" class="elsevierStyleSimplePara elsevierViewall">Pulmonary hypertension is a common finding in patients with advanced liver disease. Similarly, among patients with advanced pulmonary arterial hypertension, right heart failure leads to congestive hepatopathy. Diuretic resistant fluid overload in both advanced pulmonary hypertension and chronic liver disease is a demanding challenge for physicians. Venous congestion and ascites-induced increased intra-abdominal pressure are essential regarding recurrent hospitalization, morbidity and mortality. Due to impaired right-ventricular function, many patients cannot tolerate extracorporeal ultrafiltration. Peritoneal dialysis, a well-established, hemodynamically tolerated treatment for outpatients may be a good alternative to control fluid status. We present a patient with pulmonary arterial hypertension and congestive hepatopathy hospitalized for over 3 months due to ascites induced refractory volume overload treated with peritoneal ultrafiltration. We report the treatment benefits on fluid balance, cardiorenal and pulmonary function, as well as its safety. In conclusion, we report a case in which peritoneal ultrafiltration was an efficient treatment option for refractory ascites in patients with congestive hepatopathy.</p></span>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "f0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 539 "Ancho" => 1045 "Tamanyo" => 59385 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0005" class="elsevierStyleSimplePara elsevierViewall">Clinical course of the patient. A. The hospitalized bed-ridden patient before the PD catheter implantation on 30 October 2011. Note the severe ascites. B. The patient during her appointment in our outpatient department on 14 March 2012.</p>" ] ] 1 => array:7 [ "identificador" => "f0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 536 "Ancho" => 1017 "Tamanyo" => 83143 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0010" class="elsevierStyleSimplePara elsevierViewall">Chronological correlation of weight, eGFR (MDRD), oxygen demand and mPAP (dashed line indicates the assumed course).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bs0010" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1." 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 1 | 0 | 1 |
| 2024 October | 9 | 11 | 20 |
| 2024 September | 17 | 17 | 34 |
| 2024 August | 20 | 16 | 36 |
| 2024 July | 23 | 8 | 31 |
| 2024 June | 21 | 4 | 25 |
| 2024 May | 29 | 4 | 33 |
| 2024 April | 29 | 3 | 32 |
| 2024 March | 38 | 7 | 45 |
| 2024 February | 20 | 13 | 33 |
| 2024 January | 37 | 9 | 46 |
| 2023 December | 17 | 6 | 23 |
| 2023 November | 27 | 8 | 35 |
| 2023 October | 15 | 10 | 25 |
| 2023 September | 14 | 5 | 19 |
| 2023 August | 15 | 6 | 21 |
| 2023 July | 22 | 9 | 31 |
| 2023 June | 23 | 7 | 30 |
| 2023 May | 48 | 12 | 60 |
| 2023 April | 54 | 4 | 58 |
| 2023 March | 69 | 4 | 73 |
| 2023 February | 13 | 11 | 24 |
| 2023 January | 13 | 10 | 23 |
| 2022 December | 11 | 9 | 20 |
| 2022 November | 16 | 10 | 26 |
| 2022 October | 15 | 8 | 23 |
| 2022 September | 18 | 7 | 25 |
| 2022 August | 17 | 21 | 38 |
| 2022 July | 10 | 12 | 22 |
| 2022 June | 14 | 10 | 24 |
| 2022 May | 19 | 7 | 26 |
| 2022 April | 13 | 13 | 26 |
| 2022 March | 38 | 7 | 45 |
| 2022 February | 28 | 5 | 33 |
| 2022 January | 32 | 10 | 42 |
| 2021 December | 21 | 10 | 31 |
| 2021 November | 19 | 10 | 29 |
| 2021 October | 20 | 5 | 25 |
| 2021 September | 44 | 10 | 54 |
| 2021 August | 42 | 4 | 46 |
| 2021 July | 24 | 10 | 34 |
| 2021 June | 15 | 6 | 21 |
| 2021 May | 20 | 3 | 23 |
| 2021 April | 58 | 29 | 87 |
| 2021 March | 19 | 5 | 24 |
| 2021 February | 13 | 8 | 21 |
| 2021 January | 10 | 5 | 15 |
| 2020 December | 8 | 5 | 13 |
| 2020 November | 8 | 7 | 15 |
| 2020 October | 7 | 8 | 15 |
| 2020 September | 12 | 16 | 28 |
| 2020 August | 13 | 8 | 21 |
| 2020 July | 11 | 7 | 18 |
| 2020 June | 4 | 1 | 5 |
| 2020 May | 11 | 3 | 14 |
| 2020 April | 11 | 2 | 13 |
| 2020 March | 5 | 1 | 6 |
| 2020 February | 11 | 5 | 16 |
| 2020 January | 9 | 7 | 16 |
| 2019 December | 15 | 5 | 20 |
| 2019 November | 9 | 2 | 11 |
| 2019 October | 22 | 0 | 22 |
| 2019 September | 14 | 1 | 15 |
| 2019 August | 2 | 3 | 5 |
| 2019 July | 13 | 1 | 14 |
| 2019 June | 7 | 13 | 20 |
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