What is the management for a patient with heart failure with reduced ejection fraction (HFrEF) on peritoneal dialysis?

Management of Heart Failure with Reduced Ejection Fraction in Patients on Peritoneal Dialysis

The management of heart failure with reduced ejection fraction (HFrEF) in patients on peritoneal dialysis should follow guideline-directed medical therapy (GDMT) with careful attention to volume status, medication tolerability, and dose adjustments for renal function.

Core Pharmacological Therapy

First-Line Medications

1. Loop Diuretics

   • Should be used in patients with evidence of fluid retention to improve symptoms 1
   • Carefully titrate dose to maintain euvolemia while monitoring for electrolyte imbalances
   • Options include furosemide (20-40 mg once or twice daily), bumetanide (0.5-1.0 mg once or twice daily), or torsemide (10-20 mg once daily) 1

2. ACE Inhibitors/ARBs or ARNI

   • ACE inhibitors are recommended in HFrEF patients with current or prior symptoms to reduce morbidity and mortality 1
   • Consider switching to sacubitril/valsartan (ARNI) after clinical stability is achieved 1, 2
   • Start at lower doses and titrate carefully with close monitoring of blood pressure and renal function

3. Beta-Blockers

   • Use evidence-based beta-blockers (carvedilol, metoprolol succinate, or bisoprolol) 1
   • Start at low dose and titrate gradually after optimization of volume status 1
   • Monitor heart rate and symptoms of hypotension

4. Mineralocorticoid Receptor Antagonists (MRAs)

   • Consider in selected patients with careful monitoring of potassium levels
   • Start with low dose spironolactone (12.5-25 mg once daily) 1

5. SGLT2 Inhibitors

   • Dapagliflozin or empagliflozin should be added regardless of diabetes status 1
   • These offer unique benefits without affecting blood pressure, heart rate, or potassium levels 1

Volume Management Considerations

1. Peritoneal Dialysis Prescription

   • Optimize ultrafiltration to maintain euvolemia
   • Consider more hypertonic exchanges for patients with recurrent congestion 3
   • Monitor daily weights, vital signs, and clinical signs of congestion 1

2. Diuretic Strategy

   • When diuresis is inadequate, consider:
     • Higher doses of loop diuretics
     • Addition of a second diuretic (metolazone, spironolactone)
     • Continuous infusion of loop diuretics during acute decompensation 1

Monitoring and Follow-up

1. Regular Assessment

   • Monitor fluid intake and output, vital signs, body weight, and clinical signs of congestion 1
   • Check serum electrolytes, urea nitrogen, and creatinine concentrations during active titration of HF medications 1
   • Assess for medication side effects, especially hypotension and hyperkalemia

2. Echocardiographic Follow-up

   • Reassess LVEF after 3 months of optimal medical therapy 4
   • Continue GDMT indefinitely, even if LVEF improves to >40% 4

Device Therapy Considerations

1. ICD Therapy

   • Consider primary prevention ICD after optimizing medical therapy for 3 months if EF remains ≤35% 4

2. Cardiac Resynchronization Therapy (CRT)

   • Evaluate QRS duration and morphology
   • Consider CRT if QRS ≥150 ms or LBBB with QRS ≥130 ms 4

Special Considerations for Peritoneal Dialysis Patients

1. Medication Dosing

   • Start with lower doses of renin-angiotensin system blockers and titrate cautiously
   • Monitor for hypotension, especially during dialysis sessions
   • Be vigilant for hyperkalemia with MRAs

2. Volume Assessment

   • More challenging in PD patients - use combination of clinical assessment, biomarkers, and imaging
   • Adjust PD prescription to optimize volume status

Common Pitfalls to Avoid

1. Underutilization of GDMT

   • Don't withhold evidence-based therapies due to concerns about renal function 4
   • Continue GDMT even if LVEF improves to prevent relapse 4

2. Inadequate Volume Management

   • Failure to optimize PD prescription for volume control
   • Insufficient monitoring of fluid status

3. Premature Discontinuation of Medications

   • Don't discontinue GDMT during hospitalization unless hemodynamically unstable 1
   • Don't stop medications due to mild renal function changes or asymptomatic hypotension 4

By following this comprehensive approach to managing HFrEF in peritoneal dialysis patients, clinicians can optimize outcomes while minimizing complications related to both heart failure and end-stage kidney disease.