What is the recommended peritoneal dialysis (PD) prescription for a patient with dilated cardiomyopathy (DCM)?

Peritoneal Dialysis Prescription for Patients with Dilated Cardiomyopathy

For patients with dilated cardiomyopathy (DCM), the recommended peritoneal dialysis prescription should focus on frequent, low-volume exchanges with emphasis on optimizing ultrafiltration to manage volume overload while maintaining hemodynamic stability.

Initial PD Prescription Considerations for DCM Patients

Volume Management Strategy

• Volume control is critical in DCM patients as it directly impacts cardiac function and mortality
• Use the lowest possible dialysate dextrose concentration to achieve desired volume status 1
• Implement dietary sodium and fluid restriction to optimize volume control 1
• Ensure ultrafiltration is positive (no fluid absorption) for all exchanges in these volume-sensitive patients 1

Initial Prescription Parameters

1. Exchange Volume:

   • Start with lower fill volumes to reduce intra-abdominal pressure
   • For patients with BSA <1.7 m²: Begin with 2.0 L exchanges
   • For patients with BSA 1.7-2.0 m²: Begin with 2.5 L exchanges
   • For patients with BSA >2.0 m²: Begin with 3.0 L exchanges 1

2. Modality Selection:

   • CCPD (Continuous Cycling Peritoneal Dialysis) is often preferred for DCM patients:
     • For BSA <1.7 m²: 2.0 L (9 hours/night) with 2.0 L day dwell
     • For BSA 1.7-2.0 m²: 2.5 L (9 hours/night) with 2.0 L day dwell
     • For BSA >2.0 m²: 3.0 L (9 hours/night) with 3.0 L day dwell 1

3. Dwell Times:

   • Ensure adequate dwell time of at least 2 hours to permit sodium removal 1
   • Monitor drain volumes from overnight dwells of CAPD and daytime dwells of APD monthly 1

Special Considerations for DCM Patients

Hemodynamic Stability

• Avoid excessive ultrafiltration during initial sessions to prevent hemodynamic instability 2
• Consider using icodextrin for the long dwell to achieve adequate ultrafiltration with less glucose exposure 3
• Some evidence suggests that a single nocturnal exchange with icodextrin can be effective in patients with refractory heart failure 4

Medication Management

• Consider carvedilol as part of the treatment regimen, as it has been shown to reduce mortality in dialysis patients with DCM 5
• Diuretics may be preferred over increasing dialysate dextrose concentration if the patient has residual kidney function 1

Monitoring and Adjustment

• Review PD effluent volume monthly, with particular attention to drain volumes 1
• Perform peritoneal equilibration testing (PET) approximately 1 month after initiation 1
• Adjust prescription based on clinical response, focusing on:
  • Volume status
  • Blood pressure control
  • Cardiac function parameters
  • Solute clearance targets (weekly Kt/V >1.7) 3

Urgent Start Considerations

If urgent initiation is required:

• Use low-volume, supine dialysis if PD must be started <10 days after catheter placement 1
• Consider multiple, low-volume manual exchanges (750-1000 mL based on BSA) with 2-2.5 hour dwell times 6
• Gradually increase volumes after 7 days if no leakage occurs 6

Pitfalls to Avoid

• Avoid negative ultrafiltration in any exchange for DCM patients 1
• Do not use thiazolidinediones in patients with heart failure 1
• Avoid excessive dextrose concentration which may worsen cardiac function through fluid shifts and metabolic effects
• Do not delay adequacy testing, as DCM patients are particularly sensitive to volume overload

By following these recommendations and closely monitoring the patient's clinical response, peritoneal dialysis can be effectively used to manage patients with dilated cardiomyopathy while optimizing their cardiac function and quality of life.