Turning the Tide in Heart Failure Management: The Role of Peritoneal Ultrafiltration in a Portuguese Single-Center Experience

Introduction: Loop diuretics are essential for managing fluid overload in heart failure (HF). However, diuretic resistance is a common problem that may compromise prognosis. Peritoneal ultrafiltration (PUF) has been used to address refractory congestion. This study aims to evaluate the efficacy of PUF in patients with refractory HF. Methods: Retrospective, single-center study, conducted between April 2016 and August 2024, with follow-up until January 2025, including patients with NYHA class III-IV HF, resistant to diuretics, and without other criteria for initiating peritoneal dialysis. Clinical and laboratory parameters were analyzed before and after technique initiation. Results: Fifteen patients were included (mean age 65.6 ± 11.5 years, 80% male). The most frequent HF etiology was ischemic (47%), followed by valvular (20%). During a median follow-up of 23.5 months (IQR 9.3–43.8), median hospitalization days decreased from 10 to 0 days/year (p=0.012). NT-proBNP decreased from 9076 (IQR 6124–35000) to 6126 (IQR 3371–16561) pg/mL (n=14, p=0.004). Mean daily peritoneal ultrafiltration was 985 ± 176 mL, and residual diuresis increased from 873 to 1073 mL/24 h (p=0.001). Median furosemide-equivalent dose fell from 240 to 80 mg/day (p<0.001). The proportion of patients on RAAS inhibitors increased from 27% to 67% (p=0.031), SGLT2 inhibitors from 40% to 67%, beta-blockers from 53% to 60%, and mineralocorticoid receptor antagonists from 20% to 53%. Seven peritonitis episodes occurred in seven patients (47%), a rate of 0.20 episodes per patient-year. Mortality was 67% (10/15), with cumulative survival of 76.4% at 12 months and 59.4% at 24 months. Conclusions: PUF may represent an important therapeutic option in diuretic-resistant HF. Despite the small sample size and retrospective design, these findings suggest PUF could be a valuable approach in managing refractory heart failure with cardiorenal syndrome.