A hopeless case?

(Section Editor: A. Meyrier) End-stage renal failure in an octogenarian with advanced congestive heart failure is a daunting challenge for the physician. Many of these patients cannot tolerate haemodialysis, due to severely impaired left-ventricular function, valvular disease or both. In such patients, peritoneal dialysis may be the only feasible option but home therapy is often impossible, due to age, comorbidity and lack of a suitable caregiver. In-centre intermittent peritoneal dialysis (IPD), which must often be performed for as many as 30 h/week, offers survival, at the expense of severely compromised quality of life. We present a seemingly hopeless case of end-stage renal failure in an 81-year-old patient with advanced congestive heart failure. An 81-year-old female patient was admitted in December 2005, with recurrent syncope and dyspnoea. She had a history of multiple hospital admissions because of congestive heart failure due to advanced aortic stenosis; comorbidities included hypertension, mild dementia and osteoarthritis of the knees. On examination, the patient appeared chronically and acutely ill with cyanosis and severe orthopnoea. Blood pressure was 105/70, pulse 105 beats/min, respiratory rate was 40/min and the patient was not febrile. The jugular venous pulse was elevated and there were coarse crackles over both lungs. The apical beat was irregular and palpable in the anterior axillary line and there was a 4/6 crescendo–decrescendo systolic murmur at the second right interspace. Another soft pan-systolic murmur was audible over axilla and there was a third heart sound. Serum creatinine was 174 μmol/l and urea 30.4 mmol/l; cystatin C was 6 mg/l and a previous serum creatinine was unavailable. An electrocardiogram confirmed atrial fibrillation. Echocardiography showed severe aortic stenosis, moderate aortic incompetence, severe mitral stenosis and moderate mitral incompetence, as well as impaired left-ventricular function, severe tricuspid regurgitation and pulmonary hypertension. Intravenous diuretics, digoxin and oxygen were begun while the patient remained on a peripheral ward and without inotropic support. The serum creatinine rose to 368 µmol/l, urea was now 38 mmol/l and the creatinine clearance was 12 ml/min. A femoral dialysis catheter was placed and haemodialysis was begun, which led to some improvement of the dyspnoea, although clinical examination and chest X-ray still showed marked pulmonary congestion ( Figure 1 ). The haemodialysis sessions were complicated by hypotension, syncope and nausea. Cardiac catheterization confirmed multi-valvular disease with severe aortic stenosis (opening area 0.7 cm 2 ) and severe mitral stenosis in the lead. Severe stenosis of the right and left anterior descending coronary arteries was also detected. The cardiac surgeons felt that double-valve replacement and bypass surgery was inappropriate; the forced expiratory volume was 1.15 l/s. A peritoneal dialysis catheter was placed and the patient was referred for in-centre IPD while she was on home oxygen, torasemide 50 mg/day and digoxin.