HDCN Article Review/Hyperlink

Greenberg S, Shapiro WB, Porush JG

Hemodynamic effects of peritoneovenous shunts in hemodialysis patients with ascites

Am J Kidney Dis (Sep) 28:387-394 1996

Peritoneovenous shunts (PVS) have been employed to treat ascites and increase hemodynamic stability during hemodialysis in ESRD patients with ascites. In this report, clinical data in 3 such patients are described and the literature reviewed. Hemodynamic parameters before and after PVS included: 1. nadir BP 2. number of intradialytic hypotensive episodes 3. amount of albumin used to treat hypotension 4. interdialytic weight gain 5. hemodynamic stability during HD (change in MAP).

PVS placement had dramatic effects, with the number of hypotensive episodes decreasing from 219 prior to PVS to 0 after PVS, and was associated with discontinuation of use of albumin to maintain BP. One patient required replacement of PVS due to infection. When used in cirrhotic patients, PVS has been shown to increase cardiac output and suppress the renin angiotensin system. The authors speculate that improvement after PVS in their patients was due to: 1. increased mobilization of ascitic fluid into the vascular space during dialytic ultrafiltration 2. decreased ascitic to vascular osmotic gradient 3. decreased thirst (due to decreased renin-angiotensin stimulation during HD) 4. increased cardiac output.

Comment: Although anecdotal in nature, this report supports the use of PVS in hemodialysis patients with ascites and symptomatic hypotension during HD. An increase in ascitic fluid osmolality during HD, which would tend to result in fluid movement from the vascular to the third space and predispose to hypotension, has been demonstrated (Fajardo. ASAIO Trans 34: 617-9, 1988). Possibly isolated ultrafiltration followed by isovolumic dialysis would be beneficial in ESRD patients with ascites, since this would theoretically prevent the development of the ascitic-vascular osmotic gradient during dialytic ultrafiltration. Switching patients to CAPD would be another option.

The authors' data do not support the concept that decreased angiotensin levels and decreased thirst leading to decreased interdialytic weight gain plays a role in the clinical improvement seen after PVS, since interdialytic weight gain did not decrease after the procedure. (David J. Leehey, M.D., Loyola University at Chicago)