Peritoneal dialysis and LVAD bridge to successful heart–kidney transplant

Kidney injury and cardio–renal syndrome is a common complication of end-stage cardiomyopathy and heart failure. Although renal function often improves after placement of left ventricular assist devices (LVADs), this is frequently not sustained, and many patients progress to end-stage kidney disease (ESKD). In-centre haemodialysis (HD) is the most common dialysis modality in patients with LVADs and there are only rare case reports of maintenance dialysis with peritoneal dialysis (PD) in patients with VADs. Barriers to the use of PD as renal replacement modality in patients with LVAD include lack of familiarity with acute-start PD, concerns regarding interruption of anticoagulation for PD catheter placement and historic concerns of PD-associated peritonitis risk causing VAD drive-line infection, though this risk is reduced with modern pre-peritoneal VAD drive-lines. PD may offer advantages in this cohort including improved haemodynamic stability and avoidance of vascular access, with lower rates of bloodstream infections as compared to HD. PD may also aid preservation and restoration of kidney function in patients with LVADs and kidney injury. We report a case of a patient with non-ischaemic dilated cardiomyopathy and existing LVAD, with ESKD managed successfully with maintenance PD. The patient was maintained on PD for 10 months prior to a subsequent successful combined heart–kidney transplant.