PD has been proposed in the treatment of refractory heart failure given its ability to allow ultrafiltration, thus optimizing blood volume. This method can be used at home, and given the fact that it allows a gradual and continuous gentle reduction of excess water and solute, this gives it a minimal hemodynamic impact, thus reducing renal venous pressure and decreasing interstitial edema. Other effects of PD would be the clearance of factors associated with myocardial dysfunction such as TNF Alpha, MDF, IL-1, and IL-6, among other factors [11]. These factors have a molecular weight between 500 and 30,000 Daltons, passing easily through the peritoneal membrane. The purification of these factors positively affects the half-life of myocardial cells.

The elimination of water alone is insufficient to improve the prognosis of heart failure because sodium is the major determinant of extracellular volume and has a fundamental role in the development of congestion. The sodium extraction in DP can be obtained by the osmotic gradient generated by the infusion of a glucose dialysate. The use of an icodextrin solution (Extraneal®) producing a colloid osmotic gradient makes it possible to obtain maximum sodium extraction. Depending on the patient, CAPD or APD can be used, bearing in mind that CAPD allows greater sodium extraction than APD in whom the supine position, recruit a larger surface of the peritoneal membrane for the exchanges. Different therapeutic regimens can be proposed—either a single infusion of icodextrin solution associated or not with the infusion of another bag of isotonic or hypertonic glucose dialysate during the day or even two bags of this type of dialysate depending on the severity of associated renal failure.

Among the main benefits reported in studies using PD in congestive heart failure alongside the decrease in water and sodium overload with a parallel reduction in weight, there is a clear improvement in the NYHA class of heart failure moving from 3 or 4 to 1 or 2, along with a very clear reduction in the frequency and duration of hospitalizations by 90% in most studies [12];[13]. All these benefits are responsible for improving the quality of life. Some degree of improved cardiac function has sometimes been reported. However, in most studies, there is no correlation between improvement in symptoms and a significant improvement in cardiac performance [14]. Recently, a study involving 32 patients found a significant improvement in NYHA functional class as well as a small but still significant increase in LVEF after 6 months of PD treatment attributed to the decrease in cardiac preload by the ultrafiltration obtained [15].

The decreases in renal venous congestion and intra-abdominal pressure have been associated with a restoration of the efficacy of diuretics and a slowing down of the deterioration of renal function. The economic impact of the reduction in hospitalizations is not negligible, and the overall cost of PD treatment for congestive heart failure is lower than the cost generated by the repeated hospitalizations of patients [14].

The mortality of patients with refractory heart failure and treated conventionally is 75% at one year in different cohorts. An improvement in patient survival has been reported, in particular by Nunez, who reported a lower rate of mortality and readmission of patients treated with PD compared to diuretic medical treatment after one year of follow-up [3]. Despite the potential benefits of PD, not all patients could benefit from it. The usual contraindications of PD will be a limiting factor associated with a greater anesthetic risk given the general situation of the patient. The development of the insertion of the peritoneal catheter under loco-regional anesthesia of the TAP block type will make it possible to lift the brake of a general anesthesia and not challenge the patient any longer.

The choice of patients who can benefit from PD remains imperfectly specified. Nevertheless, patients with NYHA stage 3 to 4 heart failure having repeated episodes of water and sodium overload (requiring frequent hospitalizations or the use of intravenous diuretics) or not/imperfectly responding to a combination of diuretics and presenting with heart failure refractory to optimized medical treatment and having no contraindication to PD may benefit from this therapy. The impact of iSGLT2 on the prognosis of these patients remains to be assessed in the coming years, and this would make it possible to redefine the place of PD in these patients if necessary. To date, the use of these drugs is not recommended in patients with severe renal impairment with a GFR <25 mL/min.

About 50% of patients with chronic heart failure have impaired renal function, while 16% of patients with congestive heart failure have had glomerular filtration rates of less than 30 mL/min and 39% between 30 and 50 mL/min.

Among patients with non-end-stage chronic renal failure, most studies have not demonstrated a correlation between survival and renal function level. Thus, Courivaud et al. reported in one of the largest studies of PD in heart failure that patients with severe renal impairment were significantly older and less frequently treated with aldosterone receptor antagonists but that these conditions did not influence the survival of these patients [12]. However, other studies have found no association between survival and GFR level, and there is no statistically significant difference between GFR level before and after PD treatment [13];[14];[16];[17];[18];[19].

The theoretical advantages of PD over hemodialysis in this indication can be raised. Myocardial stunning secondary to hemodynamic phenomena is present in patients receiving hemodialysis treatment even in the absence of significant coronary artery disease. This situation leads to a reduction in long-term systolic function, thus increasing the risk of heart failure. PD is not associated with this phenomenon [20]. The continuous nature of PD makes it possible to limit variations in serum potassium and to continuously monitor the potassium stock, which may constitute an advantage to allow the use of potassium-sparing diuretics such as mineralocorticoid receptor antagonists and inhibitors of the renin-angiotensin-aldosterone system [16];[17]. The absence of an arteriovenous fistula eliminates the deleterious hemodynamic effects of a possible high flow of the fistula. Better preservation of residual renal function is much more often observed in PD than in hemodialysis.

Several studies have reported better survival rates of patients with heart failure on hemodialysis than on PD [21]. This difference may be due to the persistence of a relative hypervolemia that went unnoticed in patients treated with PD, as shown by the EURO BCM study, which found that only 40% of patients on PD were euvolemic [22]. This underlines the importance of a continuous and regular evaluation of the fluid overload in these patients; the clinical evaluation of the fluid overload can be faulted, while the use of bioimpedance could prove useful for the evaluation of blood volume and its therapeutic management.

Improvement in the left ventricular ejection fraction after the initiation of PD has been reported by several authors but not found by others. While the improvement in the functional state of the patients was observed under PD, the improvement in morbidity was only observed in patients with heart failure with preserved left ventricular ejection fractions. Other authors have found that mortality was more frequent in patients whose left ventricular function was stable and did not improve during the first year of PD treatment [17];[18]. However, it should be kept in mind that the vast majority of studies are essentially observational and retrospective, thus limiting the generalizability of the results.

Finally, right ventricular dysfunction associated with major water and sodium retention in the form of ascites, edema of the lower limbs, severe pulmonary arterial hypertension, and tricuspid insufficiency with preserved renal function could constitute a preferred indication for treatment with PD.