Dialysis Options for ESKD in Amyloidosis

Dialysis Options for ESKD in Amyloidosis: Hemodialysis vs. Peritoneal Dialysis”

1. Introduction

Amyloidosis may result in end-stage kidney disease (ESKD) as a consequence of progressive renal tissue deposition of amyloid fibrils. Once ESKD, renal replacement therapy is required to maintain life.

Both hemodialysis (HD) and peritoneal dialysis (PD) are appropriate alternatives for these patients, although choice is based on cardiac status, mobility, patient preference, and amyloidosis-associated complications.

This article discusses the advantages, limitations, patient selection, and outcomes of HD and PD among amyloidosis patients and serves as a clinician and patient-friendly guide.

2. Understanding ESKD in Amyloidosis

2.1 Pathophysiology

• Progressive amyloid deposition in glomeruli, interstitium, and renal vasculature results in proteinuria, CKD, and eventually ESKD
• Cardiac involvement frequently makes volume management during dialysis challenging

2.2 Clinical Presentation

ESKD due to amyloidosis can present with:

• Severe edema and fluid overload
• Uremic symptoms: fatigue, nausea, confusion
• Electrolyte imbalances: hyperkalemia, acidosis
• Orthostatic or hypotension symptoms if cardiac amyloidosis is present
  Case Example:

A 62-year-old patient with AL amyloidosis developed ESKD over a period of three years and needed dialysis initiation, complicated by mild restrictive cardiomyopathy.

3. Hemodialysis in Amyloidosis

3.1 Overview

Hemodialysis constitutes extracorporeal elimination of toxins and fluid by a dialysis machine and vascular access (fistula, graft, or catheter).

3.2 Advantages

• Effective removal of uremic toxins
• Rapid improvement of fluid overload and electrolyte imbalances
• Regular monitoring by healthcare personnel during sessions
• Preferable for patients who cannot cope with PD at home

3.3 Limitations

• Risk of hypotension, particularly in cardiac amyloidosis or autonomic dysfunction
• Vascular access complications (thrombosis, infection)
• Restricted mobility during dialysis sessions
• Hemodynamic instability can necessitate altered ultrafiltration rates

3.4 Clinical Considerations

• Patients with cardiac amyloidosis: Employ slower ultrafiltration and vigilant monitoring
• Anticoagulation: Necessary for extracorporeal circuit; risk-benefit must be weighed given bleeding hazard with amyloidosis
• Frequency: Generally 3 times a week, 3–4 hours per treatment

4. Peritoneal Dialysis in Amyloidosis

4.1 Overview

PD employs the natural filter of the peritoneal membrane, with the dialysis fluid being placed in the abdominal cavity to filter out toxins and excess water.

4.2 Benefits

• More hemodynamic stability; less traumatic fluid removal
• Can be done at home, increasing independence
• Continuous treatment maintains stable electrolyte and fluid balance
• Reduced risk of severe hypotension in comparison to HD

4.3 Challenges

• Risk of peritonitis and exit-site infections
• Needs training of patient or caregiver
• Not ideal in patients with a history of extensive abdominal surgery or adhesions
• Rate of volume removal might be reduced in severe fluid overload

4.4 Clinical Considerations

• Best for patients with cardiac amyloidosis and hypotension
• Ongoing monitoring for infection and adequacy of ultrafiltration
• Selection between PD modality (CAPD and APD) is based on peritoneal membrane function and patient lifestyle

5. Hemodialysis vs. Peritoneal Dialysis: Comparison

| Characteristic | Hemodialysis | Peritoneal Dialysis |

|———|————–|——————|
| Where | Clinic/hospital | Home |
| Hemodynamic Stability | Less stable | More stable |
| Autonomy | Less | More |
| Infection Risk | Vascular access complications | Peritonitis |
| Fluid Removal | Rapid | Gradual |
| Suitability | Patients with caregivers or unstable peritoneum | Patients with cardiac amyloidosis or hypotension **
Clinical Tip:

Decision should be individualized depending upon cardiac status, mobility, patient preference, and risk of infection.

6. Patient Selection Criteria

• Cardiac involvement: PD preferred for hypotension-prone patients
• Mobility and support: Home PD needs competent patient/caregiver
• Vascular access feasibility: HD needs to have functional fistula or catheter
• Infection risk: Compromised immunopatients need more stringent precautions
  Case Example:

A 60-year-old patient with AL amyloidosis having hypotensive attacks during HD was switched to PD, which stabilized blood pressure and fluid.

7. Monitoring and Complications

7.1 Hemodialysis Monitoring

• Blood pressure, heart rate, fluid status during sessions
• Vascular access inspection
• Electrolytes and kidney labs

7.2 Peritoneal Dialysis Monitoring

• Daily fluid balance
• Signs of infection (fever, cloudy effluent)
• Electrolytes and kidney function

7.3 Common Complications

• HD: Hypotension, access thrombosis, infection
• PD: Peritonitis, catheter malfunction, inadequate ultrafiltration

8. Combination with Amyloidosis-Specific Therapy

• Ongoing disease-specific therapy (e.g., chemotherapy in AL, tafamidis in ATTR)
• RAS antagonists and SGLT2 inhibitors can be continued if well tolerated
• Dialysis supports treatment by managing uremia and fluid overload while treating underlying disease

9. Case Studies and Outcomes

• Case 1: Hemodialysis in AL amyloidosis patient with stable blood pressure; effective toxin removal, but occasional hypotensive episodes
• Case 2: Peritoneal dialysis in cardiac amyloidosis patient; stable hemodynamics, reduced hospital visits, slight improvement in quality of life
  Observation: Both HD and PD are feasible; decision is based on cardiac function, patient lifestyle, and risk factors.

10. Patient Education and Lifestyle

• Practice in home PD technique
• Identify infection or hypotension symptoms
• Uphold dietary and fluid restrictions
• Underline findings for maintaining dialysis schedule in order to optimize results

11. Future Directions

• Investigations on combined cardiorenal therapies in amyloidosis
• New dialysis modalities to minimize hypotension and enhance fluid management
• Combination with anti-amyloid treatments could minimize dialysis dependency in the long term

12. Conclusion

Hemodialysis and peritoneal dialysis are both options for amyloidosis-related ESKD.

• HD offers exponential toxin elimination, although hemodynamic instability can restrict its application in cardiac amyloidosis
• PD provides more gentle, continuous treatment, suitable for patients with hypotension or impaired vascular access
  Patient individualization, monitoring, and integration with amyloidosis-specific therapy are critical to enhancing outcomes and quality of life.