Sustained low-efficiency dialysis in congested patients with advanced heart failure.

BACKGROUND: We evaluated the effects of sustained low-efficiency dialysis (SLED) as an alternative to palliative care in persistently congested patients with advanced heart failure unsuitable for mechanical circulatory support or heart transplantation. METHODS: In this single-center, non-randomised retrospective cohort study, we included patients hospitalised with advanced heart failure, persistent congestion, and renal dysfunction between September 2002 and December 2024. The index date was defined as the time SLED was considered clinically indicated. Patients who were treated with SLED formed the SLED group, patients who declined SLED and continued with standard medical therapy only were assigned to the standard therapy group. Outcomes included the number and duration of heart failure-related and all-cause hospitalisations 1 year before and after the index date, heart failure medication use, and mortality. RESULTS: We compared 107 patients treated with SLED (mean age 75 ± 10 years, 48% male, 58% HFpEF) with 32 patients in the standard therapy group (mean age 79 ± 18 years, 34% male, 53% HFpEF). During the first year after the index date, heart failure hospitalisation occurred in 13% of SLED patients compared to 78% of standard therapy patients. In the SLED group, the annual heart failure hospitalisation rate decreased from 1.5 to 0.3 events (p < 0.001), and duration of hospital stay from 21.4 to 2.5 days (p < 0.001). No significant change was observed in the standard therapy group (1.7 to 1.6 events; 16.3 to 16.3 days). All-cause hospitalisation rates were unchanged in both groups, but duration of all-cause hospital stay (25.1 to 11.5 days, p < 0.001) was significantly reduced in the SLED group. Use and titration of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, mineralocorticoid receptor antagonists, and β-blockers improved significantly in the SLED group but remained largely unchanged with standard therapy. Median survival was longer in the SLED group (23 months, 95% CI 17-29) compared with standard therapy (3 months, 95% CI 1-7; p < 0.001). CONCLUSIONS: In patients with advanced heart failure and persistent congestion, SLED was associated with fewer heart failure-related hospitalisations, enhanced optimisation of pharmacological heart failure therapy, and prolonged survival relative to standard therapy only.