Community Hemodialysis for a Patient with a Left Ventricular Assist Device: A Case Report

Introduction: Heart transplant remain the treatment of choice for patient with advance heart failure. However, due to lack of donor organ, left ventricular assist devices (LVADs) are used as a bridge until donor organs becomes available. We are seeing more patients with advanced heart failure where LVADs are being used for long term. These patients are surviving longer and hence it is not uncommon for them develop ESKD requiring dialysis. We presents a case of a patients who was on LVAD for 2 years prior to developing ESKD and how we transit her from hospital to community for her dialysis. Case Description: Ms K is a 33 year old lady who suffered from doxorubicin induced cardiomyopathy following treatment of childhood Acute Myeloid Leukemia. She presented with intra-partum decompensated heart failure requiring inotropic and ECMO support in 2021. She eventually underwent LVAD implantation. Her peri-operative and postoperative period was complicated with multiple infective issues and complications. During tthat admission she developed AKI following cardiac surgery requiring dialysis for 3 months before weaning off dialysis. Unfortunately, she had recurrent admissions over the next 2 years and developed recurrent episodes of AKI, ultimately leading to her becoming dialysis dependent. She recieve intermittent dialysis in hospital setting and was subsequently successfully transited to outpatient community dialysis after 2 month stay in hospital. Discussion: There are numerous challenges a LVAD patient on dialysis faces compared to the routine patient on maintenance dialysis. For patient on LVAD, the blood flow is none pulsatile and traditional method of measuring BP would not be able to accurately record BP. US Doppler BP measurement for mean arterial pressure is the only way to measure BP in these patients. Besides difference in monitoring, resuscitation plan also differs from routine dialysis patients. CPR peformed on these patients may disloge the LVAD and cause more harm than good. This is the first case of a patient on LVAD undergoing successful transition from the inpatient setting to community dialysis in Singapore. With more LVAD procedures being performed and patient surviving longer on LVAD, dialysis center would need to adapt to care for these patients. Dialysis nurses need to have knowlege and training in order to care for patients on LVAD.