Home Hemodialysis in Patient with a Left Ventricular Assist Device

Introduction: Cardiovascular disease is the leading cause of morbidity and mortality in patients with end stage kidney disease. Emerging evidence has supported the idea that home hemodialysis may offer a more physiologial approach. Furthermore, this may lead to improvement in several cardiovascular risk factors and outcomes, compared to thrice weekly in center hemodialysis. These principles can apply to those with implantable left ventricular assist devices (LVAD), an acceptable alternative to support patients with advanced heart failure. As the number of implants increases, the more LVAD recipients requiring dialysis will be seen. We report a case of a patient with an LVAD who successfully transitioned from in center to home hemodialysis, offering a glimpse of novel candidates to be considered for the home dialysis population. Case Description: 60 year old male with history of ischemic cardiomyopathy, LVAD (HeartMate 3 implantation) with complex postop course, which included acute kidney injury on chronic kidney disease, requiring dialysis start (declared end stage renal disease). After hospital discharge, he received in center hemodialysis at our outpatient unit (more than 1 hour away from his home) via a right internal jugular tunneled catheter. His treatments were notable for low blood pressure and low flow alarms with high ultrafiltration targets. There was also difficulty in reaching dry weight. After much deliberation, he trained and transitioned to the home hemodialyisis program. He currently performs 2.5 hour sessions 4 days per week. This has greatly improved his quality of life, helped achieve euvolemia, eliminated 2 hour commute thrice weekly to and from the dialysis center, and also improved LVAD performance. Discussion: Dialysis use in patients with LVADs is not all that frequent and more studies are needed in this arena to better understand the the impact of the various modalities. Conventional hemodialysis does pose a specific set of obstacles for this particular patient population. From the practical standpoint, few hemodialysis facilities are equipped to manage patients with LVADs, making the home environment an attractive option. Our case describes a successful transition in such a patient from in center to home hemodialysis. This is a promising and achievable alternative with hopefully more information gathered as to its benefits in the future.