Dear Kamal
The first thing I would say is that I certainly don’t want to come between you and your doctor … he IS there, he is on the spot, he knows you best, and he clearly has your best interests at heart. However, that said, I am going to present an alternative view to the suggested plan which, though reasonable, is also fraught with potential problems and may well not provide an assured solution.
Firstly, the HD you are getting (6 x nights a week x 7-8 hrs/run) is likely to be removing fluid from your intravascular space at a UFR well below 400 ml/hr … and, at a guess, more likely in the 150-200 ml/hr range.
While I don’t know your body weight, nor your inter-dialytic gain, on your frequent and long duration program, a regimen like yours is vanishingly unlikely to generate a fluid removal rate that could threaten cardiovascular instability or your coronary perfusion pressure. The UFR that I suspect you run (150-200 ml/hr) is way below the removal rates (>10ml/kg/hr) that have been associated with ANY risk of myocardial stun through dialysis-reduced coronary artery perfusion pressures.
Indeed, your UFR is likely so low that no effective change is occurring in your blood volume during dialysis as tissue fluid replenishment via your plasma refill rate is well and truly able to ‘keep up’ with the rate of dialysis fluid removal at your low level of UFR.
For conventional HD … absolutely … your nephrologist is right … but you are NOT on conventional HD and the data from MacIntyres group (specifically Jefferies CJASN 2011 6: 1326-32 who has studied RWMA in NHD) shows clearly that NHD patients do not suffer the same risk nor clinical occurrence of RWMA that conventional HD patients do.
See also my paper in an imminent edition of HDI … = currently out as an early release doi: 10.1111/HDI.12288
Next, after many episodes of prior peritonitis and KNOWN previous adhesive disease, it is vanishingly unlikely that your peritoneum is in (or has returned to) pristine condition. Don’t get me wrong … we have a very active and long term record of PD in my unit and I have >40years experience with and contentment with PD as an excellent treatment … indeed, we currently run some 20+ PD patients alongside our 45 NHD patients in our total home dialysis population of about 38% at home. So, home PD is in my DNA, too.
But, the risk here is several-fold … your peritoneum will not be restored (certainly not fully) … your adhesions will likely still be problematic … there may well now be peritoneal calcification (a CT to seek subtle calcification may prove or disprove this) … a laparoscopy +/- biopsy is not without complication and risk - especially if the scope should inadvertently perforate bowel during insertion through an unexpected loop of bowel adhered to the abdominal wall at the site of scope insertion … the physical addition of 2+ litres or PD fluid into your tummy - especially when lying down at night - risks some elevation of your diaphragms and some compression of your lung bases from below = something that may add to your sense of breathlessness … and, of course, you may climb back onto the tram of recurrent peritonitis etc that spelt doom for your PD first time round.
Further … are you sure your myocardial findings are the true cause of your breathlessness. One thing to consider is that maybe, subtly, you have lost a little muscle condition and body weight. This can happen. And, if you do not recognise this and do not commensurately drop your dialysis ‘dry’ weight, then - slowly - you risk becoming or become fluid overloaded. But, as this often builds up very slowly, it may not be easily picked up by the usual indicators - like a rising BP … or by the other usual indicators we commonly use to determine fluid overload.
Now this IS a guess, but my first and foremost thought about your predicament goes not to dialysis-induced coronary hypo-perfusion and RWMA, but to a more likely scenario = that you are - or have become - slowly, progressively and now chronically fluid overloaded.
Again … this CAN be hard to pick - as fluid (in slow chronic overload) is very good at hiding itself away.
Now, of course I can’t examine you. I am not on the spot. I can’t say this for sure. But, I would be trying, first, to drop, then drop, then drop, the drop some more your target weight … 0.25 kg each 2nd or third run, and slowly over 2-3 weeks … taking your weight down to the point where your BP begins to dip post-dialysis. We would prefer to do this here under supervision with long day runs in our home training unit (as a ‘respite’ measure) but I am not sure your circumstance there. But, as you ARE experienced, it should be quite safe to do at home.
Now this may already have been done … but excess fluid is an insidious foe, and is - 99 times out of 100 (well, maybe that’s over calling, but certainly more often than not) - the offender.
That is not to deny that you seem to have some myocardial issues, though it also would seem that there is no immediate place for any of the revascularisation options – stents, grafting, etc.
One final observation might be your respiratory function … I assume this has been cleared of implication? i.e. a chest assessment, lung function (etc) as not all breathlessness is cardiac. And, while you listed some of your drugs, I suspect some were not included. For example, some patients with heart issues can be put onto anti-arrhythmic drugs like amiodarone – a useful cardiac drug for certain rhythm disorders – and it, in particular, can cause some lung complications that may present as increasing breathlessness … just a thought.
I am not sure if any of that helps, or just confuses more.
However, as at the start, your nephrologist is clearly a caring and wise man … he is on the spot … he knows you like a book … and he must be the one to advise and manage you in the best way he can. I would hate to be thought of as ‘interfering’ … so, while taking on board what I have suggested, he must call the shots for you.