Multidisciplinary introduction of peritoneal dialysis enabling ICU liberation and home-based care in Ebstein's anomaly with refractory ascites and CKD: a case report.

Patients with refractory hepatic ascites and chronic kidney disease (CKD) secondary to right-sided heart failure pose unique therapeutic challenges when renal replacement therapy (RRT) is required in the intensive care unit (ICU). Conventional hemodialysis often worsens hypotension and venous congestion in these settings. Peritoneal dialysis (PD), by contrast, offers slow and continuous ultrafiltration that preserves hemodynamic stability, yet its use during vasopressor-dependent shock in the ICU is rarely described. We report the case of a 50-year-old woman with Ebstein's anomaly-related right heart failure, oliguria, CKD, and refractory ascites, admitted to the ICU with norepinephrine-dependent hypotension complicated by acute kidney injury (AKI). Repeated ascites drainage and attempts to taper vasopressor support led to recurrent oliguria, worsening renal function, and fluid overload. After multidisciplinary evaluation by nephrology, cardiology, critical care, anesthesia, and surgery, PD was identified as the only feasible strategy aligned with both the patient's hemodynamic status and her goal of home-based care. PD was initiated in the ICU beginning with low-volume exchanges and titrated to achieve effective ultrafiltration. PD enabled norepinephrine cessation, improvement in volume status, and eventual discharge home on ambulatory PD. This case demonstrates the utility of PD as a capable RRT modality to achieve both ICU liberation and home dialysis initiation in complex hepato-cardio-renal syndrome. Successful outcomes required cross-specialty collaboration and PD expertise within critical care. Broader recognition of PD's role in such settings may help expand therapeutic options for patients who are otherwise considered unsuitable for conventional RRT in the ICU.