Controversies in the management of the haemodialysis-related arteriovenous fistula following kidney transplantation

Abstract

Arteriovenous fistula (AVF) is regarded as the best vascular access for chronic haemodialysis (HD). Still, AVF inherently causes significant haemodynamic changes. Although the necessity for vascular access despite its putative cardiovascular complications favours AVF creation in patients under chronic HD, one may question whether sustaining a functional AVF after successful kidney transplantation extends the haemodynamic threat. Small prospective series suggest that AVF ligation causes rapid and sustained reduction in left ventricular hypertrophy. Still, the benefits of such a cardiac remodelling in long-terms of cardiovascular morbi-mortality still need to be proven. Furthermore, the elevation of diastolic blood pressure and arterial stiffness caused by AVF ligation may blunt the expected cardio-protection. Finally, the closure of a functioning AVF may accelerate the decline of kidney graft function. As a whole, the current management of a functioning AVF in kidney transplant recipients remains controversial and does not rely on strong evidence-based data. The individual risk of graft dysfunction and a return to chronic HD also needs to be balanced. Careful pre-operative functional assessments, including cardio-pulmonary testing and estimated glomerular filtration rate slope estimation, may help better selection of who might benefit the most from AVF closure. Large-scale prospective, ideally multi-centric, trials are essentially needed.

Prophylactic Ligature of AV Fistula Prevents High Output Heart Failure after Kidney Transplantation

“…Highflow fistulas are regularly closed when aneurysm with concomitant risk of rupture, steal syndrome with acral ischaemia, and/or congestive heart failure at NYHA stage Am J Nephrol 2020;51:511-519 DOI: 10.1159/000508957 III or IV are present. However, both in the presence and absence of typical clinical ligature indications, there is great variety in routine clinical management [14]. With respect to own retrospective data [6] showing up to 25% occurrence of high-output heart failure with consecutive closure of fistulas, we conducted a prospective randomized controlled trial evaluating the potential benefit of prophylactic ligature of high-flow AV fistulas.…”

Effect of arteriovenous access closure and timing on kidney function in kidney transplant recipients

“…However, in the general non-transplant population, the creation of a pre-dialysis AV access has been recently suggested to delay ESKD progression [13–16]. Due to the lack of consistency across studies, there is no consensus on the causal link between AV access creation and the progression of ESKD and heart disease [3, 4].…”

“…Conversely, another study of 285 KTRs reported that the closure of a functioning AVF for KTRs with stable kidney allograft function significantly accelerated eGFR decline over a consecutive 12-month period after KT [3]. As a whole, the current management of a functioning AV access (surgical closure versus watchful preservation) for KTRs with stable kidney allograft function remains controversial and does not rely on robust evidence-based data [4, 28]. The individual risk of allograft dysfunction and a return to chronic dialysis need to be considered [4].…”

“…As a whole, the current management of a functioning AV access (surgical closure versus watchful preservation) for KTRs with stable kidney allograft function remains controversial and does not rely on robust evidence-based data [4, 28]. The individual risk of allograft dysfunction and a return to chronic dialysis need to be considered [4]. Recently, Laranjinha et al analyzed the impact of functioning hemodialysis AV access on kidney allograft perfusion and found that temporary occlusion of the AV access resulted in a significant decline in kidney allograft resistive index and an increase in blood pressure [29].…”

Ten tips to manage renal transplant recipients

“…Post-transplant, vascular access may be challenging because of previous vein thromboses and collateralization whilst at the same time vascular access should be preserved, especially in patients at risk of transplant failure. This includes the avoidance of subclavian lines if possible and the preservation of existing AVFs [10].Femoral venous access on the side of the graft should be avoided whenever possible.…”