The Impact of Arteriovenous Fistulae on the Myocardium: The Impact of Creation and Ligation in the Transplant Era (original) (raw)
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Kidney360, 2021
BackgroundThe long-term effects of arteriovenous fistula (AVF) ligation on cardiovascular structure following kidney transplantation remain uncertain. A prospective randomized, controlled trial (RCT) examined the effect of AVF ligation at 6 months on cardiovascular magnetic resonance imaging (CMR)–derived parameters in 27 kidney transplant recipients compared with 27 controls. A mean decrease in left ventricular mass (LVM) of 22.1 g (95% CI, 15.0 to 29.1) was observed compared with an increase of 1.2 g (95% CI, −4.8 to 7.2) in the control group (P<0.001). We conducted a long-term follow-up observational cohort study in the treated cohort to determine the evolution of CMR-derived parameters compared with those documented at 6 months post-AVF ligation.MethodsWe performed CMR at long-term follow-up in the AVF ligation observational cohort from our original RCT published in 2019. Results were compared with CMR at 6 months postintervention. The coprimary end point was the change in CM...
Prophylactic Ligature of AV Fistula Prevents High Output Heart Failure after Kidney Transplantation
American Journal of Nephrology
Background: Arteriovenous (AV) fistulas are considered the gold standard for ensuring safe and long-term vascular access in patients with haemodialysis-dependent end-stage renal disease. However, previous studies demonstrated that high-flow AV fistulas might add additional cardiovascular burden in the post-transplant setting, leading to frequent fistula closure in this population. Currently, there is no consensus regarding management of high-flow fistulas in post-transplant patients with stable kidney function. The present randomized controlled trial examines the effect of prophylactic AV fistula closure on high-output heart failure. Methods: Twenty-eight kidney transplant patients with stable graft function, absence of pre-existing severe cardiac failure, and brachial arterial flow rate of at least 1,500 mL/min were recruited and randomized in a 1:1 ratio to an intervention and control group, respectively. The intervention group was subject to immediate fistula ligature. Patients w...
Cardiac remodeling after reduction of high-flow arteriovenous fistulas in end-stage renal disease
Hypertension Research, 2016
In patients with end-stage renal disease, excessive blood flow through an arteriovenous fistula (AVF) may lead to volume overload-induced cardiac remodeling and heart failure. It is unclear which patients with hyperfunctional AVF may benefit from AVF reduction or ligation. The indication for the procedure is often based on AVF flow. Because cardiac remodeling is driven by increased venous return, which is equivalent to cardiac output, we hypothesized that an elevated cardiac index (CI) might better identify subjects with reverse remodeling after AVF reduction. Thirty patients (age 52 ± 12 years, 73% male) with AVF flow ⩾ 1.5 l min − 1 underwent comprehensive echocardiographic evaluations before and after AVF reduction. At baseline, 16 patients had a normal CI (2.5-3.8 l min − 1 m − 2) and 14 had a high CI (4.0-6.0 l min − 1 m − 2). A left ventricular end-diastolic diameter decrease after operation was predicted by elevated baseline CI (Po0.01), but not elevated AVF flow (P = 0.07). There was a significant decrease in CI, left ventricular mass, left atrial and right ventricular diameter and pulmonary systolic pressure in the high CI group but not in the normal CI group. After AVF reduction, systemic vascular resistance decreased in the normal CI group, whereas it did not change in the high CI group. In conclusion, reduction of high-flow AVF leads to reverse cardiac remodeling but only in patients with elevated CI. The variability of the response of systemic vascular resistance to AVF flow may explain this observation. Increased CI but not increased AVF flow may better determine candidates for AVF reduction.
American Journal of Transplantation, 2004
The long-term effects of hemodialysis arteriovenous fistula (AVF) closure on left ventricular (LV) morphology are unknown. Using echocardiography, we prospectively studied 17 kidney transplant recipients before, 1, and, 21 months after AVF closure (mean fistula flow 1371 ± 727 mL/min). Eight kidney transplant recipients with a patent AVF, matched for age, time after AVF creation, and time after transplantation, served as controls. LV mass index (LVMI) decreased from 139 ± 44 g/m 2 before AVF closure to 127 ± 45 g/m 2 and 117 ± 40 g/m 2 at 1 and 21 months post-closure, respectively (p < 0.001), but remained unchanged in controls. LV hypertrophy prevalence (LVMI > 125 g/m 2 ) decreased from 65% before, to 41% early, and 18%, late, after surgery (p = 0.008), mostly from a decrease in LV end-diastolic diameter. Consequently, the prevalence of LV concentric remodeling (relative wall thickness > 0.45 without hypertrophy) increased from 12% before, to 35% early, and 65% late, after surgery (p = 0.003). Diastolic arterial blood pressure increased from 78 ± 15 mmHg before, to 85 ± 13 mmHg early, and 85 ± 10 mmHg late, after surgery (p < 0.015).In conclusion, closure of large and/or symptomatic AVF induces longterm regression of LV hypertrophy. However, residual concentric remodeling geometry as well as diastolic blood pressure increase may blunt the expected beneficial cardiac effects of the procedure.
Case Reports in Transplantation, 2013
Experimental and clinical studies analyzing the impact of AVF on cardiovascular and renal parameters, as well as outcomes, in kidney transplant recipients are lacking. On the other hand, it is not known whether AVF ligation after transplantation modifies hemodynamic parameters and kidney function. We report a case of a renal transplant recipient who developed an acute congestive heart failure accompanied by renal failure, which were triggered by femorofemoral AVF angioplasty. Prompt AVF ligation rapidly reversed clinical symptoms and normalized cardiac and renal functions. This paper illustrates the potential deleterious consequences of high-output AVF after kidney transplantation and raises considerations regarding the impact of the fistula on cardiac status and kidney function after kidney transplantation and, consequently, the management AVF after transplantation.
Effect of high flow arteriovenous fistula on cardiac function in hemodialysis patients
The Egyptian Heart Journal, 2018
Background: Vascular access for hemodialysis (HD) with an inappropriately high flow may underlie the onset of high output heart failure (HOHF). The aim of this study was to determine the prevalence of high flow access (HFA) in chronic HD patients, and to determine its effects on cardiac functions. Methods: This cross sectional study was conducted on 100 chronic hemodialysis patients through arteriovenous fistula (AVF). The study cohort was subdivided into 2 groups based on AVF flow: Group A (Non-HFA group with Qa < 2000 ml/min), and Group B (HFA group with Qa ! 2000 ml/min). AVF flow (Qa) was assessed using Color Doppler ultrasonography. Transthoracic echocardiography was performed for all patients to assess cardiac dimensions and functions. Results: Prevalence of HFA among study population was 24%. Mean AVF Qa was 958.63 ± 487.35 and 3430.13 ± 1256.28 ml/min, for group A and B respectively. The HFA group demonstrated a significant dilatation in LV dimensions and volumes and significantly larger LA volume as compared to non-HFA group. A significantly lower LV ejection fraction [EF] was also observed in group B with a mean value of 57.32 ± 6.19% versus 62.90 ± 5.76%. A significant association between HFA group and high Qa/cardiac output (CO) ratio (!20%) was also observed. Conclusion: HFA is a prevalent hemodialysis vascular access problem. HFA was associated with dilated LV dimensions, impaired LV systolic function. High Qa/CO ratio (!20%) was an independent predictor of high output heart failure (HOHF) in our study population.