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Saudi Journal of Kidney Diseases and Transplantation
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LETTER TO THE EDITOR  
Year : 2021  |  Volume : 32  |  Issue : 1  |  Page : 276-279
Management of Redundant Dialysis Access-Arteriovenous Fistula in Post Renal Transplant Care


Department of Nephrology, Sri Venkateswara Institute of Medical Sciences, Tirupati, India

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Date of Web Publication16-Jun-2021
 

How to cite this article:
Karanam S, Chintakayala M, Nagaraj R D, Anapalli S, Vishnubotla S. Management of Redundant Dialysis Access-Arteriovenous Fistula in Post Renal Transplant Care. Saudi J Kidney Dis Transpl 2021;32:276-9

How to cite this URL:
Karanam S, Chintakayala M, Nagaraj R D, Anapalli S, Vishnubotla S. Management of Redundant Dialysis Access-Arteriovenous Fistula in Post Renal Transplant Care. Saudi J Kidney Dis Transpl [serial online] 2021 [cited 2021 Dec 4];32:276-9. Available from: https://www.sjkdt.org/text.asp?2021/32/1/276/318542


To the Editor,

A 24-year-old young man, a live-related renal transplant recipient presented a few apprehensions for solutions regarding the functioning left brachiocephalic arteriovenous fistula (AVF). His concerns were fear of trauma to the vascular structures of AVF and cosmetic appearance.

About three years ago, he was admitted for management of chronic kidney disease (CKD), evaluation revealed end-stage renal disease (ESRD) with hypertension, secondary to IgA nephropathy. He was initiated on hemodialysis (HD) through central venous catheter initially followed by left brachiocephalic AVF subsequently for a period of two years. He went through renal transplant surgery with mother being donor, post-transplant period was uneventful and the nadir creatinine at discharge was 0.9 mg/dL. He maintained normal graft function with serum creatinine around 1 mg/dL with triple immunosuppression (predni-solone - 20 mg/day, tacrolimus - 2 mg/day and mycophenolate mofetil 2 g/day in two divided doses).

Keeping in view his genuine concerns, the decision to retain or ligate the functioning AVF had to be made in the light of existing literature support. The literature on the fate of AVF is variable, one study reported an early loss of AVF due to thrombosis in 6.3% of their cohort, while 80.4% remained patent at one year after transplantation. In this cohort, 13.1% had undergone ligation and the predominant reason was cosmetic. Around 24.6% had graft loss during the follow-up period, of them, 66.3% had a functioning AVF at the time of graft loss.[1] Also, as brought out by Stoumps et al, there are no guidelines and recommendations on the AVF in the care of renal transplant recipients as of now.[2],[3]

The dilemmas are whether to ligate the functional AVF for the concerns of the hemo-dynamic-related cardiovascular perturbations or to continue to retain, keeping a future possibility of its utilization for dialysis support in the event of the loss of graft function.

Thus, the transplant physician is subjected to a therapeutic dilemma and the clear understanding of various circulatory and hemo-dynamic changes and their effect on cardiovascular system would help in arriving at practical solutions to mitigate the issue. In light of this, we bring forth the following discussion.

AVF as vascular access is definitely a panacea in the management of ESRD patients on HD for sustaining life or preparation for transplant as a bridge. However, in the long term, it is associated with increased cardiovascular burden not only because of uremic state but also due to hemodynamic perturbations. The majority of the morbidity and mortality of CKD patients is due to cardiovascular disease. It is stated that a functioning AVF, along with anemia, hypertension, fluid overload, uremia, oxidative stress and, endothelial dysfunction would contribute to cardiovascular disease burden in CKD patients.

The creation of an AVF involves anastomosis between high pressure artery and low pressure vein, and a sudden increase in pressure and wall sheer stress of the vein entails various circulatory and hemodynamic effects[4] including an increase in cardiac output. Ori et al,[5] showed a 15% increase in cardiac output after creation of an AV access, sympathetic nervous system activity, contractility, stroke volume, heart rate, blood volume with increase in atrial natriuretic peptide and brain natriuretic peptide and an increase in pulmonary arterial flow and pressure. There was a concomitant decrease in systemic vascular resistance in the immediate phase followed by an increase in left ventricular end-diastolic volume, left ventricular mass and size, atrial chamber size, diastolic and systolic dysfunction and pulmonary hypertension in long-term, as evidenced by Dundon et al.[6] Taken together, the current literature suggests that AVF can cause or exacerbate CHF, left ventricular hypertrophy (LVH), pulmonary hypertension (PHT), right ventricular dysfunction, coronary artery disease and valvular dysfunction.[7] These changes are prominent with a high flow AVF, Qa >2 l/min. The risk factors for high flow AVF are male gender, upper arm AVFs and previous access surgery.[4] The site of AVF is important in its blood flow and impact on the CV system, which is very well elucidated by Poiseuille law, which states that the blood flow in any vessel and therefore of an AVF is determined by the following relationship.[8]

Qa (mL/min) = π delta P r4/8ηl.

Where delta P is the pressure difference between the extremities of the vessel, r is the radius of the vessel,η is the viscosity of the fluid and l is the length of the vessel. Thus, the Qa for the brachial fistula is greater than the radial fistula because Qa is directly proportional to the fourth power of the radius of the vessel.

The post-transplant scenario is specific in that various confounding factors that play a role in LVH and cardiovascular burden in an ESRD patient on HD such as anemia, hypertension, fluid overload, uremia and, oxidative stress have been corrected to a reasonable extent in patients with stable graft function. Persistence of pre-existing AVF acts as one of the main culprits for the cardiac status deterioration, apart from the other causes such as dyslipidemia, age, diabetes, and adverse effects of immunosuppressive agents in this group of patients. Thus, the factors responsible for cardiovascular pathophysiology are different between the pretransplant and posttransplant phases with normal graft function.

The data on the elective ligation of AVF posttransplant have been variable, because of varying observations from different studies. Some have showed benefit in terms of regression of LVH and LV mass index,[9] recovery from denovo heart failure and tricuspid incompetence post-transplant with ligation of AVF,[10] while some studies have showed accelerated decline in e GFR in transplant patients who underwent elective ligation.[11]

However, it is conjectural whether a fistula ligation in the post-transplant patient with normal graft function would be totally beneficial. The advantages and disadvantages of AVF in post-transplant setting are summarized in [Table 1].
Table 1: Advantages and disadvantages of closure of AVF postrenal transplant.

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The approach should be a tailor-made one instead of one size fits all, in decision making of post-transplant AVF ligation versus conservative management with periodic observation. Hence, we propose a list of questions to be answered in a post-transplant patient before ligation of AVF, which needs further validation in larger studies as shown in [Table 2].
Table 2: Questionnaire prior to elective ligation of AVF.

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Taking into consideration all these factors, elective closure of AVF post-renal transplant should be done only when the patient has stable graft function without rejections and after ruling out the possibility of recurrent disease in the graft, the status of the peripheral vascular system for future AVF creation if required along with the presence of congestive cardiac failure, persistent pulmonary hypertension, despite correction of hypertension, symptoms is to observe the response of the anemia, and other modifiable factors. One of the ways to assess the response of these cardiac parameters on 2D echocardiogram to temporary pneumatic occlusion of the AVF, which helps in selecting the patients who may benefit from ligation of the AVF[11] once the decision is taken to close the AVF. The next decision is to select the method of closure in the post-renal transplant setting; either surgical ligation or transvenous endovenorraphy, although the latter is thought to have high success rate especially in side to side AVF.

Keeping with the above and taking cue from Stoumpos et al,[2] our patient was kept on continuous monitoring of cardiac function with periodic observation of the AVF without ligation, since there was no change in cardiac parameters on serial monitoring.

Conflict of interest: None declared.



 
   References Top

1.
Aitken E, Kingsmore D. The fate of the fistula following renal transplantation. Transpl Int 2014;27:e90-1.  Back to cited text no. 1
    
2.
Stoumpos S, Mark PB. Should we ligate arteriovenous fistulas in asymptomatic patients after kidney transplantation? Circulation 2019; 139:2819-21.  Back to cited text no. 2
    
3.
Kasiske BL, Zeier MG, Chapman JR, et al. KDIGO clinical practice guideline for the care of kidney transplant recipients: A summary. Kidney Int 2010;77:299-311.  Back to cited text no. 3
    
4.
Basile C, Lomonte C. The complex relationship among arteriovenous access, heart, and circulation. Semin Dial 2018;31:15-20.  Back to cited text no. 4
    
5.
Ori Y, Korzets A, Katz M, et al. The contribution of an arteriovenous access for hemodialysis to left ventricular hypertrophy. Am J Kidney Dis 2002;40:745-52.  Back to cited text no. 5
    
6.
Faull R, Rao N, Worthley M. Do arteriovenous fistulas increase cardiac risk? Semin Dial 2018;31:357-61.  Back to cited text no. 6
    
7.
Alkhouli M, Sandhu P, Boobes K, Hatahet K, Raza F, Boobes Y. Cardiac complications of arteriovenous fistulas in patients with end-stage renal disease. Nefrologia 2015;35:234-45.  Back to cited text no. 7
    
8.
Pfitzner J. Poiseuille and his law. Anaesthesia 1976;31:273-5.  Back to cited text no. 8
    
9.
Rao NN, Stokes MB, Rajwani A, et al. Effects of arteriovenous fistula ligation on cardiac structure and function in kidney transplant recipients. Circulation 2019;139:2809-18.  Back to cited text no. 9
    
10.
Dundon BK, Torpey K, Nelson AJ, et al. The deleterious effects of arteriovenous fistula-creation on the cardiovascular system: A longitudinal magnetic resonance imaging study. Int J Nephrol Renovasc Dis 2014;7:337-45.  Back to cited text no. 10
    
11.
Weekers L, Vanderweckene P, Pottel H, et al. The closure of arteriovenous fistula in kidney transplant recipients is associated with an acceleration of kidney function decline. Nephrol Dial Transplant 2017;32:196-200.  Back to cited text no. 11
    
12.
Keane MM, Carney DN. Angiosarcoma arising from a defunctionalized arteriovenous fistula. J Urol 1993;149:364-5.  Back to cited text no. 12
    
13.
Sangeetha B, Chaitanya V, Reddy MH, Kumar AC, Ram R, Sivakumar V. Mega-fistula. Indian J Nephrol 2016;26:385-6.  Back to cited text no. 13
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Correspondence Address:
Sivaparvathi Karanam
Department of Nephrology, Sri Venkateswara Institute of Medical Sciences, Tirupati
India
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DOI: 10.4103/1319-2442.318542

PMID: 34145149

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