Should We Ligate Arteriovenous Fistulas in Asymptomatic Patients After Kidney Transplantation?

Abstract

When Brescia and Cimino first described a series of successful autogenous arteriovenous fistula (AVF) creations for hemodialysis in 1966,1 they quickly recognized the ensuing increased cardiac output as the major disadvantage of the new technique. They considered it clinically insignificant, and this was probably true in their cohort of young patients receiving dialysis (mean age 43 years), none of whom had end-stage renal disease caused by diabetes mellitus or vascular disease. Over time, however, there have been significant changes in the demographics of the prevalent hemodialysis population, with trends toward increasing age and comorbidity, including impaired baseline cardiac function. Left ventricular hypertrophy (LVH) is primarily an adaptive remodeling process as a response to increased cardiac workload aiming to minimize ventricular wall stress and is almost universal in new dialysis patients. The development, severity, and persistence of LVH are strongly associated with cardiovascular (CV) events and mortality risk in chronic kidney disease (CKD), especially in patients in the highest tertiles of change in left ventricular (LV) mass treated with conventional hemodialysis.2 Despite its detrimental effects when present, the impact of LVH regression on mortality remains uncertain. An elegant multifactorial interventional study by London et al3 has demonstrated that a 10% decrease in LV mass translated into a 28% decrease in mortality risk from CV causes over a 5-year period. Contrary to these results, Foley et al4 found that improvements in LV mass over a 1-year period after the initiation of dialysis were associated with a subsequent reduced likelihood of cardiac failure but not with mortality risk.