Abstract
Arteriovenous fistula (AVF) is the preferred type of vascular access for maintenance haemodialysis but it may contribute to maladaptive cardiovascular remodelling. We studied the effect of AVF creation on cardiac structure and function in patients with chronic kidney disease (CKD). In this prospective cohort study patients with CKD listed for first AVF creation underwent cardiac magnetic resonance (CMR) imaging at baseline and at 6 weeks. All participants had ultrasound measurements of fistula blood flow at 6 weeks. The primary outcome was the change in left ventricular (LV) mass. Secondary outcomes included changes in LV volumes, LV ejection fraction, cardiac output, LV global longitudinal strain and N-terminal-pro B-type natriuretic peptide (NT-proBNP). A total of 55 participants were enrolled, of whom 40 (mean age 59 years) had AVF creation and completed both scans. On the second CMR scan, a mean increase of 7.4 g (95% CI 1.1–13.7, p = 0.02) was observed in LV mass. Significant increases in LV end-diastolic volumes (p = 0.04) and cardiac output (p = 0.02) were also seen after AVF creation. No significant changes were observed in LV end-systolic volumes, LV ejection fraction, NT-proBNP and LV global longitudinal strain. In participants with fistula blood flows ≥ 600 mL/min (n = 22) the mean increase in LV mass was 15.5 g (95% CI 7.3–23.8) compared with a small decrease of 2.5 g (95% CI − 10.6 to 5.6) in participants with blood flows < 600 mL/min (n = 18). Creation of AVF for haemodialysis resulted in a significant increase of LV myocardial mass within weeks after surgery, which was proportional to the fistula flow.
Highlights
Arteriovenous fistula (AVF) is the preferred type of vascular access for maintenance haemodialysis but it may contribute to maladaptive cardiovascular remodelling
There was a drop in diastolic blood pressure between cardiac magnetic resonance (CMR) scans (p = 0.03) but no changes in systolic blood pressure, body weight and haematocrit were observed (Table 2). In this prospective observational study we have examined the effect of AVF creation on left ventricular (LV) mass in patients with advanced chronic kidney disease (CKD) using a high fidelity cardiac imaging modality (CMR)
There was a substantial increase in LV mass observed on the second CMR scan after an average time of 6.3 weeks from AVF surgery
Summary
Arteriovenous fistula (AVF) is the preferred type of vascular access for maintenance haemodialysis but it may contribute to maladaptive cardiovascular remodelling. Creation of AVF for haemodialysis resulted in a significant increase of LV myocardial mass within weeks after surgery, which was proportional to the fistula flow. The physiological consequences may even progress till there is myocardial decompensation, left ventricle dilatation, and a decline in ejection fraction, eventually leading to LV hypertrophy (LVH) or heart failure[1,7] All these changes are additive to underlying pre-existing LVH, dilatation, and dysfunction caused by progressive uraemic cardiomyopathy and may be associated with adverse outcomes in dialysis patients[6]. Using cardiac magnetic resonance (CMR) imaging in 24 patients with CKD stage 5 undergoing fistula creation, Dundon et al.[15] showed a mean increase of 13% in LV mass, 21% in LV end-systolic volumes, and 25% in cardiac output 6 months after AVF creation
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