Pulmonary Hypertension and Hemodialysis Access

Abstract

The purpose of this project was to identify the patient's features and the technical factors related to an increased risk of heart failure with the creation of dialysis vascular access (DVA). The study included 269 patients with chronic kidney disease who had a baseline and postoperative echocardiogram within 6 months of fistula creation at a single institution between January 2000 and March 2015. There were 37 patients with α1-antitrypsin disease, pulmonary fibrosis or sarcoidosis, and a heart or lung transplant who were excluded, leaving 232 patients in the final cohort. Patients with pulmonary hypertension (pHTN; n = 70 [30.2%]) were compared with patients without pHTN (n = 162 [69.8%]). Patients with pHTN were younger (P = .01) and were less likely to have congestive heart failure (P = .032), peripheral vascular disease (P = .044), or history of a percutaneous coronary intervention (P = .018). Patients with pHTN were more likely to have obstructive sleep apnea (P = .023). Survival was not affected by pHTN status (P = .16). The overall fistula maturation rate (defined as successful two-needle cannulation for 4 weeks) was 78.9%. An upper arm arteriovenous fistula (P = .46), an infraclavicular nonautologous graft of any diameter (P = .38), a two-stage surgery (P = .14), the history of a prior dialysis catheter (P = .56), and pharmacomechanical thrombectomy (P = .98) were not associated with the development pHTN. Patients who underwent cleaner thrombectomy (P = .048) or a subsequent 4- to 7-mm chest wall graft (P = .031) after the index fistula failed were more likely to have pHTN. Only one patient had the fistula ligated for worsening heart failure. Patients who experienced the onset of pHTN after DVA (DVA-pHTN; n = 34 [48.6%]) were compared with patients who had pHTN before DVA (pHTN-DVA; n = 36 [51.4%]). pHTN-DVA patients were less likely to have a history of a myocardial infarction (P = .029). There is no difference in the mean change in right ventricular systolic function after arteriovenous fistula creation in comparing patients with pHTN with patients without pHTN (P = .067) and comparing DVA-pHTN with pHTN-DVA (P = .77). DVA surgery does lead to pHTN, and patients should be monitored for the development of clinically significant symptoms that merit intervention. In general, it is safe to create DVA and to perform the necessary maintenance interventions regardless of the presence or severity of pHTN. Direct central venous outflow may pose a higher risk for severe pHTN warranting DVA ligation.