Removal of Noninfected Arteriovenous Fistulae after Kidney Transplantation is a Safe and Beneficial Management Strategy for Unused Dialysis Access

Abstract

Renal transplant recipients often maintain their hemodialysis access in the event of future allograft failure. Patients may develop complications related to the unused dialysis access, and it also limits vein availability for phlebotomy. Accordingly, a change in the current paradigm may be warranted. This study evaluates the indications for, and safety of, arteriovenous fistula (AVF) removal in patients after successful renal transplantation. All patients who underwent AVF excision at a single institution from 2006 to 2016 were retrospectively reviewed. Within that cohort, those undergoing removal after renal transplantation were included for analysis. Baseline patient characteristics, including renal function at the time of removal, reason for excision, and age of the AVF, were examined. The primary outcome was the need for dialysis after AVF removal. A total of 114 patients, of which 36 (31.6%) were recipients of renal transplants, underwent fistula removal during the study period. Within the transplant cohort, the median fistula age at the time of excision was 1,903days (interquartile range: 556-3,394days). The most common indications for excision included aneurysmal degeneration (n=9, 25%), pain (n=6, 16.7%), upper extremity steal syndrome (n=5, 13.9%), thrombosis (n=5, 13.9%), high cardiac output heart failure (n=4, 11%), and extremity swelling secondary to venous hypertension (n=2, 5.6%). Most patients (30, 83.3%) had intact graft function. Average creatinine and eGFR at the time of excision in these patients were 1.6mg/dL and 52.3mL/min/m2, respectively. Two of these 30 patients (6.7%), who had creatinine values of 2.0 and 9.7mg/dL, went on to require dialysis following excision. The remaining 28 have maintained normal renal function with improvement in their preoperative symptomatology. Two patients (5.6%) experienced postoperative complications-a hematoma requiring evacuation and a superficial wound infection requiring oral antibiotics. Removal of symptomatic, unused AVFs can be performed safely in renal transplant recipients. Considering the morbidity associated with large AVFs (including high output cardiac failure), the current paradigm of maintaining asymptomatic hemodialysis access in patients with normally functioning renal transplants should be reconsidered.