“To Close or not to Close?” - Fistula Ligation and Cardiac Function in Kidney Allograft Recipients

Abstract

Introduction: Arteriovenous fistulae are preferred access for haemodialysis for treatment of end-stage renal disease (ESRD). Subsequent hemodynamic changes in systemic circulation may sometimes cause cardiac failure. There are some general conclusions from a few studies that high - flow fistulae, causing symptomatic heart failure, should undergo either reconstruction or ligation. However, there is still a controversy whether to ligate a normal functioning fistula after successful kidney transplantation. The aim of our study was to assess an impact of the fistula on heart function in patients with ESRD after kidney transplantation. Methods: Eighteen patients after kidney transplantation were recruited. Inclusion criteria were serum creatinine level < 200 mmol/l, hemoglobin level > 9 g/dl, non-diabetics, no history of a cardiovascular events within the 12 months before the initiation of the study, no symptoms of heart failure and stable control of blood pressure. Five patients underwent fistula ligation for esthetic reasons, four fistulae thrombosed in a perioperative period, shortly after transplantation. Group of 9 patients with patent fistula was adjusted according to age and sex. Heart function was assessed by physical examination (shortness of breath, fatigue and reduced exercise tolerance) and echocardiography (left ventricular hypertrophy, LV dilatation, systolic and diastolic dysfunction, pulmonary hypertension, valvular disease). Results: Study group consisted of 6 female and 3 male, age 32 - 64, with 6 forearm and 3 amr fistulae, Hb level ranged from 11.2 - 15.5 g/ dl. Control group consisted of 6 female, 3 male, age 38 - 66, with 5 forearm fistulae, Hb level ranged from 11.8 - 14.9 g/dl. Control echo was performed within 3 months after fistula ligation, and did not reveal any significant differences comparing to the initial examination. Conclusions: Fistula ligation, performed in a stable kidney allograft recipient does not seem to have beneficial outcome on cardiac function. Decision making should be very careful and balanced, since creation of a new access may be extremely difficult and not always possible.