To Close, Observe, or Reconstruct: The Third Way of Managing Dialysis Fistula Aneurysms in Kidney Transplant Recipients

Management of dialysis access in the post-transplantation patient

Arteriovenous fistula (AVF) is the preferred access for hemodialysis in patients with end-stage renal disease, and arteriovenous grafts are used when AVF creation is not feasible. Post renal transplantation, hemodialysis may be needed due to delayed graft function or transplantation failure. This review aimed to summarize current evidence on the impact of maintaining versus ligating AV access on renal function and cardiovascular outcomes post transplantation. A comprehensive review of literature was conducted, analyzing studies on the effects of AVF and AV graft maintenance or ligation on renal and cardiovascular outcomes in patients post transplantation. Evidence indicates that maintaining AVF post transplantation is associated with higher estimated glomerular filtration rate and better renal function retention, but poses risks for cardiovascular complications, such as left ventricular hypertrophy. Ligation of AVF is linked to improved cardiovascular outcomes, including reduced N-terminal pro-B-type natriuretic peptide levels, but may lead to a greater decline in estimated glomerular filtration rate. No significant difference in long-term renal allograft survival was observed between maintaining and ligating AV access. The decision to maintain or ligate AV access in patients post renal transplantation should be individualized, considering both renal function preservation and cardiovascular health. Although maintaining AVF may benefit renal function, it poses cardiovascular risks, whereas ligation can mitigate these risks without significantly affecting allograft survival.

Surgical Management, Prevention and Outcomes for Aneurysms of Arteriovenous Dialysis Fistulas: A Case Series Study and Review

The escalating population of individuals afflicted with end-stage renal disease necessitates the provision of secure and efficacious vascular access for hemodialysis, with arteriovenous fistulas representing a preferred option. Nonetheless, the creation of dialysis fistulas may entail complications, including the occurrence of fistula aneurysms that may require surgical intervention. This study included eight patients with large aneurysms of dialysis fistulas and aimed to evaluate the safety and effectiveness of classic, endovascular, or hybrid methods for fistula reconstruction or ligation, depending on the indications. Vascular interventions were performed on patients on chronic hemodialysis and on those in whom hemodialysis was discontinued due to the proper functioning of the transplanted kidney. Performed procedures were considered safe and effective. The reconstructed fistulas provided the patients with patent vascular access, allowing for continued hemodialysis. No re-aneurysmal dilatation of the reconstructed or ligated fistulas was observed. Regular monitoring of dialysis fistulas is crucial to detect complications in time. Guidelines should be established to specify the dimensions at which fistula aneurysm should be excised and whether to remove asymptomatic aneurysms at all. For patients who have undergone kidney transplantation, outlines should indicate when the fistula should be preserved and when it should be ligated.

Lung Congestion Severity in Kidney Transplant Recipients Is Not Affected by Arteriovenous Fistula Function

Lung ultrasound is a bedside technique for the assessment of pulmonary congestion. The study aims to assess the severity of lung congestion in kidney transplant recipients (KTR) in relation to arteriovenous fistula (AVF) patency. One hundred fifty-seven patients at least 12 months after kidney transplantation were recruited to participate in a cross-sectional study. Apart from routine visits, lung ultrasound at 28 typical points was performed. The patients were assigned to either AVF+ or AVF− groups. The mean number of lung ultrasound B-lines (USBLs) was 5.14 ± 4.96 with no differences between groups: 5.5 ± 5.0 in AVF+ and 4.8 ± 4.9 in AVF−, p = 0.35. The number and proportion of patients with no congestion (0–5 USBLs), mild congestion (6–15 USBLs), and moderate congestion (16–30 USBLs) were as follows: 101 (64.7%), 49 (31.4%), and 6 (3.8%), respectively. In multivariate analysis, only symptoms (OR 5.90; CI 2.43,14.3; p = 0.0001), body mass index (BMI) (OR 1.09; CI 1.03,1.17; p = 0.0046), and serum cholesterol level (OR 0.994; CI 0.998,1.000; p = 0.0452) contributed significantly to the severity of lung congestion. Lung ultrasound is a valuable tool for the evaluation of KTR. Functioning AVF in KTR is not the major factor affecting the severity of pulmonary congestion.