Impact of Arteriovenous Fistula Closure on Cardiac and Renal Function in Renal Transplantation Patients

doi:10.21203/rs.3.rs-4616919/v1

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Impact of Arteriovenous Fistula Closure on Cardiac and Renal Function in Renal Transplantation Patients

https://doi.org/10.21203/rs.3.rs-4616919/v1

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Background: Due to the rapid expansion of numerous national and international transplantation programs, hemodialysis (HD) and peritoneal dialysis (PD) have become vital interim treatments for patients awaiting kidney transplantation.

Aim and objectives: Assessment of the effects of AV fistula ligation on cardiac and renal function in post-kidney transplant patients.

Patients and methods: A total of 98 kidney transplant recipients were divided into two groups: patients with closed arteriovenous fistula (AVF) (46) and patients with patent AVF (52). The study was done in outpatient nephrology clinics at Minia University and Minia Governorate Insurance Hospital.

Results: There was significant variation in terms of major and minor right-side diameter, IVC, PASP, MPAP, left ventricular hypertrophy, and left ventricular DD. In addition, there was a significant difference between the two groups regarding serum creatinine, urea, and eGFR.

Conclusion: AVF closure in renal-transplant patients can protect against severe cardiac changes and deterioration of eGFR.

Arteriovenous fistula

blood pressure

renal transplantation

Pulmonary artery systolic pressure

Chronic kidney disease (CKD) is often a progressive disease, even with preventive and therapeutic interventions. If the disease progresses to end-stage renal disease (ESRD), renal replacement therapy options such as HD, PD, or renal transplantation may be necessary. Among these options, renal transplantation is considered the most optimal for both survival and quality of life (1). Patients with progressive renal disease who are awaiting transplantation can depend on hemodialysis (HD) as a long-term solution for vascular access. Among the available options, AVF has the lowest rates of complications and the highest rates of patency (2). Although AVF continues to function following a successful kidney transplant, it is often rendered ineffective for numerous patients. In addition, AVFs adversely affect cardiac functions by causing an increase in preload and cardiac output (COP) despite their association with lower mortality (3). Numerous studies have demonstrated a positive correlation between AVF flow, cardiac output, and the severity of diastolic dysfunction, which is a problem for patients with pre-existing heart diseases. Furthermore, AVFs have been associated with more severe cardiac remodeling and higher flow compared to those further away. However, some authors have noted that the ligation of active AVF has been associated with a more rapid decline in kidney function. ^[3,4] There is a lack of guidelines or generally established strategies for the management of AVF (preservation or closure) after kidney transplantation (4). Therefore, this research aimed to evaluate the effect of AV fistula ligation on cardiac and renal function in individuals who underwent kidney transplantation.

This study was approved by the local Ethics Committee, Faculty of Medicine, Minia University REC, clinical trial no (121:01-2022). This work was carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for studies involving humans.

A total of 98 renal transplant patients were divided into two groups: 52 patients (patent AVF group) with AV fistula flow rates ranging from 600-1500ml/min (Group I) and 46 patients (closed AVF group) with AV fistula flow rates < 600ml/min (Group II). Our patient was selected from the outpatient nephrology clinic at Minia University and Minia Governorate Insurance Hospital within the first year after transplantation. The study included patients aged ≥ 18 years, received a kidney transplant from a living related or unrelated donor, had a negative PRA (panel reactive antibody) test, a mismatch score of (0/6 − 3/6), no signs of cellular or antibody rejection, recently with intact cardiac function on the protocol of (CNI, MMF, prednisone) therapy, and agreed to participate in the study. The study excluded patients with infection, cognitive impairment, rapid decline in kidney function, Mismatch (4/6–6/6), cadaveric kidney transplant, NYHA class IV, cardiac patients, high flow AVF > 2000ml/min leading to heart failure, dyslipidemia, M TOR group protocol, or ureteric obstruction of transplanted kidney. In addition, patients underwent complete clinical examination, including vital signs [blood pressure (mmHg) and pulse (beat/min)], general examination, weight (kg), and height (meter). Serum creatinine, serum urea, RBS (ml/dl), eGFR calculated using the MDRD Equation (GFR (mL/min/1.73 m2) = 175 × (Scr)-1.154 × (Age)-0.203 × (0.742 if female) × (1.212 if African American), and echocardiography were performed to assess the following parameters: Rt side diameter major, Rt side diameter minor normal, and IVC diameter. Pulmonary artery systolic pressure (PASP) and mean pulmonary artery pressure (MPAP) were also assessed.

Statistical analysis of the data:

Data was analyzed using IBM SPSS software package version 25. Qualitative data were expressed as numbers and percentages, whereas quantitative data were expressed using range (minimum & maximum), mean, SD, median, and interquartile range (IQR). The Kolmogorov–Smirnov test was utilized to validate the normality of the distribution.

In the closed AVF group, the mean age was 37.07 ± 6.77 years, with 60.9% of cases being males, and the mean weight was 71.43 ± 8.26 kg. In contrast, the mean age in the patent AVF group was 39.37 ± 6.75 years, with 57.7% of cases being males, and the mean weight was 73.44 ± 9.72 kg. There was no statistically significant difference in terms of age, sex, and weight between the two groups (p > 0.05). The severity of dyspnea and lower limb edema was significantly higher in the patent AVF group (p < 0.001), as shown in Table (1). The incidence of complications was significantly higher in the patent AVF group (p < 0.001). In the closed AVF group, complications were reported in three (6.5%) cases [one case had an aneurysm, and two cases had thrombosis]. In the patent AVF group, complications were reported in 20 cases, accounting for 38.5% of the total [4 cases had aneurysm, 6 cases had an infection, 4 cases reported rupture, and 6 cases had thrombosis], as shown in Figure (1). The echocardiographic findings at the beginning of the study revealed a statistically significant difference between the closed AVF and patent AVF groups in terms of major right-side diameter, IVC (p = 0.004), MPAP, left ventricular hypertrophy and left ventricular DD (p < 0.001). There was a significant increase in the major right-side diameter, IVC, left ventricular hypertrophy and left ventricular DD in the AVF Group. However, the closed AVF group exhibited a substantial increase in mean MPAP in comparison to the patent AVF group, as depicted in Table (2). When comparing the echocardiographic findings before and after 6 months in the patent AVF group, there was a significant increase in the diameter of both major and minor right sides, as well as in IVC, PASP, and MPAP (p < 0.001) after six months compared to their initial values. These results are presented in Table (3). In the patent AVF group, there was a substantial rise in serum creatinine and urea levels and a decrease in eGFR, as indicated in Table 4 (p < 0.001). The eGFR exhibited a notable decrease after six months in the patent AVF group compared to its initial value, as depicted in Figure (2).

AVF closure has been the focus of numerous research studies as most ESRD patients prefer to ensure readiness for any urgent HD session following renal transplantation. There is a conflict regarding the beneficial effect of AVF closure in renal-transplanted patients (5). Our study included 98 renal transplant recipients. Out of the total, 46 patients presented with fistulas that spontaneously stopped or closed, and all of them were on HD before transplantation. There was no statistically significant difference in age, sex, and weight between the two groups (p > 0.05). This can be attributed to the fact that the patients were selected from a specific age group. A statistically significant difference was observed in the presence of dyspnea and lower limb edema between the closed and patent AVF groups (p < 0.001). The severity of dyspnea and lower limb edema was significantly higher in the patent AVF group. The study found that 23.4% of the patients had AVF complications. Furthermore, thrombosis was the most common complication, occurring in (8.16%) of cases, which is consistent with Trampuž et al. They reported a 12.5% incidence of AVF complications in renal transplant patients, with thrombosis being the most frequently reported complication (6). Patard et al. also reported that spontaneous thrombosis of AVF occurred in 31% of patients after long-term follow-up (7). The incidence of AVF-related complications in our study was lower than that reported by Vajdič et al. (4), with a rate of 29% among patients. The most common complication was thrombosis, occurring in 76% of AVF failure cases. Furthermore, a notable and statistically significant difference was observed between the closed and patent AVF groups in terms of complications (p < 0.001), with the patent AVF group experiencing significantly higher rates of complications. Based on the echocardiographic findings at the beginning of the study, we observed significant statistical differences in major right-side diameter, IVC, left ventricular hypertrophy, and left ventricular DD. These parameters showed a significant increase in the patent AVF group compared to the closed AVF group (p = 0.004, 0.004, 0.001, and 0.001, respectively). Conversely, the closed AVF group showed a significant increase in MPAP (p = 0.001). This result can be elucidated by the increased preload on the heart caused by AVF, leading to subsequent increases in all right-side parameters and high cardiac output failure. Additionally, the blood pressure is higher in the AVF group compared to the closed AVF group, resulting in increased DD and LVH in the patent AVF group compared to the closed AVF group.

Our results are in agreement with Cridlig et al. (8), who examined the echocardiographic results of patients with and without AVF. They observed that the IVC, PASP, left ventricular hypertrophy, and left ventricular diastolic dysfunction (DD) were significantly lower in the group with closed AVF. However, both groups demonstrated no significant differences in pulmonary artery pressure (PAP). Contrary to our findings, Gorgulu et al found no differences in any of the echocardiographic findings studied between patent and closed AVF groups (9).

When comparing the echocardiographic findings before and after 6 months in the group with patent AVF, there was a statistically significant increase in the major and minor diameters of the right side, IVC, PASP, and MPAP (p < 0.001) after six months when compared to their baseline values.

Regarding renal function tests, we observed a significant increase in serum creatinine and urea, along with a decline in eGFR in the patent AVF group compared to the closed AVF group. These results can be attributed to the higher blood pressure in patients with patent AVF than in the closed AVF group. This is because elevated blood pressure can lead to increased arterial atherosclerosis in the transplanted kidney. Furthermore, the closure of AVF can improve cardiac parameters such as LV mass, cardiac output, and renal blood supply, thereby enhancing renal oxygenation of the transplanted kidney. It is noteworthy that eGFR showed significant decline after six months compared to its baseline value in the open AVF group.

In contrast, Weekers et al (5) reported a significant decline after AVF closure, which is inconsistent with our results. Similarly, Grégoire et al. (10) reported that serum creatinine and eGFR showed no significant change after AVF closure.

Our findings revealed a significant difference between the two examined groups concerning major right-side diameter, IVC, PASP, MPAP, left ventricular hypertrophy, and left ventricular DD. In addition, there was a statistically significant difference between the two groups under study in terms of serum creatinine, serum urea, and eGFR.

RECOMMENDATIONS:

The ligation of patent AVF is advisable in renal transplantation patients to prevent severe cardiac and degenerative alterations on the transplanted kidney caused by the AVF.

Authors' contributions

"HM had the point of research of this scientific work and helped in writing, MA performed echocardiography and collected the patient's data, MS had rule in statical analysis and final revision, MR had a important rule in patients follow up, and BF was the major contributor in writing the manuscript and helped in statical analysis. All authors read and approved the final manuscript."

All Authors declare that they have no conflict of interest.

Informed consent was obtained from the patients and or their guardians.

This study was approved by the local Ethics Committee, Faculty of Medicine, Minia University REC, clinical trial no (121:01-2022). This work was carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for studies involving humans.

Funding: none

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Tables 1 to 4 are available in the Supplementary Files section

No competing interests reported.

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Impact of Arteriovenous Fistula Closure on Cardiac and Renal Function in Renal Transplantation Patients

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Abstract

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INTRODUCTION

Patients and methods

Statistical analysis of the data:

RESULTS

DISCUSSION

CONCLUSION

Declarations

References

Tables

Additional Declarations

Supplementary Files

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