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Cardiac Effects of AVF Ligation in Kidney Transplant Recipients
Study Questions:
What is the effect of arteriovenous fistula (AVF) ligation on cardiac structure and function in stable kidney transplant recipients?
Methods:
The investigators randomized kidney transplant recipients (>12 months post-transplant with stable graft function) to AVF ligation or no intervention in a randomized controlled trial. All participants underwent cardiac magnetic resonance (CMR) imaging at baseline and at six months. The primary outcome was the change in left ventricular (LV) mass. Secondary outcomes included changes in LV volumes, left and right atrial areas, LV ejection fraction, N-terminal pro–B-type natriuretic peptide (NT-proBNP) levels, cardiac output/index, brachial flows (ipsilateral to AVF) and pulmonary artery velocity.
Results:
A total of 93 patients were screened, of whom 64 met the inclusion criteria and were randomized to AVF ligation (n = 33) or control (n = 31) groups. A total of 54 participants completed the study; 27 in the AVF ligation group and 27 in the control group. On the second CMR scan, a mean decrease of 22.1 g (95% confidence interval, 15.0-29.1) was observed in LV mass in the AVF ligation group compared to a small rise of 1.2 g (95% CI, -4.8 to 7.2) in the control group (p < 0.001). Significant decreases in LV end-diastolic volumes, LV end-systolic volumes, cardiac output, cardiac index, atrial volumes, and NT-proBNP were also seen in the AVF closure group (p < 0.01). No significant changes were observed in LV ejection fraction (p = 0.93) and pulmonary artery velocity (p = 0.07). No significant complications were noted after AVF ligation. No changes in estimated glomerular filtration rate or systolic and diastolic blood pressures were observed between CMR scans.
Conclusions:
The authors concluded that elective ligation of patent AVF in adults with stable kidney transplant function resulted in clinically significant reduction of LV myocardial mass.
Perspective:
This randomized study reports that AVF ligation is associated with a significant reduction in CMR-derived LV myocardial mass. In addition, surgical AVF ligation was associated with improvement in cardiac chamber dimensions and a reduction in NT-proBNP levels. As these surrogate markers are strongly associated with cardiovascular outcomes, and the fact that a single outpatient procedure may have the potential to improve cardiovascular outcomes, there is a need for systematic investigation of the impact of routine AVF ligation in stable kidney transplant recipients on clinical outcomes.
Keywords: Arteriovenous Fistula, Blood Pressure, Cardiac Output, Glomerular Filtration Rate, Kidney Transplantation, Ligation, Magnetic Resonance Imaging, Metabolic Syndrome, Myocardial Ischemia, Natriuretic Peptide, Brain, Primary Prevention, Stroke Volume, Vascular Diseases
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