Cardiac Remodeling Following Ligation of Arteriovenous Fistula in Stable Renal Transplant Recipients - AV Fistula Ligation Study

Contribution To Literature:

The AV Fistula Ligation study showed that ligation of the hemodialysis AV fistula in stable post–renal transplant patients improves LV remodeling and also reduces NT-proBNP at 6 months.

Description:

The goal of the trial was to assess the efficacy of arteriovenous (AV) fistula ligation on cardiovascular structure and function in stable kidney transplant recipients.


Study Design

Eligible patients were randomized in a 1:1 fashion to either AV fistula ligation (n = 32) or no ligation (n = 31). All participants underwent baseline cardiac magnetic resonance imaging (MRI). Patients assigned to the intervention group then underwent AV fistula ligation, which was performed as a same-day procedure under local anesthesia.

  • Total screened: 93
  • Total number of enrollees: 63
  • Duration of follow-up: 6 months
  • Mean patient age: 60 years
  • Percentage female: 35%

Inclusion criteria:

  • Adult (≥18 years) kidney transplant recipients
  • ≥12 months post–successful transplant
  • Stable kidney function
  • Persistent and functioning AV fistula; deemed at low risk of graft failure

Exclusion criteria:

  • Contraindication to MRI scan
  • Unstable or deteriorating post-transplant kidney anticipated to require re-institution of hemodialysis within 24 months

Other salient features/characteristics:

  • AV fistula creation to first scan: 125 months
  • Diabetes mellitus: 29%
  • Baseline left ventricular (LV) mass: 152 g
  • Baseline LV ejection fraction (LVEF): 68%

Principal Findings:

The primary outcome of LV mass reduction at 6 months, for AV fistula ligation vs. control, was -22.1 g vs. 1.2 g, p < 0.001.

  • Change in LV mass index: -11.8 vs. 1 g/m2, p < 0.001

Secondary outcomes:

  • Significant improvements noted in N-terminal pro–B-type natriuretic peptide (NT-proBNP), LV end-diastolic volume, LV end-systolic volume, and left and right atrial area in the AV fistula ligation arm, but not in the control arm
  • Cardiac output at 6 months: 6.8 vs. 4.8 L/min, p < 0.05

Interpretation:

The results of this trial indicate that ligation of the hemodialysis AV fistula in stable post–renal transplant patients improves LV remodeling and also reduces NT-proBNP at 6 months. These are very interesting findings given the large burden of cardiovascular mortality and morbidity in this patient population. Although this is a small, unblinded study, outcomes assessed were objective, and thus, this may be instructive for clinical care in these patients. 

References:

Presented by Dr. Michael B. Stokes at the American Heart Association Annual Scientific Sessions (AHA 2018), Chicago, IL, November 11, 2018.

Keywords: AHA Annual Scientific Sessions, AHA18, Arteriovenous Fistula, Atrial Fibrillation, Diastole, Fistula, Heart Failure, Kidney Transplantation, Magnetic Resonance Imaging, Natriuretic Peptide, Brain, Peptide Fragments, Primary Prevention, Renal Dialysis, Systole


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