There are pro and contra opinions regarding the keeping of the AV Fistula or not after KTX. What is your experience?
Arteriovenous fistula after renal transplantation: utility, futility or threat? Nephrology Dialysis Transplantation 2006 21(2):254-257; doi:10.1093/ndt/gfi276
AV fistula closure reduces left ventricular volume and mass in renal transplant patients. Whether fistula closure will reduce the associated high cardiac morbidity and mortality is unknown. There are clearly insufficient data yet to promote systematic closure of AV fistulas in kidney transplant patients with stable renal function, unless symptoms are present. The balance might favour closure in selected asymptomatic patients, with a large AV fistula, a dilated left ventricle,a low probability of graft loss and a high risk of cardiac events. Randomized large-scale prospective studies are clearly needed and, potentially, will better define the protective role of fistula closure.
Effect of closure of the arteriovenous fistula on left ventricular dimensions in renal transplant patients Nephrol Dial Transplant (2001) 16: 368-372
Closure of the arteriovenous fistula in stablerenal transplant patients results in a decrease in LVMi, dueto a reduction in LVEDD. The change in LVMi is significantlyrelated to the LVMi and LVEDD before fistula closing. In patients with a well-functioning allograft and persistent LV dilatation,closure of the AV fistula might be considered.
Arteriovenous fistula closure after renal transplantation: a prospective study with 24-hour ambulatory blood pressure monitoring. Transplantation. 2008 Feb 15;85(3):482-5.
Because the increase in diastolic blood pressure after arteriovenous fistula closure occurred regardless of the preoperative level of diastolic pressure, we suggest that blood pressure should be monitored after fistula closure, particularly when preoperative diastolic blood pressure is borderline or elevated.
Cardiac impact of the arteriovenous fistula after kidney transplantation: a case-controlled, match-paired study (Transplant International, Volume 21, Number 10, October 2008 , pp. 948-954(7))
In kidney transplant (KT) recipients, cardiac impact of the persistence of an asymptomatic arteriovenous fistula (AVF) for hemodialysis has not been fully elucidated.
The number of vascular access sites for hemodialysis is limited to about 8 (3 in each upper extremity and 1 in each lower extremity). Even the best kidney transplant grafts do not last forever. The conclusions by Manca et al from almost a decade ago are still valid: " we conclude that the definite indications for AVF closure in well functioning renal transplanted patients are heart failure, high flow fistula, VA complications and important aesthetic reasons. Routine AVF closure is not indicated until prospective and randomized studies can demonstrate the ability of this procedure to reduce the high incidence of cardiac morbidity and mortality that is present, even after renal transplantation." From "The management of hemodialysis arteriovenous fistulas in well functioning renal transplanted patients: many doubts, few certainties" in Journal of Vascular Access (Oct-Dec 2005) Vol 6 Number 4:182-186
Many AV-fistulas close spontaneously after renal transplantation by thrombosis. If an AVF is a major cardiac stress and graft function is good, it should be closed. Otherwise you should wait and see.
One of the most important complication fistula -related is the high-output heart failure.As clearly stated by Basile et Al. an access flow >or= 2.0 l/min has a high predictive power for high-output cardiac failure occurrence . (The relationship between the flow of arteriovenous fistula and cardiac output in haemodialysis patients - Nephrol Dial Transplant. 2008 Jan;23(1):282-7.).
In my opinion could be a good choice to measure AVF flow by ultrasound after renal transplantation and to send to surgical ligation without delay all the high flow vascular access as above described.
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Unless the av-fistula results in complications for the patient we leave it. The number of sites deminsh if you remove it. As mentioned nature quite often takes care of the problem by closing it
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There is no right or wrong in the indication for fistula closure. If cardiac problems related to the fistula occur or aneurysmatic fistulas with or without Inflammation develop, an individual indication for closure is given. Otherwise, many fistulas become thrombotic over time.
If you have a good graft function, no need to keep it which crates extra load for heart.
The experience we have is based purely on AV fistulas which utilize native vessels in predominantly younger patients. Although closure may have a definite effect on patterns of venous return, these patients remain largely asymptomatic and it is worthwhile having this "safety net" held in reserve in case problems develop later on in this group of patients.
Due to the hypercoagulability condition after surgery, often the AV fistula spntaneously closes. If not, in the case of cardiac disease should be closed, otherwise no need to by closed
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