Abstract: SA-PO1114
Resolution of High-Output Heart Failure, Recurrent Ascites, and AKI in a Renal Allograft After Ligation of the Arteriovenous Graft
Session Information
- Transplant Trainee Case Reports
November 09, 2019 | Location: Exhibit Hall, Walter E. Washington Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Trainee Case Report
- 103 AKI: Mechanisms
Authors
- Padala, Sandeep A, Augusta University, Augusta, Georgia, United States
- Hinnant, George M., Augusta University, Augusta, Georgia, United States
- Kapoor, Rajan, Augusta University / Medical College of Georgia, Augusta, Georgia, United States
- Gani, Imran Yaseen, SELF, Augusta, Georgia, United States
Introduction
A good vascular acces is crucial for effective dialysis. Arteriovenous graft (AVG) is an arteriovenous fistula (AVF) with a prosthetic interposition between the artery and vein. The complications can include infection, lymphedema, aneurysmal dilations, stenosis, high output heart failure (HOHF), steal syndrome and thrombosis. Ligation of the AVG should be considered in patients presenting with unexplained HOHF. Herein, we present a case of HOHF, recurrent ascites, AKI and slow graft function following a kidney transplant that resolved only with ligation of the AV graft.
Case Description
A 48-year-old Caucasian female with past medical history significant for end Stage Renal Disease (ESRD) secondary to congenital anomalies of the kidneys. She was on hemodialysis (HD) via right thigh AVG. Following AVG placement, she experienced recurrent ascites (on and off) requiring multiple paracentesis. Extensive Gastrointestinal (GI) and cardiovascular (CVS) workup did not reveal any etiology and she was taken off the transplant list due to the ascites. Due to poor clearance through her AVG, she underwent right upper extremity AVF to continue dialysis. Eventually her ascites resolved without any intervention, following which she had a deceased donor kidney transplant (DDKT). It was complicated by volume overload and recurrent ascites resistant to diuretics and required multiple paracentesis. The creatinine did not come below 3.7 and was diagnosed with slow graft function. The sister donor kidney achieved a normal creatinine in two weeks after transplant. Echo was suggestive of normal EF, elevated left atrial pressures, severely dilated left atrium and moderate pulmonary hypertension ~ 57 mmHg. Serum Albumin Ascites Gradient (SAAG) was 1.5 g/dL and ascitic protein > 2.5 g/dL. A decision was made to ligate the old right femoral AVG and soon the Cr improved to 1.5 with complete resolution of ascites.
Discussion
Our case emphasizes the importance of hemodialysis access ligation to treat HOHF, a known complication of hemodialysis access. Our case is unique in that the patient is a kidney transplant patient who was taken off the transplant list due to unexplained ascites and who again developed recurrent ascites, slow graft function and AKI post-transplant that completely resolved with ligation of AVF.