Abstract: PUB223
When Access Becomes Excess: High-Flow Arteriovenous Fistula Causing Cardiac Dysfunction After Kidney Transplantation
Session Information
Category: Transplantation
- 2002 Transplantation: Clinical
Authors
- Agarwal, Krishna A., Baystate Medical Center, Springfield, Massachusetts, United States
- Maturostrakul, Boonyanuth N., Baystate Medical Center, Springfield, Massachusetts, United States
- Barbash, Daniel, Baystate Medical Center, Springfield, Massachusetts, United States
- McPartland, Kenneth J., Baystate Medical Center, Springfield, Massachusetts, United States
Group or Team Name
- Baystate
Introduction
There is no consensus on routine ligation versus preservation of arteriovenous (AV) access after successful kidney transplantation, and current international guidelines do not address this issue. Traditionally, AV access is preserved as a contingency for potential graft failure requiring dialysis. However, maintaining a functional AV fistula carries risks, including aneurysm, steal syndrome, and thrombosis (up to 29%). High-flow AV fistulas, seen in ~22% of post-transplant patients, may contribute to pulmonary hypertension and high-output heart failure. We report two cases of symptomatic high-flow AV fistulas in kidney transplant recipients with clinical improvement following intervention.
Case Description
A 72-year-old woman with ESKD due to hypertension underwent deceased donor kidney transplantation after hemodialysis via a left arm AV fistula. Three months post-transplant, she developed volume overload with weight gain and edema. Echocardiography showed severe tricuspid regurgitation, right ventricular dilation, and preserved LVEF (60–65%). Duplex ultrasound revealed AVF flow of 4.7 L/min. Following AVF ligation, she experienced a 20-lb weight loss, symptomatic improvement, and improved right ventricular size on repeat echocardiography.
A 68-year-old man with ESKD from IgA nephropathy underwent deceased donor transplantation. Eight months later, he presented with edema, weight gain, and ipsilateral hand numbness. AVF flow measured 8.7 L/min. Echocardiography demonstrated reduced LVEF (35–40%), LA/LV dilation, and elevated CVP (15 mmHg). After narrowing the AVF, his symptoms improved. Follow-up showed AVF flow of 1.8 L/min, LVEF improved to 51% with normalization of filling pressures.
Discussion
In the absence of evidence-based guidance, periodic assessment of AV access and cardiovascular status in transplant recipients is essential. Unexplained volume overload in patients with unused AV access should prompt evaluation for high flow using Doppler ultrasound; echocardiography is warranted when flow exceeds 1.5 L/min. Management strategies, including ligation or flow reduction, should be individualized based on patient factors and graft function. These cases highlight high-flow AV fistula as an important, potentially reversible cause of hemodynamic compromise after kidney transplantation. Further studies are needed to guide post-transplant AV access management.