Removal of Non-infected Arteriovenous Fistulae Following Kidney Transplantation: A Safe and Beneficial Management Strategy for Unused Dialysis Access
Charles D. Fraser, III, MD, Joshua C. Grimm, MD, Russell N. Wesson, MD, Faris Azar, MD, Roberty J. Beaulieu, MD, Thomas Reifsnyder, MD.
The Johns Hopkins Hospital, Baltimore, MD, USA.
Renal transplant recipients often maintain their hemodialysis access in the event of future allograft failure. Patients may develop complications related to the unused dialysis access and it also limits vein availability for phlebotomy. Accordingly, a change in the current paradigm may be warranted. This study evaluates the indications for, and safety of, AVF removal in patients following successful renal transplantation.
All patients that underwent arteriovenous fistula (AVF) excision at a single institution from 2003-2016 were retrospectively reviewed. Within that cohort, we focused on those undergoing removal following renal transplantation. Baseline patient characteristics, including renal function at the time of removal, reason for ligation, and age of the AVF were examined. The primary outcome was the need for dialysis following AVF removal.
A total of 114 patients, of which 36 (31.6%) were recipients of renal transplants, underwent fistula removal during the study period. Within the transplant cohort, the median fistula age at the time of ligation was 1903 days. The main reasons for ligation included aneurysmal degeneration (n=9, 25%), pain (n=6, 16.7%), upper extremity steal syndrome (n=5, 13.9%), thrombosis (n=5, 13.9%), high cardiac output heart failure (n=4, 11%), and extremity swelling secondary to venous hypertension (n=2, 5.6%). Of these 36 patients, 30 (83.3%) had intact graft function. Average creatinine and eGFR at the time of ligation in these patients were 1.6 mg/dL and 52.3 mL/min/m2, respectively. Two of these 30 patients (6.7%), who had creatinines of 2.0 and 9.7 mg/dL, went on to require dialysis following ligation. These patients had nonfunctioning, aneurysmal fistulae and, therefore, securing new access would be required regardless. The remaining 28 have maintained normal renal function with improvement in their preoperative symptomatology. Two patients (5.6%) experienced postoperative complications - a hematoma requiring evacuation and a superficial wound infection requiring oral antibiotics.
Removal of symptomatic, unused AVFs can be performed safely in renal transplant recipients. Considering the morbidity associated with large AVFs (including high output cardiac failure), the current paradigm of maintaining asymptomatic hemodialysis access in patients with normally functioning renal transplants should be reconsidered.
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