Resolution of Class III Heart failure in Renal Transplant Patient After Revision of High Flow Arterio-Venous Fistula
Priyam K. Vyas, MD, Matthias Ojo, Mohammed M. Chaudry, MD.
Christiana Care, Wilmington, DE, USA.
Objective:
Congestive heart failure is a common cause of morbidity and mortality in patients with end-stage kidney disease on hemodialysis via non catheter based access. The complex relationship between heart failure and the presence of a high debit AVF in this patient population has yet to be clearly defined. Consequently, management guidelines for patients with heart failure who also have chronic high flow AVFs remain elusive. Herein, we present a case report of a patient with high flow AVF who developed symptomatic Class III heart failure and failing transplanted kidney which were successfully managed with ligation of the brachiocephalic AVF and creation of a radiocephalic AVF.
Methods:
60 year old female with history of right brachiocephalic AVF presented with symptoms of class III congestive heart failure and worsening function of transplant kidney despite maximal medical management. Fistula duplex demonstrated fistula flow volumes of more than 5L/min. In anticipation of needing HD in the near future, the patient underwent de novo creation of a right radiocephalic AVF with spliced interposition vein graft excised from her brachiocephalic AVF, which in turn was ligated.
Results:
Patient's orthopnea symptoms resolved and her transplant kidney function improved with 2 liters of urine output during her 23 hours admission. She lost 20 pounds with resolution of her edema and dyspnea symptoms over 3 weeks. Patient sustained a 90% reduction in her fistula flow volumes on duplex after surgery, measuring a fistula flow volume of just under 500 mL/min. One month after surgery, patient was off disability, returned to work and resumed her activities for daily living without limitation.
Conclusion:
Fistula flow volumes can be difficult to assess and nearly impossible to manage especially in cases presenting with congestive heart failure. Periodic surveillance fistula duplex with flow volume measurements in conjunction with good history and physical can be used to monitor chronic arteriovenous fistulas to identify early signs of failure and over maturation. Class III heart failure and failing kidney transplant in the setting of an overflow AVF were successfully treated with ligation of overflow brachiocephalic AVF and creation of a radiocephalic AVF. Flow-volume targeted management of this patient's AVF allowed her to return to work, independently perform her activities for daily living and preserved the function of her transplanted kidney.
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