Effects of Arteriovenous Fistula Ligation on Cardiac Structure and Function in Kidney Transplant Recipients.
BACKGROUND
Cardiovascular morbidity and mortality remain high in recipients of a kidney transplant. The persistence of a patent arteriovenous fistula (AVF) after transplantation may contribute to ongoing maladaptive cardiovascular remodeling. The ability to reverse this maladaptive remodeling by ligation of this AVF is unknown. We conducted the first randomized controlled trial to evaluate the effect of AVF ligation on cardiac structure and function in stable kidney transplant recipients.


METHODS
In this randomized controlled trial, kidney transplant recipients (>12 months after transplantation with stable graft function) were randomized to AVF ligation or no intervention. All participants underwent cardiac magnetic resonance imaging at baseline and at 6 months. The primary outcome was the change in left ventricular (LV) mass. Secondary outcomes included changes in LV volumes, left and right atrial areas, LV ejection fraction, NT-proBNP (N-terminal pro-B-type natriuretic peptide) levels, cardiac output/index, brachial flows (ipsilateral to AVF), and pulmonary artery velocity.


RESULTS
A total of 93 patients were screened, of whom 64 met the inclusion criteria and were randomized to the AVF ligation (n=33) or control (n=31) group. Fifty-four participants completed the study: 27 in the AVF ligation group and 27 in the control group. On the second cardiac magnetic resonance scan, a mean decrease of 22.1 g (95% CI, 15.0-29.1) was observed in LV mass in the AVF ligation group compared with a small increase of 1.2 g (95% CI, -4.8 to 7.2) in the control group ( P<0.001). Significant decreases in LV end-diastolic volumes, LV end-systolic volumes, cardiac output, cardiac index, atrial volumes, and NT-proBNP were also seen in the AVF closure group ( P<0.01). No significant changes were observed in LV ejection fraction ( P=0.93) and pulmonary artery velocity ( P=0.07). No significant complications were noted after AVF ligation. No changes in estimated glomerular filtration rate or systolic and diastolic blood pressures were observed between cardiac magnetic resonance scans.


CONCLUSIONS
Elective ligation of patent AVF in adults with stable kidney transplant function resulted in clinically significant reduction of LV myocardial mass.


CLINICAL TRIAL REGISTRATION
Australian and New Zealand Clinical Trials Registry URL: https://www.anzctr.org.au . Unique Identifier: ACTRN12613001302741.
['Rao|Nitesh N|NN|', 'Stokes|Michael B|MB|', 'Rajwani|Adil|A|', 'Ullah|Shahid|S|', 'Williams|Kerry|K|', 'King|David|D|', 'Macaulay|Ewan|E|', 'Russell|Christine H|CH|', 'Olakkengil|Santosh|S|', 'Carroll|Robert P|RP|', 'Faull|Randall J|RJ|', 'Teo|Karen S L|KSL|', 'McDonald|Stephen P|SP|', 'Worthley|Matthew I|MI|', 'Coates|P Toby|PT|']
D000368:Aged D001166:Arteriovenous Shunt, Surgical D015415:Biomarkers D005260:Female D005919:Glomerular Filtration Rate D006439:Hemodynamics D006801:Humans D017379:Hypertrophy, Left Ventricular D007676:Kidney Failure, Chronic D016030:Kidney Transplantation D008026:Ligation D008279:Magnetic Resonance Imaging D008297:Male D008875:Middle Aged D020097:Natriuretic Peptide, Brain D010446:Peptide Fragments D011446:Prospective Studies D020127:Recovery of Function D006435:Renal Dialysis D013021:South Australia D013318:Stroke Volume D013997:Time Factors D016896:Treatment Outcome D016277:Ventricular Function, Left D020257:Ventricular Remodeling
arteriovenous fistula kidney transplantation magnetic resonance imaging heart ventricles