AVF post transplantation: to keep or not to keep ? Dominique - - PowerPoint PPT Presentation

AVF post transplantation: to keep or not to keep ?

Dominique BERTRAND – Rouen University Hospital Friday, September 14th 2018

@dommibertrand

Fistula First !!!

Ravani, JASN, 2013

Haemodynamic impacts of AVF

AVF AVF Drop in peripheral vascular resistance Drop in peripheral vascular resistance Increase in venous return and preload Increase in venous return and preload Increase in pulmonary flow +/- pressure Increase in pulmonary flow +/- pressure Stroke volume Heart rate Cardiac output Impact on: Left and right ventricules LA Pulmonary Hypertension Volume overload controlled with ultrafiltration !!! 1 2 3 4

Haemodynamic impacts of AVF

AVF AVF Drop in peripheral vascular resistance Drop in peripheral vascular resistance Increase in venous return and preload Increase in venous return and preload Increase in pulmonary flow +/- pressure Increase in pulmonary flow +/- pressure Volume overload controlled with ultrafiltration !!! 1 2 3 4 AVF flow > 2 L/min AVF flow/CO > 20% Basile, NDT, 2008

AVF and steal syndrome

To keep or not to keep????

Expert guidelines No sytematic ligation

• f AVF after successfull KT

A close monitoring and 2 options!

We need to preserve AVF after KT!!! We have to close AVF after KT!!! MONITORING AVF +++

We need to preserve a functioning AVF after KT !

Benefit from AVF after KT

Blood sampling +++ Blood sampling +++ Plasmapheresis for ABMR / recurrent nephropathy Plasmapheresis for ABMR / recurrent nephropathy Iterative infusions Iterative infusions

About kidney graft survival and the use of AVF for dialysis one day…

Disease recurrence Acute rejection Chronic rejection Bk virus CNI toxicity Disease recurrence Acute rejection Chronic rejection Bk virus CNI toxicity

survival Death censored graft survival (1993-2009) Living donor Donor after brain death Time (months)

The fate of the fistula following renal transplantation

Manca, JVA, 2005

542 KT recipients – long term followup (10 years) for AVF patency

THROMBOSE FAV APRES GREFFE 34%

Manca, JVA, 2005

CREATION NOUVEL FAV SUR THROMBOSE 35%

The fate of the fistula following renal transplantation

542 KT recipients – long term followup (10 years) for AVF patency

Trampuz, Therapeutic apheresis and dialysis, 2013 01/2006 – 04/2012: 592 KT 74 KT recipients (12,5%) with AVF complication after KT 51 forearm AVF 9 upper arm AVF 14 elbow AVF Painful thrombosis with or without thrombophlebitis: 32 patients (43,2%) Growing aneurysms: 20 patients (27%) Venous hypertension with arm edema: 6 patients (8,1%) Distal ischemia (steal syndrome): 6 patients (8,1%) High-flow AVF with cardiac symptoms: 6 patients (8,1%) Injury of the AVF vein with acute bleeding: 1 patient (1,3%) Cosmetic appearance: 3 patients (4%) 51 surgical interventions were performed in 49 patients: 50% = ligation Painful thrombosis with or without thrombophlebitis: 32 patients (43,2%) Growing aneurysms: 20 patients (27%) Venous hypertension with arm edema: 6 patients (8,1%) Distal ischemia (steal syndrome): 6 patients (8,1%) High-flow AVF with cardiac symptoms: 6 patients (8,1%) Injury of the AVF vein with acute bleeding: 1 patient (1,3%) Cosmetic appearance: 3 patients (4%) 51 surgical interventions were performed in 49 patients: 50% = ligation

A close monitoring is warranted!

We have to close AVF after KT!

AVF, Heart and Kidney transplant

Volume overload controlled by the kidney graft !!!

AVF, Heart and Kidney transplant

Volume overload controlled by the kidney graft !!!

FLUID OVERLOAD +++

De Lima, Cardiology, 1999

1/ Cardiac impact of AVF

61 KT recipients with stable graft function (creatinine > 2,0 mg /dL) 39 patients with functional AVF and 22 with closed AVF (esthetic reason within 2 months post transplant) Echocardiography performed 14 months after KT 61 KT recipients with stable graft function (creatinine > 2,0 mg /dL) 39 patients with functional AVF and 22 with closed AVF (esthetic reason within 2 months post transplant) Echocardiography performed 14 months after KT Modest LV dilation in stable renal transplant recipients , do not support routine closure

17 KT recipients Symptomatic AVF AVF flow : 1371 ± 727 mL/min Echocardiography before, 1 et 21 months after ligation 17 KT recipients Symptomatic AVF AVF flow : 1371 ± 727 mL/min Echocardiography before, 1 et 21 months after ligation Unger, AJT, 2004

LV mass index decreased even with low AVF flow (800mL/min). Increase of diastolic arterial blood pressure and concentric remodeling LV mass index decreased even with low AVF flow (800mL/min). Increase of diastolic arterial blood pressure and concentric remodeling

Unger, AJT, 2004

Decrease in LV end-diastolic diameter

Meier et al, Transpl Int, 2010 4 kidney transplant recipients Delayed graft function after KT Graft biopsy: ATN Ehocardiography: moderately to severely dilated right ventricle Elevated PAP Left ventricular function not impaired 4 kidney transplant recipients Delayed graft function after KT Graft biopsy: ATN Ehocardiography: moderately to severely dilated right ventricle Elevated PAP Left ventricular function not impaired

2/ Renal impact 2/ Renal impact

Meier et al, Transpl Int, 2010

Dramatic improvement of renal function Cardio renal syndrome with venous congestion Dramatic improvement of renal function Cardio renal syndrome with venous congestion

(mL)

(μmol/L) (mL/min)

Weekers, NDT, 2016 AVF ligation after KT in 114 patients 653 ± 441 days post-KTx thrombosis : ligation ratio of 19:95 Acceleration of eGFR decline is observed

• ver the 12 months following the closure
• f AVF

Indication of ligation? AVF flow? Confounding factors??? Selection bias +++

When? 1 year post KT?

Hariharan , Kidney International, 2002 S Creatinine 1 y post KT < 150 μmol/L Delta M6 – 1 y < 30 μmol/L Before ligation, always consider the feasibility of a new vascular access

To keep or not to keep????

Kidney transplantation AVF blood flow and cardiac output monitoring CONSIDER AVF LIGATION Or FLOW REDUCTION Feasibility of a new vascular access? AVF blood flow Echocardiography and CO 1 y post KT

AVF monitoring +++

Steal syndrome Growing aneurysms Infection High CO

• u Heart insufficiency

Pulmonary hypertension Cardio renal syndrome Symptomatic AVF Symptomatic AVF

Asymptomatic Asymptomatic AVF blood flow Echocardiography and CO 1 y post KT Normal echocardiography Normal echocardiography AVF blood flow < 2 L/min AVF blood flow /CO < 20% AVF blood flow < 2 L/min AVF blood flow /CO < 20% Stable renal function Stable renal function Young patient, no comorbidities Young patient, no comorbidities Monitoring +++: clinical and echography (AVF and Heart) Monitoring +++: clinical and echography (AVF and Heart)

AVF blood flow Echocardiography and CO 1 y post KT Pathological echocardiography Pathological echocardiography AVF blood flow > 2 L/min AVF blood flow /CO > 20% AVF blood flow > 2 L/min AVF blood flow /CO > 20% Graft dysfunction related to cardio renal syndrome (normal biopsy) Graft dysfunction related to cardio renal syndrome (normal biopsy) Older recipients with comorbidities +++ Older recipients with comorbidities +++ Consider and discuss AVF LIGATION Or FLOW REDUCTION Consider and discuss AVF LIGATION Or FLOW REDUCTION Asymptomatic Asymptomatic

Please don’t forget the AVF after KT!

Cardiac impact! Renal impact ??? AVF complications!!! Cardiac impact! Renal impact ??? AVF complications!!! Best vascular access for hemodialysis AVF monitoring is NECESSARY after kidney transplantation!!! AVF monitoring is NECESSARY after kidney transplantation!!! Ligation! Preserve! Monitoring…

We need a RCT!