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

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

AVF and steal syndrome

To keep or not to keep????

Expert guidelines No sytematic ligation of AVF after successfull KT

A close monitoring and 2 options! We need to preserve AVF We have to close AVF after KT!!! after KT!!! MONITORING AVF +++

We need to preserve a functioning AVF after KT !

Benefit from AVF after KT Plasmapheresis for Plasmapheresis for Blood sampling +++ Blood sampling +++ Iterative infusions Iterative infusions ABMR / recurrent ABMR / recurrent nephropathy nephropathy

About kidney graft survival and the use of AVF for dialysis one day… Death censored graft survival (1993-2009) survival Disease recurrence Disease recurrence Acute rejection Acute rejection Chronic rejection Chronic rejection Bk virus Bk virus Living donor CNI toxicity CNI toxicity Donor after brain death Time (months)

The fate of the fistula following renal transplantation 542 KT recipients – long term followup (10 years) for AVF patency THROMBOSE FAV APRES GREFFE 34% Manca, JVA, 2005

The fate of the fistula following renal transplantation 542 KT recipients – long term followup (10 years) for AVF patency CREATION NOUVEL FAV SUR THROMBOSE 35% Manca, JVA, 2005

A close monitoring is warranted! 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%) Painful thrombosis with or without thrombophlebitis: 32 patients (43,2%) Growing aneurysms: 20 patients (27%) Growing aneurysms: 20 patients (27%) Venous hypertension with arm edema: 6 patients (8,1%) Venous hypertension with arm edema: 6 patients (8,1%) Distal ischemia (steal syndrome): 6 patients (8,1%) Distal ischemia (steal syndrome): 6 patients (8,1%) High-flow AVF with cardiac symptoms: 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%) Injury of the AVF vein with acute bleeding: 1 patient (1,3%) Cosmetic appearance: 3 patients (4%) Cosmetic appearance: 3 patients (4%) 51 surgical interventions were performed in 49 patients: 50% = ligation 51 surgical interventions were performed in 49 patients: 50% = ligation Trampuz, Therapeutic apheresis and dialysis, 2013

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 +++

1/ Cardiac impact of AVF 61 KT recipients with stable graft function (creatinine > 2,0 mg /dL) 61 KT recipients with stable graft function (creatinine > 2,0 mg /dL) 39 patients with functional AVF and 22 with closed AVF 39 patients with functional AVF and 22 with closed AVF (esthetic reason within 2 months post transplant) (esthetic reason within 2 months post transplant) Echocardiography performed 14 months after KT Echocardiography performed 14 months after KT Modest LV dilation in stable renal transplant recipients , do not support routine closure De Lima, Cardiology, 1999

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

Decrease in LV end-diastolic diameter LV mass index decreased even with low AVF flow (800mL/min). LV mass index decreased even with low AVF flow (800mL/min). Increase of diastolic arterial blood pressure Increase of diastolic arterial blood pressure and concentric remodeling and concentric remodeling Unger, AJT, 2004

2/ Renal impact 2/ Renal impact 4 kidney transplant recipients 4 kidney transplant recipients Delayed graft function after KT Delayed graft function after KT Graft biopsy: ATN Graft biopsy: ATN Ehocardiography: moderately Ehocardiography: moderately to severely dilated right ventricle to severely dilated right ventricle Elevated PAP Elevated PAP Left ventricular function not impaired Left ventricular function not impaired Meier et al, Transpl Int, 2010

( μ mol/L) (mL/min) (mL) Dramatic improvement of renal function Dramatic improvement of renal function Cardio renal syndrome with venous congestion Cardio renal syndrome with venous congestion Meier et al, Transpl Int, 2010

AVF ligation after KT in 114 patients 653 ± 441 days post-KTx thrombosis : ligation ratio of 19:95 Acceleration of eGFR decline is observed over the 12 months following the closure of AVF Indication of ligation? AVF flow? Confounding factors??? Selection bias +++ Weekers, NDT, 2016

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

To keep or not to keep????

Kidney transplantation AVF blood flow and cardiac output monitoring AVF monitoring +++ Symptomatic AVF Symptomatic AVF Steal syndrome Feasibility of a Growing aneurysms new vascular access? Infection CONSIDER AVF LIGATION Or High CO FLOW REDUCTION ou Heart insufficiency Pulmonary hypertension Cardio renal syndrome AVF blood flow Echocardiography and CO 1 y post KT

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 < 2 L/min AVF blood flow /CO < 20% 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)

Asymptomatic Asymptomatic AVF blood flow Echocardiography and CO 1 y post KT Pathological echocardiography Pathological echocardiography AVF blood flow > 2 L/min AVF blood flow > 2 L/min AVF blood flow /CO > 20% AVF blood flow /CO > 20% Graft dysfunction related to cardio renal Graft dysfunction related to cardio renal syndrome (normal biopsy) 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

Please don’t forget the AVF after KT! Ligation! Preserve! Monitoring… Cardiac impact! Cardiac impact! Best vascular access Renal impact ??? Renal impact ??? for hemodialysis AVF complications!!! AVF complications!!! We need a RCT! AVF monitoring is NECESSARY after kidney transplantation!!! AVF monitoring is NECESSARY after kidney transplantation!!!