To Ligate or not Ligate Arteriovenous Accesses: CON

Kidney transplantation remains the best treatment option for patients with end stage kidney disease (ESKD). However, a dilemma faces healthcare providers when they care for ESKD patients: whether to ligate the patient’s arteriovenous (AV) access after kidney transplantation or leave it patent and maintain it. There is still considerable disagreement among providers on the best course of action when dealing with an AV access after kidney transplantation (1). In this article, I will discuss the disadvantages of ligating an AV access after kidney transplantation.

The 1-year and 5-year kidney graft survival rates range between 87% and 95% and 65% and 83%, respectively, based on a donor’s status (2). Therefore, significant numbers of kidney transplant recipients will end up receiving dialysis again in the future. And this means that these patients will need AV access when reinitiating dialysis. Creating a new AV access, if the original access was ligated, carries its own challenges and risks. They include not only the risk of the procedure itself, the lead time to maturation, the primary failure rate, the failure rate of related procedures, and the need for tunneled hemodialysis catheters (TDC) but also the difficulty of finding a suitable artery and vein that meet the criteria for AV access creation (3). Two-thirds of patients with a failed kidney transplant start hemodialysis with a TDC (4). Using a TDC by itself adds significant morbidity and mortality to patients with an already higher morbidity and mortality risk than their peers (5).

There is no proven benefit to patient mortality of an access ligation after kidney transplantation. Hicks et al. (6) used the United States Renal Data System to look at 16,845 patients with AV access who received kidney transplants between January 2011 and December 2013. Access ligation occurred in 4.6% of these patients. There was no statistically significant difference between the two groups in all-cause mortality and post-transplantation allograft failure. This study highlighted that the current practice pattern in the United States is to ligate problematic AV accesses only, hence the low rate of access ligation. At the same time, Maresca et al. (7) evaluated six hemodialysis patients and four transplant patients with high AVF blood flow (>1.5 L/min per 1.73 m²) coupled with symptoms of heart failure. The patients underwent an AVF flow reduction procedure. The flow reduction rate was approximately 58.4%. The results showed that 80% of patients had an improvement in heart failure symptoms. Improvement in systolic pulmonary artery pressure was also noted. However, there is an increased risk of recurrence of high blood flow after flow reduction procedures. Vaes et al. (8) have shown that AV access high flow (>2 L/min) recurred in 52% of patients during the observation period (1 year) among patients who underwent flow reduction procedures.

It is also important to mention that studies have shown some conflicting results of the effect of AV access ligation on cardiac parameters. Rao et al. (9) conducted a randomized controlled trial among kidney transplant recipients (>12 months after transplantation with stable kidney graft function) comparing AVF ligation with no ligation. They randomized 64 patients and used cardiac magnetic resonance imaging at baseline and at 6 months after ligation. AVF ligation resulted in a significant reduction in left ventricular (LV) mass as compared with an increase in the control group but with no significant changes in LV ejection fraction. In other work, Laranjinha et al. (10) conducted a study on 17 patients after kidney transplantation with functioning AV accesses. The team looked at transplanted kidney resistive indices before and after 30 seconds of compression on the AV access and while the AV access was still blocked. They found that 82.4% of patients had a significant decrease in their resistive indices and an increase in their mean arterial blood pressure during compression. All patients had a decrease in heart rate. These are interesting findings; however, more research is needed to investigate the clinical impact of these practices. Nonetheless, Cortesi et al. (11) performed a retrospective study evaluating patients with established LV hypertrophy who underwent AVF banding. The patients underwent two-dimensional echocardiography before and after the procedure. The study authors found that AV access ligation did not result in significant changes in LV mass index. These results contradicted previous findings of the effects of AV access ligation on cardiac parameters.

Although there is enough evidence to suggest that AV access ligation leads to a reduction in LV mass (9), it is important to mention that not all studies have shown this benefit of AV access ligation on LV mass (11, 12). Additionally, it will be important to correlate various AV access blood flow rates with LV mass and cardiac parameters.

Patients with a stable kidney transplant and patent AV access who experience AV access–related complications such as hand ischemia, arm edema, or other changes should receive a careful assessment weighing the benefit of treating these complications versus AV access ligation. However, there is no evidence to suggest that mortality improves by the ligation of an AV access without AV access–related complications among patients with kidney transplants. Additionally, although evidence suggests the benefit of AV access ligation on LV mass, some evidence has shown no benefit. With these conflicting results, the practice should continue to keep and maintain nonproblematic AV accesses after kidney transplantation. There is a need for well-designed and well-powered studies to investigate whether ligating a noncomplicated AV access reduces morbidity and mortality after kidney transplantation (1).