Practice Patterns in Arteriovenous Fistula Ligation among Kidney Transplant Recipients in the United States Renal Data Systems
Caitlin W. Hicks, MD, MS, Sunjae Bae, KMD, MPH, Sandra R. DiBrito, MD, Jaqueline Garonzik-Wang, MD, PhD, Dorry L. Segev, MD, Thomas Reifsnyder, MD.
Johns Hopkins Hospital, Baltimore, MD, USA.
Arteriovenous fistulas (AVF) and grafts (AVG) have been associated with significant cardiac morbidity that often improves after ligation. However, AV access ligation after kidney transplant is controversial due to concern for potential long-term allograft failure. We investigated US trends in AV access ligation after kidney transplant.
All adult Medicare patients on pre-transplant hemodialysis with a functioning AVF or AVG who underwent first-time kidney transplant were studied using the United States Renal Data Systems (01/2011-12/2013). Post-transplant AV access ligation was determined using ICD-9 codes. Temporal trends in post-transplant AV access ligation were described, and characteristics for ligated vs. non-ligated patients were compared. Long-term allograft failure was analyzed for both groups using Kaplan-Meier curves and Cox proportional hazard models.
A total of 16,845 patients with functioning AVF/AVG received a kidney transplant during the study period. Of these, 779 (4.6%) underwent post-transplant AV access ligation. Patients who were ligated were more frequently female (40% vs. 37%), had lower median body mass index (BMI) (27.6 vs. 28.4 kg/m2), more years on dialysis (4.2 vs. 4.0 years), and less frequently suffered from diabetic end stage renal disease (25% vs. 35%) (all, P≤0.03). Timing of ligation post-transplant was relatively constant over time (R-squared=0.97). After adjusting for baseline differences between groups, non-diabetic renal disease (HR=1.59 for glomerulonephritis; 1.45 for hypertension), and increasing time on dialysis up to 5 years (HR=1.10 per year) were associated with receiving AV access ligation (P≤0.002). Black race (HR 0.82) and increasing BMI (HR 0.98 per increase in kg/m2) was negatively associated with ligation (P≤0.02). There were no significant differences in allograft failure between ligated vs. non-ligated groups (5% vs. 10% at 36 months; HR=0.80, P=0.39; Figure 1).
Ligation of permanent AV access post-kidney transplant is uncommon, and generally reserved for thinner, non-black patients with non-diabetic end stage renal disease. Importantly, ligation is not associated with allograft failure, which occurs in less than 10% of patients by 36 months post-transplant. These data support a call for increased consideration of AV access ligation following successful renal transplant in appropriately selected patients.
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