To keep or not to keep: hemodialysis arteriovenous fistula following kidney transplantation.

449 Letter to the Editor I read with great interest the article by Głowiński et al.1 The study focused on the issue of whether arteriovenous (AV) fistula closure among recipients with successful kidney transplants had an effect on cardiac function. The authors concluded that AV fistula closure in kidney recipients with well-functioning renal grafts had no significant beneficial effect on the heart in a short-term follow-up. In another study, in a group of 180 kidney transplant patients, AV fistula closure was also not associated with a beneficial effect on cardiac function.2 Although transplant physicians frequently face the difficult task of advising kidney transplant patients whether it is safe to keep the functioning AV fistula or not, surprisingly few studies have reported the cardiac effect of AV fistula closure after successful kidney transplantation. In 2 prospective studies on kidney transplant recipients with stable allograft function, an improvement in left ventricular (LV) hypertrophy and a reduction in the LV end-diastolic diameter were observed after AV fistula ligation.3,4 Moreover, patent AV fistula was independently associated with increased arterial stiffness in a multivariate analysis.5 On the other hand, several studies showed that AV fistula had no significant adverse effects on cardiac function in long-term periods.6,7 It should be noted that symptomatic cardiac failure associated with a high-flow AV fistula is uncommon and usually occurs in pre-existing heart disease.8 In a series of 311 kidney transplant patients, AV fistula ligation was associated with a better allograft renal function at 1 year after transplantation, and the risk of future allograft loss was decreased compared with recipients with patent AV fistula.9 This study provides an additional argument in favor of AV fistula closure in kidney recipients after successful kidney transplantation. Although AV fistula closure after renal transplantation could be beneficial for cardiac and renal function, there is no consensus over the strategy for keeping or ligating AV fistula among kidney transplant patients with well-functioning grafts. Furthermore, despite controversial findings, most transplant physicians suggest that AV fistula ligation is not routinely required in kidney recipients with stable renal allograft function. They believe that AV fistula closure should only be considered in patients with strong indications such as the presence of a large, high-flow AV fistula, cosmetic reasons, or high risk of cardiovascular diseases.