Hemodializna arteriovenska fistula po uspešni presaditvi ledvice

Vajdič Trampuž, Barbara (author), Buturović Ponikvar, Jadranka (mentor)

Namen: Raziskati dolgoročno delovanje, uporabo, zaplete dializne arteriovenske fistule (AVF) in vpliv AVF na delovanje in preživetje presadka po uspešni presaditvi ledvice. Bolniki in metode. Raziskava je potekala kot retrospektivna kohortna raziskava. Analizirali smo vse bolnike, ki so bili transplantirani od 1.1.2000 do 31.12.2015 in ki so ob času presaditve imeli delujočo arteriovensko fistulo. Bolnike smo spremljali do 31.12.2019. Rezultati. Med 1.1.2000 in 31.12.2015 je bilo v Univerzitetnem Kliničnem Centru Ljubljana opravljenih 757 presaditev ledvice. V raziskavo je bilo vključenih 626 (82.7%) bolnikov, ki so ob času presaditve imeli delujočo AVF. Mediano sledenje je bilo 4,9 let. En mesec po presaditvi je delovalo 90% AVF, eno leto po presaditvi 82% AVF, tri leta po presaditvi 70% AVF in pet let po presaditvi 61% AVF; mediani čas delovanja AVF je bil 7.9 let. Glavni vrok prenehanja delovanja AVF je bila spontana tromboza. Moški spol je bil povezan z manj pogostimi trombozami AVF, grafti s pogostejšimi trombozami AVF. Po presaditvi ledvice je bila AVF uporabljena v približno eni tretjini bolnikov. Simptomatski zaplet z delujočo AVF je imelo 29 % bolnikov (183/626). Kirurško zdravljenje je potrebovalo 15,5% vseh bolnikov (53 % bolnikov z zapletom na AVF). Bolniki z delujočo AVF (N=239) eno leto po presaditvi so imeli višji kreatinin in nižjo ocenjeno glomerulno filtracijo (oGF) kot bolniki z nedelujočo AVF (110+/-38 umol/L in 69+/-21 mL/min/1,73m2 vs. 99 +/-30 umol/L in 74+/-19 mL/min/1.73 m2; P <0.05). Ocenjena glomerulna filtracija (oGF) se je pred zaprtjem AVF blago izboljševala (0.224 mL/min/1.73m2 mesečno), nato pa po zaprtju blago zniževala (-0.023 mL/min/1.73m2 mesečno). Krivulji spreminjanja hitrosti oGF v času pred in po zaprtju AVF sta se med seboj statistično značilno razlikovali (P = 0.044). Po zaprtju AVF se je sistolni krvni tlak povišal iz 134±16 na 138±15 mmHg (P=0.001), diastolni krvni tlak pa se je povišal iz 79±10 na 84±10 mmHg (P<0.001). Zaključek. Dializna AVF ostane po presaditvi ledvice delujoča pri večini bolnikov in je velikokrat ponovno uporabljena po odpovedi presajene ledvice. Zapleti z AVF so pogosti in v polovici primerov potrebujejo tudi kirurško oskrbo. Bolniki z delujočo AVF so imeli višji kreatinin in nižjo glomerulno filtracijo. V letu po zaprtju AVF pride do blagega upada glomerulne filtracije. Zaprtje AVF je povezano s porastom sistolnega in diastolnega krvnega tlaka. Odločitev glede morebitne ligacije AVF ostaja individualna.

• Language: Slovenian
• Keywords: hemodializna arteriovenska fistula (AVF), hemodializa, presaditev ledvice, delovanje AVF, uporaba AVF, zapleti AVF, tromboflebitis, kirurško zdravljenje zapletov AVF
• Work type: Doctoral dissertation
• Organization: MF - Faculty of Medicine
• Year: 2023
• PID: 20.500.12556/RUL-144872
• COBISS.SI-ID: 151833859
• Publication date in RUL: 19.03.2023

Secondary language

• Language: English
• Title: ​Hemodialysis arteriovenous fistula after successful kidney transplantation

Abstract

Objective. To describe the long-term hemodialysis arteriovenous fistula (AVF) patency, AVF use, incidence and nature of AVF complications and surgery and impact of functional AVF on kidney graft function and survival in patients after kidney transplantation. Patients and Methods. We retrospectively analysed the AVF outcome and complications in all adult kidney allograft recipients transplanted between January 1st, 2000 and December 31, 2015 with a functional AVF at the time of transplantation. Follow-up was until December 31, 2019. Results. We included 626 patients with functioning AVF at the time of transplantation. Median AVF follow-up was 4.9 years. One month after kidney transplantation estimated AVF patency rate was 90%, at 1 year it was 82%, at 3 years it was 70% and at 5 years it was 61%; median estimated AVF patency was 7.9 years. The main cause of AVF failure was spontaneous thrombosis occurring in 76% of AVF failure cases, whereas 24% of AVFs were ligated or extirpated. In a Cox multivariate model female sex and grafts were independently associated with more frequent AVF thrombosis. AVF was used in about one third of our patients. AVF-related complications occurred in 29 % of patients and included: growing aneurysms, complicated thrombosis, high-flow AVF, signs of distal hypoperfusion, venous hypertension, trauma of the AVF arm, or pain in the AVF/arm. Patients with functional AVF had a higher serum creatinine and a lower eGFR than patients with nonfunctional AVF 110+/-38 umol/L in 69+/-21 mL/min/1,73m2 vs. 99 +/-30 umol/L in 74+/-19 mL/min/1.73 m2; P <0.05). The mean eGFR slope improved before AVF closure (0.224 mL/min/1.73m2 per month) and slightly deteriorated after AVF closure (-0.023 mL/min/1.73m2 per month). The slopes are significantly different from each other (P = 0.044). Following AVF closure, SBP increased from 134±16 to 138±15 mmHg (P=0.001), and DBP increased from 79±10 to 84±10 mmHg (P<0.001). Conclusions. AVFs remain functional after kidney transplantation in the majority of patients and are often re-used after graft failure. AVF-related complications are common and require proper care. Patients with functional AVF had a higher serum creatinine and a lower eGFR than patients with nonfunctional AVF. The mean eGFR slope slightly deteriorated after AVF closure. Following AVF closure, SBP and DBP increased. The decision to close an AVF after transplantation should always be made on an individual basis.

• Keywords: hemodialysis arteriovenous fistula (AVF), hemodialysis, kidney transplantation, AVF function, AVF use, AVF related complications, AVF related surgery