LAUSR

OBJECTIVE After a successful renal transplant, the haemodialysis (HD) vascular access (VA) is often maintained in the event of renal graft failure. However, unused access may cause both local and systemic complications over time. Evidence to recommend the systematic ligation or maintenance of the VA are lacking. This study aimed to investigate the effects of VA preservation/ligation once HD has been stopped in successfully transplanted patients. METHODS A retrospective analysis of all patients who underwent successful renal transplantation after HD in a single Institution, between 2009 and 2016, were conducted. Both patients with a functioning VA, those undergoing ligation and presenting with post-transplantation VA spontaneous thrombosis were included in the analysis. Demographics, comorbidities, reasons for ligation, need for secondary interventions, complications and return in dialysis during the follow-up period were assessed. RESULTS Among a total of 542 HD patients, 114(21%) (76, 66.7% male, median age 50 years, range 20-70) were included according to the inclusion criteria. A total of 8 (7%) accesses spontaneously thrombosed within a mean of 1.4 days (range 1-3) after transplant and 42(36.8%) patients with normal creatinine and eGFR level underwent fistula ligation. In the remaining 64(56.1%) cases the VA was functioning and preserved. The most common reasons for access ligation were patient's request (35, 83.3%), steal syndrome (5, 11.9%), heart failure (1, 2.4%) and aneurysmal degeneration (1, 2.4%). During a mean follow-up period of 724.9 days (range 80-1082) 25 patients developed complications over the maintained access (10, 40% of stenosis; 8,32% high flow and 7,28% thrombosis), 18 (15.8%) patients needed reoperation, and seventeen (15%) patients required further HD following the VA ligation. Multivariate analysis showed that patients presenting with a pre-existing coronary artery disease (OR= 12.566 [2.056- 76.805], P<.06) and those aged more than 60 years (OR=0.181 [(0.044-0.735)], P=0.017) were at significant risk to develop complications over unused VA. CONCLUSION The vascular access often remains functional after kidney transplantation possibly representing the cause of systemic and local morbidity. The ligation should not be systematically performed and evaluated in an individualized basis. Patients with pre-existing cardiovascular disease and those aged more than 60 years should be monitored closely during follow-up as they are at higher risk of complications.