LAUSR

Circulation. 2019;140:e802–e803. DOI: 10.1161/CIRCULATIONAHA.119.041747 e802 Dimitrios Moris, MD, PhD Georgia-Sofia Karachaliou, MD, MSc Diamantis I. Tsilimigras, MD To the Editor: We read with great interest the recent publication by Rao et al1 on the effect of arteriovenous fistula ligation on cardiac function after kidney transplantation. The striking and possibly practice-changing finding of the study was the clinically and radiographically significant reduction of left ventricular myocardial mass in patients with stable kidney function after kidney transplantation.1 We congratulate the authors for their important contribution to the field. We have some queries that might be helpful for a deeper understanding of the results of the study. First, we were wondering whether the choice of arteriovenous fistula configuration (radiocephalic vs brachiocephalic versus brachiobasilic) had any effect on the pattern of left ventricular hypertrophy and its regression after ligation. Do the authors think that the proximity to the heart is a risk factor for left ventricular hypertrophy, or is it irrelevant? Second, it seems that the authors randomized patients 12 months after kidney transplantation. We were wondering whether the authors took into consideration the years that patients spent on hemodialysis before entering into the study. On the basis of the data presented, it is reasonable to assume that patients who stayed longer in hemodialysis had chronic cardiovascular effects that might be related to irreversible cardiac remodeling.2 Third, we were wondering whether the authors have any long-term data on the outcomes of the patients who developed allograft rejection and had to return to hemodialysis. How easy was it for them to get another vascular access? How many of them were able to have successful vascular access from native vessels, and how many of them ended up having catheter-dependent dialysis or grafts to serve their dialysis needs? These findings are of clinical relevance because these patients have well-known vessel exhaustion, affecting both arteries and veins, which significantly increases the possibility of a nonnative access that is related to decreased patency and increased infection rates.3 Because it was outside the design and scope of the study to follow up patients for many years after enrollment in the trial, it is difficult to predict the durability of the effect of arteriovenous fistula ligation on cardiac remodeling. In the same frame, the lack of superiority in terms of survival and estimated glomerular filtration rate values could make clinicians more reluctant to adopt the suggested unanimous practice of arteriovenous fistula ligation after kidney transplantation. Our opinion is that the study presents strong enough data to be instructive for clinical care in these patients, but these findings should be applied with extreme caution and in a personalized manner, taking into consideration individual needs and peculiarities.