Management of the Access After Kidney Transplantation

There are no guidelines for the management of arteriovenous hemodialysis access following successful renal transplant, and there is no consensus on the utility of routine ligation of these accesses. Approximately 5% of patients undergo ligation of their vascular access post-transplant. Strong indications for ligation post-successful transplant include venous hypertension, bleeding aneurysm, graft infection, hemodialysis access-induced distal ischemia, and high output cardiac failure. The cardiac structural and functional derangements that occur in the setting of patent arteriovenous access have been associated with increased morbidity and mortality in both pre- and post-transplant patients. While some data have shown improvement of unfavorable cardiac remodeling after ligation of arteriovenous access, the data are mixed as to the impact on graft survival and on all-cause mortality. Additionally, given a 10-year deceased donor renal allograft survival rate of 50%, there is a reasonable chance that a patient will return to hemodialysis in his/her lifetime, and will require active arteriovenous access. As such, the relatively small number of patients undergoing ligation post-transplant and the unclear advantage for graft and patient survival suggest that routine ligation of the arteriovenous access is not indicated. If there is a strong indication to ligate, then it should be pursued.