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High-flow arteriovenous fistula and heart failure: could the indexation of blood flow rate and echocardiography have a role in the identification of patients at higher risk?

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Abstract

Background

Although only high-flow arteriovenous fistulas (AVFs) are postulated to cause high-output cardiac failure (HOCF), there are currently no universally accepted criteria defining a high-flow fistula.

Methods

To verify if vascular access blood flow (Qa) ≥ 2000 ml/min provides an accurate definition of high-flow fistula, we selected 29 consecutive patients with Qa ≥ 2000 ml/min at color-duplex ultrasound examination and assessed them for the presence of cardiac failure symptoms; transthoracic echocardiography was also performed.

Results

Nineteen patients (65%) had heart failure symptoms and were classified with HOCF. At receiver operating characteristic (ROC) curve analysis, Qa ml/min values did not identify patients with heart failure symptoms but when AVF blood flow was indexed for height2.7, Qa ≥ 603 ml/min/m2.7 detected the occurrence of HOCF with good accuracy (sensitivity 100%, specificity 60%, efficiency 86%, positive predictive value 83%, negative predictive value 100%, area under curve 0.75). At echocardiographic evaluation, patients with Qa ≥ 603 ml/min/m2.7 had a more severe increase of left ventricular mass (63 ± 18 vs. 47 ± 7 g/m2.7, p < 0.003), left ventricular diastolic volume (140 ± 42 vs. 109 ± 14 ml, p < 0.007), left atrial volume (53 ± 23 vs. 39 ± 5 ml/m2, p < 0.015), a higher incidence of diastolic dysfunction (70 vs. 17%, p < 0.019) and higher CO reduction after AVF manual compression (2151 ± 875 vs. 1292 ± 527 ml/min, p < 0.009) than patients with Qa < 603 ml/min/m2.7.

Conclusions

Indexation of AVF blood flow should be considered in defining high-flow fistula because the effect of Qa may differ in individuals of different sizes. A Qa value ≥ 603 ml/min/m2.7 and its association with some echocardiographic alterations could identify patients at higher risk for HOCF.

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Acknowledgements

Our data were previously published in form of “abstract” at the 9th Congress of Vascular Access Society (April 15–18, 2015 Barcelona)

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Authors and Affiliations

  1. Division of Nephrology, University of Campania “Luigi Vanvitelli”, Via M. Longo 50, 80138, Naples, Italy

    Pasquale Zamboli, Silvio Borrelli, Carlo Garofalo, Maria Elena Liberti & Mario Pacilio

  2. Department of Cardiology, S.M.d.P Incurabili Hospital, Naples, Italy

    Sergio Lucà & Stefano Lucà

  3. Department of Nephrology, Dialysis and Transplantation, San Giovanni di Dio and Ruggi D’Aragona Hospital, Salerno, Italy

    Pasquale Zamboli, Giuseppe Palladino & Massimo Punzi

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  1. Pasquale Zamboli
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  2. Sergio Lucà
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  4. Carlo Garofalo
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  5. Maria Elena Liberti
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Correspondence to Pasquale Zamboli.

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Ethical statement

All procedures performed in this study were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Informed consent was obtained from all participants included in the study.

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Zamboli, P., Lucà, S., Borrelli, S. et al. High-flow arteriovenous fistula and heart failure: could the indexation of blood flow rate and echocardiography have a role in the identification of patients at higher risk?. J Nephrol 31, 975–983 (2018). https://doi.org/10.1007/s40620-018-0472-8

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