Chronic kidney disease is associated with increased cardiovascular morbidity and mortality. A well-functioning vascular access is associated with improved survival and among the available types of vascular access the arterio-venous (AV) fistula is the one associated with the best outcomes. However, AV access may affect heart function and, in some patients, could worsen the clinical status. This review article focuses on the specific cardiovascular hemodynamics of dialysis patients and how it is affected by the AV access; the effects of an excessive increase in AV access flow, leading to high-output heart failure; congestive heart failure in CKD patients and the contraindications to AV access; pulmonary hypertension. In severe heart failure, peritoneal dialysis (PD) might be the better choice for cardiac health, but if contraindicated suggestions for vascular access selection are provided based on the individual clinical presentation. Management of the AV access after kidney transplantation is also addressed, considering the cardiovascular benefit of AV access ligation compared to the advantage of having a functioning AVF as backup in case of allograft failure. In PD patients, who need to switch to hemodialysis, vascular access should be created timely. The influence of AV access in patients undergoing cardiac surgery for valvular or ischemic heart disease is also addressed. Cardiovascular implantable electronic devices are increasingly implanted in dialysis patients, but when doing so, the type and location of vascular access should be considered.

2nd Department of Surgery General University Hospital 1st Faculty of Medicine Charles University Prague Czech Republic

3rd Department of Internal Medicine General University Hospital 1st Faculty of Medicine Charles University Prague Czech Republic

Department of Internal Medicine Leiden University Medical Center Leiden The Netherlands

Department of Nephrology and Transplantation Medicine Wroclaw Medical University Wroclaw Poland

Department of Nephrology Hospital de Mollet Fundació Sanitària Mollet Barcelona Spain

Miulli General Hospital Division of Nephrology Acquaviva delle Fonti Italy

Nephrology and Dialysis Unit ASST Fatebenefratelli Sacco Department of Biomedical and Clinical Sciences 'L Sacco' University of Milano Milano Italy

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