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.

• Keywords
• Chronic kidney disease, arteriovenous fistula, heart failure, hemodialysis, peritoneal dialysis, pulmonary hypertension,
• MeSH
• Arteriovenous Fistula * MeSH
• Arteriovenous Shunt, Surgical * adverse effects   MeSH
• Renal Insufficiency, Chronic * diagnosis   therapy   MeSH
• Kidney Failure, Chronic * MeSH
• Renal Dialysis MeSH
• Humans MeSH
• Ligation MeSH
• Kidney Transplantation * MeSH
• Check Tag
• Humans MeSH
• Publication type
• Journal Article MeSH
• Review MeSH

The prevalence of the left ventricular hypertrophy (LVH) is very high in end-stage renal disease treated by hemodialysis. Diastolic dysfunction is a frequent consequence and leads to the development of heart failure with preserved ejection fraction. New American/European echocardiographic guidelines for the assessment of diastolic function simplified the evaluation and were published recently. The aim of this study was to reveal if the new guidelines stratify asymptomatic hemodialysis patients by the levels of brain-natriuretic peptide (BNP). A cohort of 46 patients hemodialyzed in one center with the lack of overt heart failure, systolic dysfunction, arrhythmia or significant valvular disease were examined by echocardiography before and after a single hemodialysis and blood samples for BNP analysis were drawn at both occasions. The LVH was present in 53% of patients, concentric remodeling in another 17%. Higher indexed left ventricular mass was related to higher BNP levels (r = 0.58, p = 0.0001). Before hemodialysis, diastolic dysfunction was present in 61%: grade 1 in 25%, grade 2 in 21% and grade 3 in 8%. The higher grade of diastolic dysfunction was associated with the incremental increase of BNP. The post-dialysis echocardiography did not allow the assessment of diastolic function in as many as 37% of patients. Our study has shown that the application of the current guidelines for the assessment of diastolic function based on simple four criteria differentiate hemodialysis symptomless patients with preserved systolic function according to BNP levels. BNP levels also rose together with the left ventricular mass. The ratio E/e' medial seemed to be a better predictor of increased BNP than E/e' lateral or E/e' averaged.

• Keywords
• Chronic kidney disease, Diastolic dysfunction, Echocardiography, Heart failure, Hemodialysis,
• MeSH
• Asymptomatic Diseases MeSH
• Biomarkers blood   MeSH
• Time Factors MeSH
• Kidney Failure, Chronic complications   diagnosis   physiopathology   therapy   MeSH
• Renal Dialysis * adverse effects   MeSH
• Diastole MeSH
• Echocardiography, Doppler * MeSH
• Ventricular Dysfunction, Left diagnostic imaging   etiology   physiopathology   MeSH
• Ventricular Function, Left * MeSH
• Hypertrophy, Left Ventricular diagnostic imaging   etiology   physiopathology   MeSH
• Middle Aged MeSH
• Humans MeSH
• Natriuretic Peptide, Brain blood   MeSH
• Predictive Value of Tests MeSH
• Ventricular Remodeling MeSH
• Risk Factors MeSH
• Aged MeSH
• Stroke Volume MeSH
• Treatment Outcome MeSH
• Check Tag
• Middle Aged MeSH
• Humans MeSH
• Male MeSH
• Aged MeSH
• Female MeSH
• Publication type
• Journal Article MeSH
• Names of Substances
• Biomarkers MeSH
• Natriuretic Peptide, Brain MeSH