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.

• Klíčová slova
• Chronic kidney disease, arteriovenous fistula, heart failure, hemodialysis, peritoneal dialysis, pulmonary hypertension,
• MeSH
• arteriovenózní píštěl * MeSH
• arteriovenózní zkrat * škodlivé účinky   MeSH
• chronická renální insuficience * diagnóza   terapie   MeSH
• chronické selhání ledvin * MeSH
• dialýza ledvin MeSH
• lidé MeSH
• ligace MeSH
• transplantace ledvin * MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• přehledy MeSH

AIMS: High-flow arteriovenous fistula (AVF) for haemodialysis leads to profound haemodynamic changes and sometimes to heart failure (HF). Cardiac output (CO) is divided between the AVF and body tissues. The term effective CO (COef) represents the difference between CO and AVF flow volume (Qa) and better characterizes the altered haemodynamics that may result in organ hypoxia. We investigated the effects of Qa reduction on systemic haemodynamics and on brain oxygenation. METHODS AND RESULTS: This is a single-centre interventional study. Twenty-six patients on chronic haemodialysis with high Qa (>1500 mL/min) were indicated for surgical Qa reduction for HF symptoms and/or signs of structural heart disease on echocardiography. The included patients underwent three sets of examinations: at 4 months and then 2 days prior and 6 weeks post-surgical procedure. Clinical status, echocardiographical haemodynamic assessment, Qa, and brain oximetry were recorded. All parameters remained stable from selection to inclusion. After the procedure, Qa decreased from 3.0 ± 1.4 to 1.3 ± 0.5 L/min, P < 0.00001, CO from 7.8 ± 1.9 to 6.6 ± 1.5 L/min, P = 0.0002, but COef increased from 4.6 ± 1.4 to 5.3 ± 1.4 L/min, P = 0.036. Brain tissue oxygen saturation increased from 56 ± 11% to 60 ± 9%, P = 0.001. CONCLUSIONS: Qa reduction led to increased COef. This was explained by a decreased proportion of CO running through the AVF in patients with Qa > 2.0 L/min. These observations were mirrored by higher brain oxygenation and might explain HF symptoms and improved haemodynamics even in asymptomatic high Qa patients.

• Klíčová slova
• Arteriovenous fistula, Brain oximetry, Effective cardiac output, High-output heart failure,
• MeSH
• arteriovenózní píštěl * MeSH
• arteriovenózní zkrat * MeSH
• dialýza ledvin MeSH
• hemodynamika MeSH
• lidé MeSH
• mozek diagnostické zobrazování   MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• práce podpořená grantem MeSH

A 79-year-old woman who was on chronic hemodialysis due to diabetic nephropathy and had previously undergo surgery for radiocephalic arteriovenous fistula (AVF) in her right wrist needed percutaneous transluminal angioplasty (PTA) for stenosis at the juxta-anastomotic access site. After successful PTA, the systemic blood pressure decreased from 144/93 mm Hg to 117/67 mm Hg in response to the increase in AVF blood flow. Furthermore, the regional oxygen saturation (rSO2) value in her dorsal hand decreased from 67.9% to 64.9% and, simultaneously, the cerebral rSO2 decreased from 63.6% to 60.1%. Our experience indicates that the PTA procedure may affect the rapid deterioration of systemic oxygenation, including that in the hand and brain, in association with the increase in the AVF blood flow and change in systemic circulation.

• Klíčová slova
• Arteriovenous fistula, Cerebral oxygenation, Hand oxygenation, Hemodialysis, Hemodynamic instability, Percutaneous transluminal angioplasty,
• Publikační typ
• časopisecké články MeSH
• kazuistiky MeSH