Abstract
Purpose
A proportion of patients who undergo kidney transplantation (KT) eventually experience graft failure and require dialysis. However, the characteristics of posttransplant patients differ from non-KT patients considering the long-term use of immunosuppressants, steroids, and associated complications. These differences may influence the outcomes of vascular access (VA). This study aims to compare the VA outcomes and infection rates between KT with allograft failures and non-KT patients.
Methods
We retrospectively analyzed patients who underwent VA creation between January 2018 and November 2023. A propensity score-matched cohort was created based on age and sex, comparing 61 patients who received their first VA creation after KT to 222 patients who had never undergone KT before VA creation.
Results
The median VA patency was 841 days. VA abandonment within 3 months occurred in 3.2% in the non-KT group and 1.6% in the KT with failed allograft group (P = 0.845). Infection rates were also similar (4.1% vs. 3.3%, P = 0.226). Cox regression indicated that KT was not a significant risk factor for VA patency, whereas low body mass index and diabetes mellitus were significant risk factors for long-term patency. In the KT group, steroid and mammalian target of rapamycin (mTOR) inhibitor use before VA formation were identified as risk factors for primary patency.
Conclusion
VA outcomes in KT patients with allograft failure were comparable to those of non-KT patients. While KT status itself does not adversely affect VA patency or infection rates, patients with low body mass index, diabetes mellitus, or who are receiving steroid or mTOR inhibitors should be carefully managed.
Keywords: Arteriovenous fistula, Kidney transplantation, Vascular access, Vascular patency
INTRODUCTION
Patients with end-stage renal disease (ESRD) require dialysis, and among them, a certain percentage undergo kidney transplantation (KT) [1]. A significant percentage of KT recipients experience graft failure and return to dialysis [2,3]. These patients often have comorbidities such as hypertension, diabetes mellitus (DM), and cardiovascular disease (CVD). After KT, the incidence of posttransplant DM increases, leading to a higher risk of major adverse cardiovascular events. Additionally, KT patients receiving immunosuppressive therapy, such as mammalian target of rapamycin (mTOR) inhibitors and steroids, may have impaired healing and increased perioperative infection risk [4,5,6,7,8,9,10].
Therefore, we hypothesized that KT and the associated use of immunosuppressive agents might act as a risk factor for surgical complications in vascular surgery, affecting both short-term and long-term patency outcomes of vascular access (VA). Previous studies on VA in KT patients mainly focused on whether it is beneficial to ligate existing arteriovenous fistulas (AVFs) after KT [11,12,13,14,15,16]. Some studies suggested that maintaining an AVF in transplant patients could lead to cardiovascular events due to left ventricular ejection fraction reduction, with high-flow AVFs potentially causing cardiac failure [16,17]. However, there is a lack of research on surgical outcomes such as VA patency and surgical site infection in transplant patients. This study aims to address these questions by examining primary patency as the primary outcome and infection of VAs as the secondary outcome.
METHODS
Study design and participants
We retrospectively reviewed consecutive patients who underwent VA formation between January 2018 and November 2023 at Severance Hospital, Seoul, Korea. We excluded patients who were under 18 years of age, those who had undergone other organ transplantations, those who received a KT within 3 years after VA creation, those with a previous VA history, and those with missing data or loss of follow-up. A propensity score-matched cohort was created, matching patients by age and sex. Out of a total of 283 patients who underwent their first VA creation at our hospital, we compared 61 patients who received KT and 222 who did not.
All study procedures were conducted in accordance with the Declaration of Helsinki and were approved by the Institutional Review Board (IRB) of Severance Hospital (No. 4-2025-0438). Informed consent was waived by the IRB of Severance Hospital because of the study’s retrospective design.
Follow-up methods
Preoperative vascular mapping is performed on all patients before surgery to plan the procedure. The surgery follows standard procedures recognized as reasonable by various reputable guidelines [18,19,20,21,22]. After the surgery, a follow-up visit is scheduled 1–2 weeks later to check the surgical wound and ensure that the thrill is palpable, to detect any acute surgical complications. A Doppler sonography is conducted 1 month after surgery to assess the progress of AVF maturation. Regular follow-ups are continued until the AVF is sufficiently mature for hemodialysis. If there are no issues with dialysis, annual follow-ups are conducted.
Study endpoints and definitions
The primary study endpoint was primary patency and the secondary outcome was infection. In this study, the terminology used follows the definitions provided by the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines [18]. Primary patency refers to the duration of intra-access patency starting from the date of VA creation (for arteriovenous access) or insertion (for a central venous catheter) to the occurrence of either thrombosis or any intervention aimed at facilitating, maintaining, or reestablishing patency. VA abandonment was defined as the permanent discontinuation of a VA when its function cannot be restored or maintained. Surgical intervention was defined as a procedure performed under local anesthesia involving a direct incision at the VA site. AVF infection was defined as a clinically suspected infection with signs of erythema or seroma, treated with antibiotics. Loop grafts were used for brachiobasilic and brachiocephalic arteriovenous grafts (AVGs), whereas straight grafts were used for brachioaxillary and radiocephalic AVGs.
Statistical analysis
Depending on the type of variable, data were presented as frequency, mean ± standard deviation, or median with interquartile range (IQR). Continuous variables were compared using the Student t-test for parametric data and the Mann-Whitney test for nonparametric data. Categorical variables were compared using the chi-square test or Fisher exact test, as appropriate. Multivariable logistic regression analysis was conducted with KT as the outcome variable. VA primary patency was analyzed using the Kaplan-Meier curves and the log-rank test. The associations between KT and VA patency were assessed using Cox proportional hazard models, which included the following covariates: age, sex, body mass index (BMI), comorbidities (hypertension, DM, CVD, systemic lupus erythematosus [SLE]), use of antiplatelet or anticoagulant agents, type of VA, and KT. Clinically significant variables and those with a P-value ≤0.1 in univariable analyses were included in the multivariable regression models. Propensity score matching analysis was performed by matching patients’ age and sex.
Statistical analyses were conducted using IBM SPSS Statistics ver. 26.0 (IBM Corp.) and R software ver. 3.6.3 (R Foundation for Statistical Computing). All tests were 2-tailed, and P-values <0.05 were considered statistically significant.
RESULTS
Baseline characteristics of vascular access
In this study, we reviewed 283 cases of VAs, employing propensity score matching to ensure equal age and sex distribution. The patient population was predominantly male (59.4%), with a median age of 53.0 years (IQR, 36.0–70.0 years). The proportion of patients who underwent dialysis before AVF creation did not differ significantly between the 2 groups (P = 0.536).
The median follow-up period for VAs was 2.8 years and the median VA primary patency was 2.3 years. The overall primary failure rate was 12.0%. The proportion of AVGs was 14.8%. The proportion of VAs abandoned within 3 months was 3.2% (n = 7) in the non-KT group and 1.6% (n = 1) in the KT with failed allograft group (P = 0.845). The 1-year primary patency was 67.5%, the primary-assisted patency was 86.6%, and the secondary patency was 97.1%. The average number of percutaneous transluminal angioplasty (PTA) procedures performed per year was compared between the non-KT and KT with failed allograft groups. In the non-KT group, the average number of PTA procedures per year was 1.9 ± 2.4, while in the KT with failed allograft group, it was 1.4 ± 1.1. The difference between the 2 groups was not statistically significant (P = 0.272). Surgical interventions were more frequent in the non-KT group, but the difference was not statistically significant (Table 1). In the non-KT group, 47.7% had radiocephalic fistulas (RCFs) and 37.4% had brachiocephalic fistulas (BCFs), whereas in the KT group, 44.3% had BCF and 32.8% had RCF (Table 2). There was a significant difference in the distribution of AVF types between the KT with allograft failure and non-KT groups (P = 0.024). More endovascular interventions for central vein stenosis were performed in the KT with failed allograft group, but the difference was not statistically significant (Table 3).
Table 1. Baseline characteristics.
Values are presented as number only, mean ± standard deviation, number (%).
KT, kidney transplantation; AVF, arteriovenous fistula; PTA, percutaneous transluminal angioplasty.
Table 2. Type of vascular access.
Values are presented as number (%).
KT, kidney transplantation; AVF, arteriovenous fistula; AVG, arteriovenous graft.
Table 3. Comparison of locations for endovascular intervention.
Values are presented as number (%).
KT, kidney transplantation.
Comparison of primary patency according to kidney transplantation
At the time of VA creation, most KT patients with allograft failure were maintained on low-dose methylprednisolone 5–10 mg/day or deflazacort 6 mg/day, and 54 patients (88.5%) were receiving steroids. Among KT recipients with allograft failure, 7 (11.5%) experienced primary failure, compared with 27 (12.2%) in the non-KT group.
A Kaplan-Meier analysis was performed to compare primary patency between the non-KT and KT with failed allograft groups. The 1-year and 3-year primary patency rates showed no difference between the KT group and the non-KT group (Fig. 1).
Fig. 1. The Kaplan-Meier curves for (A) 1-year primary patency and (B) 3-year primary patency in the kidney transplantation (KT) and non-KT groups.
Based on VA type subgroup, when comparing primary patency according to whether KT was performed, it was found that there was also no difference in patency for both AVF and AVG (Fig. 2).
Fig. 2. The Kaplan-Meier curves for (A) primary patency of arteriovenous fistula (AVF) and (B) primary patency of arteriovenous graft (AVG) in the kidney transplantation (KT) and non-KT groups.
Risk factor analysis for vascular patency
In multivariable Cox regression analysis, KT was not a risk factor for 1-year VA patency (adjusted hazard ratio [aHR], 0.79; 95% confidence interval [CI], 0.43–1.45; P = 0.451) (Table 4). Similarly, KT was not a risk factor for 3-year patency (aHR, 0.79; 95% CI, 0.39–1.59; P = 0.506) (Table 5). Also, lower BMI was a significant risk factor for 3-year patency (aHR, 0.91; 95% CI, 0.84–0.98; P = 0.009) (Table 5). While DM was not a major risk factor for 1-year patency (aHR, 1.47; 95% CI, 0.89–2.44; P = 0.136) (Table 4), it was significant for 3-year patency (aHR, 2.03; 95% CI, 1.12–3.70; P = 0.020) (Table 5).
Table 4. Risk factor assessment for 1-year primary patency of vascular access.
cHR, crude hazard ratio; CI, confidence interval; aHR, adjusted hazard ratio; BMI, body mass index.
Table 5. Risk factor assessment for 3-year primary patency of vascular access.
cHR, crude hazard ratio; CI, confidence interval; aHR, adjusted hazard ratio; BMI, body mass index.
Comparison of infection rates after vascular access
There were no infections among patients who underwent AVF creation. The percentage of AVGs was 18.5% in the total patients and 14.8% in the propensity score-matched cohort. In the non-KT group, 31 (14.0%) had AVGs, compared to 11 (18.0%) in the KT with failed allograft group, indicating a higher proportion of AVGs in the KT with failed allograft group. However, the difference was not statistically significant (P = 0.556). Infection rates were 4.1% (n = 9) in the non-KT group and 3.3% (n = 2) in the KT with failed allograft group, with no significant difference between the groups (P = 0.226).
Risk factor analysis for short-term and long-term patency in kidney transplantation patients with allograft failure
In KT patients with allograft failure, factors such as age, sex, BMI, and comorbidities were not associated with the maintenance of patency during the initial 3-month period following VA (Supplementary Table 1). However, after excluding early failure patients who underwent endovascular or surgical intervention within the first 3 months, a risk factor analysis for long-term patency revealed that the dose of steroids used before VA creation and the use of mTOR inhibitors were significant risk factors for maintaining VA patency (aHR, 1.18; 95% CI, 1.01–1.37; P = 0.038) (Supplementary Table 2). The reasons for surgical interventions are presented in Supplementary Table 3.
DISCUSSION
We analyzed 283 patients who underwent their first VA surgery. This study aimed to compare VAs outcomes, specifically primary patency and infection rates, between KT patients with allograft failure and non-KT patients. The results indicate that there were no significant differences in primary patency or infection rates between the 2 groups.
We used an age- and sex-matched cohort and the proportion of patients who had already initiated dialysis at the time of VA creation was similar between the 2 groups. The proportion of VAs abandoned within 3 months was slightly higher in the non-KT group compared to the KT with failed allograft group, but this difference was not statistically significant (P = 0.845). Kaplan-Meier analysis showed no significant differences in the 1-year and 3-year primary patency rates between the KT with allograft failure and non-KT groups. Cox regression analysis revealed that KT was not a significant risk factor for either 1-year or 3-year VA primary patency.
Conversely, lower BMI was identified as a significant risk factor for long-term primary patency, highlighting the need for careful monitoring and management of patients with lower BMI to ensure VA success. Although there are existing studies reporting an increased risk of AVF maturation failure in patients with severe obesity [23,24], our findings are consistent with previous research showing that underweight patients (BMI <18.5 kg/m2) have lower primary, primary-assisted, and secondary patency rates [25]. Sarcopenia and frailty are common in patients with chronic kidney disease, and prior studies have demonstrated a significant association between frailty and AVF maturation failure [26,27]. There could be several possible reasons why a lower BMI may negatively impact AVF patency, including poor nutritional status and sarcopenia that impair healing, reduced blood flow due to hypotension, and smaller vessels with fragile tissue that increase operative difficulty.
DM was also found to be a significant risk factor for 3-year primary patency, but not for 1-year primary patency. Multiple studies [28,29] have also reported that patients with DM have a significantly higher rate of AVF failure compared to non-diabetic patients, and DM has been identified as an independent risk factor for reduced AVF patency.
Pathophysiology of SLE is associated with immune-complex vasculitis, endothelial dysfunction, and a prothrombotic tendency, all of which can predispose to arterial/venous stenosis, thrombosis, and impaired remodeling. In addition, SLE patients often have chronic inflammation and long-term corticosteroid, immunosuppressant exposure, which can delay wound healing and increase infection risk, further compromising access to outcomes. Consistent with these mechanisms, a prior cohort study reported inferior long-term VA prognosis in hemodialysis patients with SLE. While previous studies have reported poor VAs outcomes in patients with SLE [30], our study did not identify SLE as a risk factor. The differences observed relative to previous studies will require further research.
Infection rates were also similar between the groups, with 4.1% in the non-KT group and 3.3% in the KT with failed allograft group (P = 0.226). This suggests that KT does not significantly increase the risk of infection in AVG patients when appropriate preoperative and postoperative care is provided.
In KT patients with allograft failure, long-term preoperative steroid use, and mTOR inhibitor use were significant risk factors for long-term patency. These findings emphasize the importance of considering these factors when planning and managing VAs in KT patients with allograft failure who are using mTOR inhibitors or have a history of steroid use to minimize complications and improve outcomes.
Systemic corticosteroids can delay wound healing, raise infection risk, and weaken vascular integrity. By contrast, their anti-inflammatory effects may lessen neointimal hyperplasia. We conducted this study under the assumption that the overall effect may depend on the timing of steroid administration and differ between the early and late stages of VAs maturation. Although not statistically significant, AVGs appear to show better patency in the KT with the failed allograft group. This may suggest a possible benefit of anti-inflammatory or immunosuppressive therapy on VA outcomes.
Several studies have reported that local application of mTOR inhibitors such as sirolimus-coated balloons or intraperitoneal administration, reduces AVF intimal hyperplasia [31]. In our cohort, however, mTOR inhibitors were discontinued in most cases either before surgery or within one year postoperatively. Thus, it is possible that any association with reduced VA patency reflects primarily preoperative systemic effects on patient conditions (e.g., increased fragility, thin vessel wall), rather than sustained postoperative therapy. The underlying mechanisms require further investigation.
At our institution, the transplantation and vascular surgery teams work closely together, performing over 180 cases of KTs and over 300 VA procedures annually. Consequently, we frequently encounter patients who have undergone KT and subsequently experienced graft failure, requiring VA creation. This provides a unique opportunity to study VAs outcomes specifically in KT patients with allograft failure.
In the non-KT group, 47.7% had RCF and 37.4% had BCF, whereas in the KT with failed allograft group, 44.3% had BCF and 32.8% had RCF. The comparable patency outcomes observed between the groups may be attributed to our thorough preoperative evaluations, which consider various patient conditions and optimize their surgical plan. Preoperative vascular mapping is routinely performed to evaluate factors such as vascular calcification, diameter, and blood flow, previous central catheterization history, and underlying comorbidities. Such well-programmed VAs can improve patient outcomes [32,33,34], and we speculate that the similar patency rates observed in KT patients with allograft failure at our institution are due to this reason.
Interestingly, despite initially hypothesizing that KT patients with allograft failure would have more central vein stenosis due to more frequent use of tunneled central venous catheters for desensitization and dialysis, the actual insertion history did not differ significantly between the groups. Most tunneled central venous catheters (98.6%) were placed on the right side, with only 3 patients having VAs created on the ipsilateral side; none of these patients developed central venous stenosis. The only patient with a left VA created on the ipsilateral side of tunneled central venous catheter insertion had no central vein stenosis. Therefore, previous tunneled central venous catheter insertion history alone does not explain the higher central vein stenosis rates in KT patients with allograft failure. It would be beneficial to analyze the reasons through further studies.
The study’s strengths include the use of a well-defined cohort and comprehensive follow-up protocols. However, it also has limitations. Given the retrospective design, records of external interventions (e.g., PTA) may be incomplete, especially for patients whose VAs matured and who did not return for regular follow-up, introducing potential bias. In addition, the study’s sample size and single-center design might limit the generalizability of the findings. Although we did not analyze ESRD etiology in the present study, given the absence of differences in general comorbidities between groups, we consider it unlikely that ESRD etiology materially influenced VA patency.
This study suggests that with meticulous preoperative planning and postoperative care, the outcomes of VAs in KT patients with allograft failure can be comparable to those in non-KT patients. However, specific risk factors such as lower BMI, DM, long-term steroid use, and mTOR inhibitors should be carefully managed to optimize VA patency and minimize complications.
Footnotes
Fund/Grant Support: None.
Conflicts of Interest: No potential conflict of interest relevant to this article was reported.
- Conceptualization, Formal Analysis, Investigation: MK, SJK.
- Data curation: MK, SJK, HHK, YJY.
- Methodology: MK, SJK, SHH.
- Writing – Original Draft: MK, SJK.
- Writing – Review & Editing: SJK, SHH.
SUPPLEMENTARY MATERIALS
Supplementary Tables 1–3 can be found via https://doi.org/10.4174/astr.2026.110.2.104.
Risk factor assessment for short-term patency of vascular access in kidney transplantation patients with allograft failure
Risk factor assessment for long-term patency of vascular access in kidney transplantation patients with allograft failure
Reasons for surgical interventions
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Associated Data
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Supplementary Materials
Risk factor assessment for short-term patency of vascular access in kidney transplantation patients with allograft failure
Risk factor assessment for long-term patency of vascular access in kidney transplantation patients with allograft failure
Reasons for surgical interventions