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A few previous reports propose that there could be a deceleration of eGFR decline trajectory following vascular access creation and postulated mechanisms for such observed improved renal function remain speculative and unproven. Our recent observation of the dramatic doubling of eGFR about five months following the creation of an upper extremity aretriovenous fistula in preparation for initiation of renal replacement therapy calls for further inquiry.
Case Report.
A 56-yo male with previously uncontrolled diabetes mellitus, hypertension and sleep apnea, with biopsy-proven diabetic nephropathy had experienced accelerated CKD progression in late 2023-2024. At the time, he was on Amlodipine 10 mg/d, Losartan-Hydrochlorothiazide 100-25 mg/d, Spironolactone 25 mg/d, insulin and levothyroxine. Work up of acute kidney injury in November 2023 was negative. Due to concerns for possible drug-induced nephrotoxicity, Losartan 100 mg daily, was discontinued in March 2024. Renal ultrasound was non-diagnostic in April 2024. Kidney biopsy in May 2024 revealed diabetic nephropathy. In May 2024, he developed transient hypercalcemia of 11.7 mg/dL, one month after starting TUMS for phosphorus binder. TUMS was promptly replaced with Sevelamer and hypercalcemia quickly resolved. Nevertheless, CKD progression persisted, with serum creatinine at 5.54 mg/dL (eGFR=11) in early October 2024 (FIGURE). LVEF was 60-65%, and RV systolic function was normal in November 2024. The successful creation of a percutaneous left arm perforator vein to radial artery AVF in late November 2024 with a Medtronic Ellipsys Device was followed by an elective balloon angioplasty and 4 mm coil embolization of a venous side branch of the AVF after 3 weeks. Then followed an elective left basilic vein ligation in mid-March 2025, after Doppler review of the AVF. As at last Nephrology Clinic in mid-April 2025, serum creatinine had decreased to 3.22 mg/dL (eGFR=22) (FIGURE). Blood pressure during the April visit 127/77 mm Hg and the patient felt well.
During the Nephrology Clinic visit in late April 2025, the patient feeling generally good had stated inter alia "I was also surprised by the improved kidney function".
We have described a spontaneous and dramatic doubling of eGFR from 11 to 22 ml/min/1.73 square meters BSA in a span of 5 months following the surgical creation of a left arm perforator vein to radial artery AVF with Medtronic Ellipsys. What are the implications of this observation? Would such improvements in eGFR be related to the mechanics of an AVF creation or would it have any specific causal relationship with the use of the Medtronic Ellipsys Device? Answers to these questions will for now only remain speculative.
Our observations call for further inquiry.
Similar content was submitted to the American Society of Nephrology 2025 Kidney Week.
