LIGATION VERSUS MAINTENANCE OF ARTERIOVENOUS FISTULA IN KIDNEY TRANSPLANT RECIPIENTS: CARDIOVASCULAR IMPLICATIONS AND LONG-TERM OUTCOMES — A SYSTEMATIC REVIEW AND META-ANALYSIS

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Abstract Title *

LIGATION VERSUS MAINTENANCE OF ARTERIOVENOUS FISTULA IN KIDNEY TRANSPLANT RECIPIENTS: CARDIOVASCULAR IMPLICATIONS AND LONG-TERM OUTCOMES — A SYSTEMATIC REVIEW AND META-ANALYSIS

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Co-author 1

Putu Agus Marciyasa dr.marciyasa@gmail.com Prof. dr. I G. N. G. Ngoerah General Hospital Denpasar Student of Sub Specialist Study Program, Concentration of Nephrology and Hypertension, Faculty of Medicine Udayana University Denpasar Indonesia *

Co-author 2

Nyoman Paramita Ayu drparamitaayu@gmail.com Udayana University Department of Internal Medicince, Faculty of Medicine Udayana University Denpasar Indonesia -

Co-author 3

I Gde Raka Widiana rakawidiana@yahoo.com Udayana University Department of Internal Medicince, Faculty of Medicine Udayana University Denpasar Indonesia -

Co-author 4

Yenny Kandarini yenny_kandarini@unud.ac.id Udayana University Department of Internal Medicince, Faculty of Medicine Udayana University Denpasar Indonesia -

Co-author 5

Gede Wira Mahadita wira_mahadita@unud.ac.id Udayana University Department of Internal Medicince, Faculty of Medicine Udayana University Denpasar Indonesia -

Co-author 6

Co-author 7

Co-author 8

Co-author 9

Co-author 10

Co-author 11

Co-author 12

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Introduction

The management of arteriovenous fistula (AVF) after kidney transplantation remains debated. Persistent AVF patency may cause chronic cardiac overload, while ligation could reverse hemodynamic strain but risks loss of future dialysis access. This systematic review and meta-analysis evaluated the left ventricular, renal, and mortality of AVF ligation versus maintenance in kidney transplant recipients.

Methods

A comprehensive search of PubMed, ScienceDirect, and Cochrane Library (up to October 2025) identified studies comparing AVF ligation and maintenance. Data were synthesized using fixed- or random-effects models and expressed as mean differences (MD) or odds ratios (OR) with 95% confidence intervals (CI). Study quality was assessed using the Newcastle–Ottawa Scale.

Results

Eleven studies (n ≈ 18,000) met inclusion criteria. AVF ligation significantly reduced left ventricular mass (MD −23.69 g; 95% CI −35.93 to −11.44) and left ventricular mass index (MD −12.91 g/m²; 95% CI −19.43 to −6.38; p < 0.001). Renal function remained stable with no change in serum creatinine (MD −0.00; 95% CI −0.28 to 0.28) and improved eGFR (MD +0.29 mL/s/1.73 m²; p < 0.00001). Ligation markedly lowered AVF-related complications (OR 0.17; 95% CI 0.14–0.21) without increasing mortality (OR 0.77; 95% CI 0.54–1.09; p = 0.14).

Conclusion

AVF ligation after kidney transplantation improves cardiac remodeling, preserves renal function, but there is no different between mortality. Elective ligation is a safe, beneficial option for stable transplant recipients, especially those with high-flow AVFs or cardiac strain.

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