High-flow arteriovenous fistula is not associated with increased extracellular volume or right ventricular dysfunction in haemodialysis patients

Nephrol Dial Transplant. 2021 Feb 20;36(3):536-543. doi: 10.1093/ndt/gfaa188.


Background: High-output congestive heart failure secondary to high-flow arteriovenous fistula (AVF) has been reported in haemodialysis (HD) patients. As high-flow AVF (HFA) would be expected to result in fluid retention, we conducted an observational study to characterize the relationship between AVF flow (Qa) and extracellular water (ECW) in HD patients.

Methods: We measured Qa by ultrasound dilution in prevalent HD outpatients with an AVF in two dialysis centres. The ECW:total body water (TBW) ratio was measured both pre- and post-dialysis by multifrequency bioimpedance analysis. Transthoracic echocardiograms (TTEs) were performed as part of routine clinical management.

Results: We included 140 patients, mean age 62.7 ± 15.7 years, 60.7% male, 47.9% diabetic and 22.9% with coronary revascularization. Mean Qa was 1339 ± 761 mL/min and 22 (15.7%) patients had HFA defined as Qa >2.0 L/min. Qa was positively associated with an upper arm AVF (P = 0.005), body mass index (P = 0.012) and N-terminal pro-brain natriuretic peptide (NT-proBNP) (P = 0.047) and negatively associated with diabetes (P < 0.001) and coronary revascularization (P = 0.005). The ECW:TBW ratio was positively associated with age (P < 0.001), Davies comorbidity index (P = 0.034), peripheral vascular disease (P = 0.030) and NT-proBNP (P = 0.002) and negatively associated with serum albumin (P < 0.001). Qa was not associated with the ECW:TBW ratio (P = 0.744). TTE parameters were not associated with Qa.

Conclusions: In our outpatient HD cohort, high AVF flow was not associated with ECW expansion, either pre- or post-dialysis when accounting for potential confounders. By controlling ECW, high access flow should not necessarily be perceived as a threat to cardiovascular physiology.

Keywords: arteriovenous fistula; bioimpedance; echocardiography; extracellular volume; haemodialysis.

MeSH terms

  • Arteriovenous Fistula / diagnosis
  • Arteriovenous Fistula / etiology*
  • Arteriovenous Fistula / pathology
  • Female
  • Humans
  • Male
  • Middle Aged
  • Natriuretic Peptide, Brain / metabolism
  • Peptide Fragments / metabolism
  • Prognosis
  • Renal Dialysis / adverse effects*
  • Ventricular Dysfunction, Right / complications*
  • Water-Electrolyte Imbalance / complications*


  • Peptide Fragments
  • pro-brain natriuretic peptide (1-76)
  • Natriuretic Peptide, Brain