Published online Mar 25, 2026. doi: 10.5527/wjn.v15.i1.115895
Revised: November 24, 2025
Accepted: January 7, 2026
Published online: March 25, 2026
Processing time: 137 Days and 7.3 Hours
Arteriovenous fistulae (AVFs) are the preferred mode of vascular access amongst patients with end-stage kidney disease, and many remain patent following kidney transplantation. While emerging evidence demonstrates cardiovascular benefits to AVF ligation post-transplantation, current guidelines provide no clear consensus on the management of functioning AVFs post-transplant. Additionally, the impact of AVF ligation on allograft outcomes is unclear. Therefore, clarifying the po
To investigate the clinical impact of AVF ligation post-transplantation and compare the outcomes in kidney transplant recipients on dialysis via a central venous catheter (CVC) vs AVF prior to transplantation.
Kidney transplant recipients who had undergone AVF ligation or excision at a single center (n = 176) were identified using electronic health records. Two co
There were significant differences in patient characteristics between transplant recipients undergoing post-transplant AVF ligation vs non-ligation; the former were more likely to be female (P = 0.045), younger (P = 0.002), and non-diabetic (P < 0.001). There were further differences in patient and allograft characteristics between recipients with pre-transplant AVF vs CVC. Patients receiving dialysis via pre-transplant CVC had superior death-censored allograft survival compared with patients with pre-transplant AVFs [hazard ratio (HR): 0.74, 0.57-0.97, P = 0.028]. Post-transplant AVF ligation was associated with improved death-censored allograft survival amongst kidney transplant recipients compared to non-ligation (HR: 0.42, 0.26-0.66, P < 0.001). There were no differences in mortality rates.
Post-transplant AVF ligation may improve allograft survival. However, due to significant differences between patients undergoing AVF ligation vs non-ligation, these findings are susceptible to selection bias and should be interpreted cautiously. Randomized controlled trials are needed in patient groups who may stand to benefit the most from cardiovascular protection from AVF ligation.
Core Tip: This study examines long-term outcomes following arteriovenous fistula (AVF) ligation in kidney transplant recipients, a topic with limited prior evidence. In this large, single-center cohort with extended follow-up, post-transplant AVF ligation was independently associated with improved death-censored allograft survival without differences in patient mortality. Furthermore, recipients who were “AVF-free” from transplantation, having previously been on dialysis via central venous catheter, demonstrated similarly superior allograft survival compared to those with pre-transplant AVFs. These findings suggest that the presence of AVFs may influence graft longevity, and post-transplant ligation may confer graft survival benefits in addition to previously reported cardiovascular advantages.
- Citation: Zhu JX, Willicombe M, Crane JS. Long-term outcomes following arteriovenous fistula ligation in kidney transplant recipients. World J Nephrol 2026; 15(1): 115895
- URL: https://www.wjgnet.com/2220-6124/full/v15/i1/115895.htm
- DOI: https://dx.doi.org/10.5527/wjn.v15.i1.115895
Arteriovenous fistulae (AVFs) are the preferred mode of vascular access amongst patients with end-stage kidney disease (ESKD)[1,2]. However, international guidelines provide no recommendations on the management of functioning AVFs following successful renal transplantation[3-5]. Due to the paucity of strong clinical evidence, current management of patent AVFs post-transplant is largely driven by physician and patient preferences and remains inconsistent across patient populations[6].
In most patients, pre-existing AVFs remain patent and functional following renal transplantation. Patient preference, such as cosmetic concerns, is the predominant reason for post-transplant AVF ligation or excision; medically-driven reasons include pain, aneurysm formation, high-output heart failure, as well as steal syndrome[7]. AVF ligation or excision may also be considered for its potential cardioprotective effects[8,9], which are particularly important given the burden of cardiovascular mortality amongst renal transplant recipients[10,11]. The decision against ligating patent AVFs is often made to preserve vascular access, which may be necessary in the case of graft failure. The relationship between AVF ligation post-transplant and allograft outcomes is currently unclear. Previous studies have found improvements in allograft function and reductions in risk of future allograft loss following AVF ligation post-transplant[12-14]. In contrast, more recent studies have found no significant changes in estimated glomerular filtration rates (eGFR), allograft failure risk or patient mortality with AVF ligation post-transplant[8,15], which were sustained even with long-term follow-up[9,16]. Without any clear consensus on the benefits of AVF ligation in kidney transplant patients, surgical ligation of asymptomatic fistulae following transplantation remains controversial and is potentially an underutilized aspect of post-transplant care.
The study’s primary aim is to investigate the effect of post-transplant AVF ligation on patient and allograft outcomes in a large cohort of kidney transplant recipients with long-term follow-up. Patient characteristics and peri-transplant clinical variables associated with AVF ligation, allograft function and survival were analyzed. Additionally, the study aims to compare the outcomes in kidney transplant recipients who received hemodialysis via an AVF vs a tunneled central venous catheter (CVC) prior to transplantation, the latter group being ‘AVF-free’ from point of transplant.
All kidney transplant recipients who had undergone post-transplant AVF ligation between March 2008 and June 2022 at Imperial College Healthcare NHS Trust were retrospectively identified using electronic medical records. Clinical demographic and transplant outcome data were obtained using a prospectively maintained transplant database.
Cases were defined as kidney transplant recipients who underwent surgical intervention to terminate fistula flow, including both AVF ligation and complete excision, at any time following kidney transplantation and prior to allograft failure or death. For consistency, the term ‘AVF ligation’ is used throughout the manuscript to refer to both procedures. All patients were included regardless of indication for AVF ligation; at our center, the main indication for AVF ligation was patient-initiated requests in the setting of stable graft function at least 1 year post-transplant. Cases were matched by date of transplant against two comparator groups at a 1:2 ratio: Patients without documented AVF ligation, previously receiving hemodialysis via an AVF pre-transplant, and patients without documented AVF ligation, previously receiving hemodialysis via a tunneled CVC pre-transplant.
The outcomes of interest were allograft outcomes in transplant recipients with AVFs, stratified by post-transplant ligation status. As recipients dialyzed via a CVC may be considered ‘AVF-free’ from time of transplantation, outcomes were also compared by type of hemodialysis access at time of transplant (AVF vs CVC). The study was approved by the West of Scotland Research Ethics Committee (20/WS/0181). The approval includes the reporting of anonymized routinely collected clinical data, without individualized informed consent.
All statistical analyses were performed using IBM SPSS Statistics software version 26. Comparisons of means and frequencies of normally distributed variables were performed using t-tests and χ2 tests. The Mann-Whitney U test was used for non-parametric variables.
Survival curves were estimated using the Kaplan-Meier method and compared using log-rank testing. Risk-adjusted Cox proportional hazards regression was used to calculate hazard ratios (HRs) and 95% confidence intervals (CI). Proportional hazards assumptions were checked graphically. Cox regression with time-varying covariates was used to compare allograft outcomes in patients following AVF ligation vs non-intervention. For allograft and patient survival, we investigated the effect of multiple predictor variables that could be associated with outcomes, including age, gender, ethnicity, cause of ESKD, time at ESKD, type of donor, allograft number, induction, diabetes, total human leukocyte antigen (HLA) mismatch, HLA sensitization, in addition to type of hemodialysis access (and management thereof). Potentially significant variables (P < 0.15) identified by univariable analysis were included in the multivariable analysis. Repeated measures analysis of allograft function was performed using Friedman’s test. A two-sided P < 0.05 was deemed statistically significant.
One hundred and seventy-six patients who had undergone AVF ligation post-transplant between March 2008 and June 2022 were identified. They were matched with 352 patients without post-transplant AVF ligation, as well as 352 patients who had undergone hemodialysis via a CVC pre-transplant (Table 1). Most patients who underwent AVF ligation had a brachiocephalic AVF (n = 124, 70.1%); 37 patients (20.9%) had a radiocephalic AVF, 1 patient (0.6%) had a saphenofemoral fistula, and fistula anatomy was not available in 15 (8.5%) cases. Median duration to AVF ligation post-transplant was 25 (12-56) months, and median duration of follow-up post-ligation was 90 (47-117) months.
| AVF ligation, n = 176 | No AVF ligation, n = 352 | P value | All AVF, n = 528 | CVC, n = 352 | P value | |
| Sex | ||||||
| Female | 52 (29.5) | 76 (21.6) | 0.045 | 128 (24.2) | 125 (35.5) | < 0.001 |
| Male | 124 (70.5) | 276 (78.4) | 400 (75.8) | 227 (64.5) | ||
| Age at Tx | ||||||
| Years (median) | 50 (40-59) | 54 (45-63) | 0.002 | 53 (43-62) | 52 (42-62) | 0.38 |
| Ethnicity | ||||||
| Black | 25 (14.2) | 68 (19.3) | 0.2 | 93 (17.6) | 73 (20.7) | 0.013 |
| Caucasian | 60 (34.1) | 94 (26.7) | 154 (29.2) | 114 (32.4) | ||
| Indoasian | 64 (36.5) | 125 (35.5) | 189 (35.8) | 131 (37.2) | ||
| Other | 27 (15.3) | 65 (18.5) | 92 (17.4) | 34 (9.7) | ||
| Cause of ESKD | ||||||
| APKD | 20 (11.4) | 38 (10.8) | < 0.001 | 58 (11.0) | 28 (8.0) | 0.09 |
| Diabetes | 27 (15.3) | 106 (30.1) | 133 (25.2) | 86 (24.4) | ||
| GN | 62 (35.2) | 82 (23.3) | 144 (27.3) | 78 (22.2) | ||
| Other | 9 (5.1) | 35 (9.9) | 44 (8.3) | 34 (9.7) | ||
| Unknown | 54 (30.7) | 74 (21.0) | 128 (24.2) | 103 (29.3) | ||
| Urological | 4 (2.3) | 17 (4.8) | 21 (4.0) | 23 (6.5) | ||
| Time at ESKD | ||||||
| Years (median) | 3.5 (1.8-5.8) | 2.7 (1.5-4.6) | 0.023 | 2.9 (1.6-5.0) | 2.9 (1.3-5.7) | 0.95 |
| Transplant type | ||||||
| LD | 24 (13.6) | 41 (11.6) | 0.09 | 65 (12.3) | 99 (28.1) | < 0.001 |
| DD | 136 (77.3) | 297 (84.4) | 433 (82.0) | 220 (62.5) | ||
| SPK | 8 (4.5) | 7 (2.0) | 15 (2.8) | 21 (6.0) | ||
| Antibody incompatible | 8 (4.5) | 7 (2.0) | 15 (2.8) | 12 (3.4) | ||
| Diabetes | ||||||
| Yes | 34 (19.3) | 135 (38.5) | < 0.001 | 169 (32.1) | 121 (34.4) | 0.48 |
| No | 142 (80.7) | 216 (61.5) | 358 (67.9) | 232 (65.6) | ||
| Graft number | ||||||
| 1st | 155 (88.1) | 318 (90.3) | 0.42 | 473 (89.6) | 300 (85.2) | 0.05 |
| ≥ 2nd | 21 (11.9) | 34 (9.7) | 55 (10.4) | 52 (14.8) | ||
| Induction | ||||||
| Alemtuzumab | 150 (85.2) | 314 (89.2) | 0.19 | 465 (88.1) | 298 (84.7) | 0.14 |
| IL2 | 26 (14.8) | 38 (10.8) | 63 (11.9) | 54 (15.3) | ||
| DGF | ||||||
| No | 139 (79.0) | 245 (69.6) | 0.02 | 384 (72.7) | 260 (73.9) | 0.71 |
| Yes | 37 (21.0) | 107 (30.4) | 144 (27.3) | 92 (26.1) | ||
| HLA sensitization status | ||||||
| Non-sensitized | 119 (67.6) | 235 (66.8) | 0.92 | 354 (67.0) | 229 (65.1) | 0.33 |
| Sensitized | 48 (27.3) | 101 (28.7) | 149 (28.2) | 98 (27.8) | ||
| Preformed | 9 (5.1) | 16 (4.5) | 25 (4.7) | 25 (7.1) | ||
| Total HLA mismatch | ||||||
| Median ABDR | 3 (3-4) | 3 (3-4) | 0.29 | 3 (3-4) | 3 (3-4) | 0.73 |
| Duration of follow-up | ||||||
| Months (median) | 128 (83-177) | 82 (54-121) | < 0.001 | 96 (58-145) | 123 (72-173) | < 0.001 |
There were significant differences in characteristics between patients who underwent AVF ligation vs those who did not (Table 1). Patients who underwent AVF ligation were more likely to be female (P = 0.045), younger at time of transplant (P = 0.002), non-diabetic (P < 0.0001), and less likely to have experienced delayed graft function (P = 0.02). In addition, the AVF ligation group had longer duration of follow-up post-transplant (P < 0.001) compared to the non-ligation group.
When comparing all patients with pre-transplant AVFs to those with CVCs, there were also statistically significant differences in patient characteristics (Table 1). A higher proportion of patients with pre-transplant AVFs were male (P < 0.001), and they were more likely to have received deceased donor kidney transplants (P < 0.0001).
Analysis of peri-transplant clinical variables associated with allograft outcomes is shown in Table 2. Considering access type at the time of transplantation alone, there was no difference in all-cause allograft survival between patients with pre-transplant AVFs vs those with pre-transplant CVC (P = 0.37, log-rank). Univariable analyses were subsequently performed for the two components of all-cause allograft loss: Death-censored allograft survival and death with a functioning graft. In comparison with pre-transplant CVC, pre-transplant AVF was associated with inferior death-censored allograft survival (P = 0.02, log-rank), with no association with death with a functioning graft (P = 0.38, log-rank).
| Univariate | Multivariate | |||||
| HR | 95%CI | P value | HR | 95%CI | P value | |
| All-cause allograft survival | ||||||
| Age (years) | 1.03 | 1.02-1.03 | < 0.001 | 1.02 | 1.01-1.03 | < 0.001 |
| Black ethnicity | 1.21 | 0.95-1.55 | 0.13 | |||
| Female | 0.82 | 0.65-1.02 | 0.08 | |||
| Diabetes | 1.66 | 1.35-2.03 | < 0.001 | 1.46 | 1.18-1.81 | < 0.001 |
| Time at ESKD | 1.04 | 1.01-1.07 | 0.003 | 1.03 | 1.00-1.06 | 0.04 |
| Living donor transplant | 0.76 | 0.60-0.97 | 0.025 | |||
| Total HLA mismatch | 1.08 | 1.00-1.16 | 0.04 | |||
| Delayed graft function | 1.91 | 1.55-2.36 | < 0.001 | 1.68 | 1.36-2.08 | < 0.001 |
| CVC | 0.91 | 0.75-1.12 | 0.37 | |||
| Death with a functioning graft | ||||||
| Age (years) | 1.07 | 1.05-1.08 | < 0.001 | 1.06 | 1.05-1.08 | < 0.001 |
| Female | 1.03 | 0.43-0.91 | 0.015 | 0.64 | 0.43-0.94 | 0.021 |
| Diabetes | 1.96 | 1.43-2.69 | < 0.001 | 1.57 | 1.13-2.19 | 0.008 |
| Time at ESKD | 1.05 | 1.01-1.09 | 0.013 | |||
| Living donor transplant | 0.62 | 0.42-0.92 | 0.019 | |||
| Delayed graft function | 1.82 | 1.31-2.54 | < 0.001 | |||
| CVC | 1.15 | 0.84-1.57 | 0.38 | |||
| Death-censored allograft survival | ||||||
| Black ethnicity | 1.35 | 0.99-1.85 | 0.06 | |||
| Diabetes | 1.48 | 1.13-1.95 | 0.005 | 1.48 | 1.11-1.97 | 0.007 |
| Time at ESKD | 1.03 | 0.999-1.07 | 0.05 | |||
| No alemtuzumab induction | 1.34 | 0.96-1.87 | 0.09 | |||
| Total HLA mismatch | 1.10 | 1.00-1.21 | 0.043 | |||
| Delayed graft function | 2.01 | 1.54-2.64 | < 0.001 | 1.80 | 1.37-2.38 | < 0.001 |
| CVC | 0.74 | 0.56-0.96 | 0.023 | 0.74 | 0.57-0.97 | 0.028 |
On multivariable analysis (Table 2), increasing age at transplantation (HR: 1.02, 1.01-1.03, P < 0.0001), diabetes (HR: 1.46, 1.18-1.82, P < 0.001) and delayed graft function (DGF) (HR: 1.67, 1.34-2.07, P < 0.0001) were independently associated with all-cause allograft loss. Increasing age at transplantation (HR: 1.06, 1.05-1.08, P < 0.0001), diabetes (HR: 1.57, 1.27-2.20, P = 0.008) and DGF (HR: 1.42, 1.00-2.02, P = 0.048) were also associated with an increased risk of death with a functioning graft, while female sex was protective (HR: 0.64, 0.43-0.94, P = 0.021). Both diabetes (HR: 1.48, 1.12-1.97, P = 0.007) and DGF (HR: 1.80, 1.37-2.38, P < 0.0001) were associated with death-censored allograft loss, while pre-transplantation CVC remained independently associated with superior allograft survival (HR: 0.74, 0.57-0.97, P = 0.028).
Analysis of allograft outcomes comparing patients with and without post-transplant AVF ligation is presented in Table 3. Only patients with pre-transplant AVFs were included in this analysis. Additional details on cause of death and allograft loss are available in the Supplementary material. Using a Cox regression model with time-varying events, we found that post-transplant AVF ligation was associated with improved all-cause allograft survival (HR: 0.64, 0.46-0.90, P = 0.011). AVF ligation was not associated with death with a functioning graft (HR: 1.25, 0.76-2.06, P = 0.39) but significantly improved death-censored allograft survival (HR: 0.41, 0.26-0.65, P < 0.001).
| Univariate | Multivariate | |||||
| HR | 95%CI | P value | HR | 95%CI | P value | |
| All-cause allograft survival | ||||||
| Age (years) | 1.02 | 1.01-1.03 | < 0.001 | 1.02 | 1.01-1.03 | < 0.001 |
| Diabetes | 1.59 | 1.18-2.14 | 0.002 | 1.59 | 1.20-2.10 | 0.001 |
| Time at ESKD | 1.03 | 0.99-1.07 | 0.14 | |||
| Living donor transplant | 0.67 | 0.43-1.05 | 0.08 | |||
| Delayed graft function | 1.53 | 1.15-2.03 | 0.004 | 1.56 | 1.18-2.06 | 0.002 |
| AVF ligation | 0.73 | 0.52-1.03 | 0.072 | 0.72 | 0.51-1.01 | 0.059 |
| Death with a functioning graft | ||||||
| Age (years) | 1.08 | 1.06-1.11 | < 0.001 | 1.08 | 1.05-1.10 | < 0.001 |
| Diabetes | 1.89 | 1.18-3.04 | 0.009 | 2.02 | 1.30-3.16 | 0.002 |
| Living donor transplant | 0.43 | 0.17-1.08 | 0.072 | 0.39 | 0.15-0.96 | 0.042 |
| AVF ligation | 1.55 | 0.93-2.58 | 0.1 | |||
| Death-censored allograft survival | ||||||
| Diabetes | 1.41 | 0.98-2.04 | 0.067 | |||
| Time at ESKD | 1.03 | 0.99-1.08 | 0.14 | |||
| Delayed graft function | 1.71 | 1.20-2.44 | 0.003 | 0.85 | 1.31-2.59 | < 0.001 |
| AVF ligation | 0.43 | 0.27-0.69 | < 0.001 | 0.42 | 0.26-0.66 | < 0.001 |
We next performed multivariable analysis using clinical factors significantly associated with the respective clinical outcome on univariable analysis (Table 3). Notably, AVF ligation was independently associated with improved death-censored allograft survival (HR: 0.42, 0.26-0.66, P < 0.001) after adjustment for clinical confounders. In contrast, AVF ligation was not significantly associated with all-cause allograft survival (HR: 0.72, 0.51-1.01, P = 0.059).
Multivariable analysis of other clinical factors remained significant across outcomes. All-cause allograft loss was associated with increasing age at transplantation (HR: 1.02, 1.01-1.03, P < 0.001), diabetes (HR: 1.59, 1.20-2.10, P = 0.001) and DGF (HR: 1.56, 1.18-2.06, P = 0.002). When considering death with a functioning graft, diabetes was independently associated with increased risk of death (HR: 2.53, 1.63-3.92, P < 0.001), while receipt of a living donor transplant was associated with superior survival (HR: 0.65, 0.14-0.86, P = 0.022). DGF was also associated with increased risk of death-censored allograft loss (HR: 1.85, 1.31-2.59, P < 0.001).
Longitudinal measures of eGFR were collected at 12 months post-transplant, at time of AVF ligation, and at 6 and 12 months post-ligation. At 12-months post-transplant, the AVF ligation group had significantly higher median eGFR (55 mL/minute, 43-72 mL/minute) compared to the non-ligation group (44 mL/minute, 30-61 mL/minute, P < 0.001). During this period, 2 patients (1.1%) in the ligation group and 38 patients (10.8%) in the non-ligation group died or experienced allograft failure. Longitudinally, there was no improvement in graft function following AVF ligation; median eGFR at time of ligation, 6-months and 12-months post-ligation was 50 mL/minute (41-66 mL/minute), 52 mL/minute (41-67 mL/minute) and 51 mL/minute (40-66 mL/minute), respectively (P = 0.837). Three patients (1.7%) experienced death or graft loss 6 months post-ligation, and 1 patient (0.58%) at 12 months post-ligation.
In this study, we demonstrated that AVF ligation following successful renal transplantation is independently associated with superior death-censored allograft survival amongst kidney transplant recipients. No association between AVF ligation and patient survival was found. Importantly however, there were significant differences in both patient and allograft characteristics in those undergoing AVF ligation vs non-ligation, which may influence our observations.
The current relationship between AVF ligation and allograft function is unclear. Vajdič et al[12] demonstrated significant improvements in eGFR 1 year post-AVF ligation compared to patients with patent AVFs; however, Weekers et al[13] demonstrated the opposite, with a significant decrease in eGFR after AVF ligation. Other retrospective studies have not found an association between allograft function and AVF status[8,9,16]. While we found superior death-censored allograft survival in patients who had undergone AVF ligation, this was not accompanied by improvements in allograft function in patients over a 12-month follow-up period. Intriguingly, patients with pre-transplant CVCs, effectively ‘AVF free’ from the time of transplant, also demonstrated superior allograft survival compared to patients with functioning AVFs, further supporting a possible association between being ‘AVF-free’ and improved graft survival. However, given the conflicting evidence, our current understanding of the effect of AVF closure on kidney allograft function remains rudimentary and requires further investigation.
One proposed mechanism for observed improvements in function following AVF ligation is a theoretical increase in graft perfusion. This is based on the understanding that AVFs create a low-resistance compartment, which attenuates increases in arterial stiffness and arterial pressure[17]. Magnetti et al[18] described a decrease in graft resistive index, a well-established predictor of graft survival[19-21], amongst kidney transplant recipients following AVF ligation. Allograft function is not the only consideration when managing AVFs post-transplant, and existing studies have largely focused on the cardiovascular impacts of AVFs. AVF formation is strongly correlated with maladaptive cardiac remodeling through various complex and multifactorial processes[22,23], eventually leading to increased left ventricular (LV) mass, which is a robust predictor of adverse cardiovascular events amongst both kidney transplant recipients and the general population[24]. Several cohort and prospective studies have shown an association between AVF ligation post-transplant and improvements in various cardiac indices, including LV end-diastolic diameter, LV mass and cardiac output[25-27]. A multicenter randomized controlled trial by Rao et al[8] supported these findings by demonstrating various improvements in cardiac morphology and function in renal transplant recipients post-AVF ligation, which were sustained through 5-year follow-up[8,9]. Given the significant burden of cardiovascular mortality amongst kidney transplant recipients[10,11], these potential cardioprotective effects are an important consideration in the discussion around AVF ligation. The present study proposes an additional benefit of AVF ligation: The improvement in allograft survival.
Our center offers AVF ligation for patients with stable allograft function 1 year-post-transplant, predominantly at the patient’s request. This likely introduces bias towards improved survival, and also highlights that patients who may have increased cardiovascular benefits from ligation, such as older male patients with diabetes, are the ones least likely to be offered the intervention[10,11]. Traditionally, the rationale for preserving functioning AVFs post-transplant is largely to maintain vascular access in case return to hemodialysis is necessary. Recent studies have shown the 5-year death-censored allograft survival amongst kidney transplant recipients to be 79.6%, representing significant improvements in graft survival compared to previous decades[28,29]. Findings from the present study suggest that AVF ligation post-transplant could result in further improvements in allograft survival, and discussions around AVF ligations should balance these potential benefits with the chances of requiring future vascular access. Data on the natural patency of AVFs post-transplant, estimated at 7.9 years post-transplant[30], is also important to support such decision-making.
This study has several important limitations, some of which have already been addressed. Due to the retrospective nature of this study, heterogeneity between cases and control populations exists, which is unlikely to be fully adjusted for in our models. The lack of data regarding AVF patency in the non-intervention group is a significant limitation, and such data, if available, would have been included in our time-varying event analysis. While patient preference was the most common indication for AVF ligation, more data regarding indications would improve the comprehensiveness of our analysis. Data on flow rates of all AVFs in both the ligation and non-intervention groups would have enriched our dataset, in addition to cardiac assessments. Nevertheless, our dataset includes a large and diverse population with long-term follow-up. We have therefore been able to describe adjusted allograft survival following AVF ligation as a novel finding. We have also included comparative data on survival post-transplant by dialysis access, demonstrating the differences between the cohorts, which are likely to influence the corresponding outcome.
In conclusion, we have shown superior long-term allograft survival amongst kidney transplant recipients with post-transplant AVF ligation, without differences in patient survival. However, an important caveat is the significant differences in patient and allograft characteristics between the cohorts, which would have resulted in a significant selection bias in favor of better outcomes in the AVF ligation group. Considering these limitations, the evidence on the absolute benefit remains unknown. However, given the lack of reported harm of ligation, potential cardiac benefits, as well as allograft longevity negating the potential need to maintain access, further randomized studies with meaningful clinical endpoints are justified. Importantly, such studies should include unselected populations, with particular emphasis on including patients who could potentially experience the greatest benefit, e.g. older patients.
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