Early cardiopulmonary adaptation following arteriovenous fistula creation in pre-dialysis chronic kidney disease patients: a prospective echocardiographic study

Abstract Background Arteriovenous fistula (AVF) creation induces substantial haemodynamic alterations through increased venous return and reduced systemic vascular resistance. Although cardiovascular remodelling after AVF creation has been described in haemodialysis populations, prospective echocardiographic data in pre-dialysis chronic kidney disease (CKD) patients remain limited. Methods This prospective observational study enrolled adult pre-dialysis CKD patients undergoing elective AVF creation at the University of Malaya Medical Centre between March 2021 and December 2022. Transthoracic echocardiography was performed before AVF creation, at early follow-up (4–12 weeks), and at late follow-up ( ≥ ≥ 6 months). Parameters assessed included left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), left ventricular ejection fraction (LVEF), stroke volume (SV), left ventricular mass index (LVMI), cardiac index (CI), pulmonary artery systolic pressure (PASP), and right ventricular functional indices. Paired analyses were performed using paired t-tests or Wilcoxon signed-rank tests according to normality of paired differences. Results Thirty-four patients underwent baseline echocardiography, with 27 completing early follow-up and 14 completing late follow-up. Mean age was 65.2 ± 8.9 years, and 52.9% were male. At early follow-up, LVEDV increased from 79.8 ± 21.8 mL to 104.8 ± 32.0 mL (mean difference + 25.0 mL, 95% CI 11.1–39.0; p = 0.001), and LVESV increased from 29.4 ± 10.5 mL to 37.5 ± 15.5 mL (mean difference + 8.1 mL, 95% CI 2.1–14.1; p = 0.012). SV increased from 50.5 ± 13.5 mL to 66.2 ± 21.0 mL (mean difference + 15.8 mL, 95% CI 6.5–24.9; p = 0.002), accompanied by an increase in CI from 2.18 ± 0.65 to 3.05 ± 1.15 L/min/m² (mean difference + 0.87 L/min/m², 95% CI 0.28–1.46; p = 0.007). LVEF remained preserved throughout follow-up. PASP increased from 28.0 ± 8.6 mmHg to 34.2 ± 9.9 mmHg (mean difference + 6.2 mmHg, 95% CI 0.7–11.7; p = 0.032), while TAPSE also increased. Patients with proximal AVFs demonstrated greater PASP increases than those with distal AVFs. Conclusions AVF creation induces early cardiopulmonary adaptation in pre-dialysis CKD patients, characterised by increased LV volume loading, augmented cardiac output, and increased pulmonary haemodynamic burden while preserving systolic function. Proximal AVFs may confer greater pulmonary circulatory burden, supporting selective cardiovascular surveillance in higher-risk patients, although larger studies are needed to confirm these findings.