Abstract Background Pulmonary hypertension (PH) is very prevalent among patients with end-stage renal disease (ESRD), particularly those receiving hemodialysis (HD) via arteriovenous fistulae (AVFs). High-output heart failure (HOHF) due to AVF-associated left-to-right shunting is one of the contributory mechanisms for the development of PH. However, clinical guidance remains limited with regards to the management of PH in ESRD patients, especially in the context of kidney transplantation (KT) evaluation. Case Presentations We present two cases of ESRD-associated PH with divergent post-transplant clinical trajectories based on differing management of AVF-related HOHF. In Case 1, a patient with combined pre- and post-capillary PH underwent KT without adequate pre-transplant hemodynamic optimization. He developed worsening PH and heart failure symptoms post-KT, which improved following AVF flow reduction as a result of AVF revision. However, he eventually experienced allograft failure and developed recurrent PH upon resuming HD. In Case 2, a patient being evaluated for KT with PH and elevated cardiac output underwent AVF ligation followed by careful evaluation and treatment of residual pre-capillary PH. This strategy led to the normalization of pulmonary pressures and successful KT, with sustained post-transplant renal and cardiopulmonary stability. Conclusions These contrasting cases underscore the importance of pre-transplant screening and targeted management of PH in ESRD, particularly when AVF-driven high-output physiology is suspected. AVF ligation or reduction may ameliorate PH and improve transplant candidacy. In carefully selected cases with persistent pre-capillary PH despite AVF ligation and volume optimization, short-term vasodilator therapy may serve as a bridge to transplantation. Multidisciplinary evaluation in an experienced pulmonary vascular disease program is essential to optimize outcomes in this patient population. This abstract is funded by: none
Shah et al. (Fri,) studied this question.