Hetz P, Pirklbauer M, Müller S, et al. - In patients with hemodialysis-dependent end-stage renal disease, arteriovenous (AV) fistulas are considered the gold standard for ensuring safe and long-term vascular access. However, prior studies suggest that in the posttransplant setting, high-flow AV fistulas might add additional cardiovascular burden, resulting in frequent closure of fistula in this population. Researchers here investigated the effect of prophylactic AV fistula closure on high-output heart failure via performing a randomized controlled trial. They randomized 28 kidney transplant patients with stable graft function, absence of preexisting severe cardiac failure, and brachial arterial flow rate of at least 1,500 mL/min to either an intervention group or a control group. Immediate fistula ligature was performed in the intervention group. They referred patients within the control group to fistula ligature only on reaching the main study endpoint high-output heart failure. Five of thirteen control patients (38.5%) had high-output heart failure attributable to high-flow fistula, whereas there was no patient in the intervention group presenting with clinical and echocardiographic signs of high-output heart failure during the follow-up period. Per outcomes, high-output heart failure can be avoided with prophylactic ligature of high-flow AV fistulas after kidney transplantation, and a more liberal approach to close AV fistulas might be justified.