End‐stage renal disease patients undergoing angioplasty and bypass for critical limb ischemia have worse outcomes compared to non‐ESRD patients: Systematic review and meta‐analysis

Abstract

Background End‐stage renal disease (ESRD) is associated with increased morbidity and mortality following lower extremity amputation for critical limb ischemia (CLI). Angioplasty and bypass are used in ESRD patients with CLI; however, the treatment of choice remains controversial. We compared the long‐term outcomes in patients with CLI undergoing angioplasty or bypass to evaluate the differences between patients with ESRD and those without ESRD. Methods Established databases were searched for observational studies comparing outcomes following bypass or angioplasty for CLI in patients with ESRD to those in non‐ESRD patients. End points included survival, limb salvage, amputation‐free survival (AFS), and primary and secondary patency at 1‐year post‐procedure. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated using a random effect model. Results We included 20 studies with a total of 24,851 patients. ESRD patients compared to non‐ESRD patients with CLI had significantly lower survival post‐angioplasty (OR 0.51, 95% CI 0.36–0.72, p < .001) and post‐bypass (OR 0.26, 95% CI 0.15–0.45, p < .001). ESRD patients had lower rates of limb salvage post‐bypass (OR 0.33, 95% CI 0.21–0.53, p < .001) and post‐angioplasty (OR 0.54, 95% CI 0.41–0.70, p < .001). AFS was significantly lower in ESRD patients compared to non‐ESRD patients following angioplasty (OR 0.48, 95% CI 0.32–0.71, p < .001) and bypass (OR 0.28, 95% CI 0.16–0.47, p < .001) despite no significant differences in primary patency. ESRD patients had overall worse secondary patency post‐angioplasty and/or bypass (OR 0.54, 95% CI 0.32–0.94, p = .03) compared to non‐ESRD patients. A meta‐analysis of four studies directly comparing survival in ESRD patients with CLI based on whether they underwent angioplasty or bypass showed no difference (OR 0.93, 95% CI 0.64–1.35, p = .69). Conclusion ESRD patients have worse survival, limb salvage, and AFS outcomes following angioplasty and bypass for CLI compared to non‐ESRD patients. Large randomized controlled trials comparing these two modalities of treatment in this patient population are needed for further clarity.

National Treatment Patterns and Outcomes for Hospitalized Patients with Chronic Limb-Threatening Ischemia and End-Stage Kidney Disease

“…Dawson et al performed a comprehensive metaanalysis of 20 studies with 24 851 patients to examine outcomes of revascularization in patients with CLTI + ESKD compared to those with CLTI only. 14 They found that CLTI + ESKD patients had worse post-revascularization (endovascular and open) survival, limb salvage, and amputation-free survival. 14 The importance and novel contribution of this analysis also derive from the quantification of the association between ESKD and CLTI and the effects on patient presentation, increased resource utilization, LOS, total hospital charges, and higher probability of non-home discharge.…”

“…Dawson et al performed a comprehensive metaanalysis of 20 studies with 24 851 patients to examine outcomes of revascularization in patients with CLTI + ESKD compared to those with CLTI only. 14 They found that CLTI + ESKD patients had worse post-revascularization (endovascular and open) survival, limb salvage, and amputation-free survival. 14…”

“…Correspondingly, CLTI + ESKD admissions had higher median hospital charges ($107,000 vs CLTI alone, $85,000, P < .0001) and (LOS, 8 [5,14] vs CLTI alone, 7 [4,11] days, P < .0001). In contrast, CLTI + ESKD admissions were less frequently discharged home (21.1% vs CLTI alone, 30.8%, P < .0001), but were more likely to be transferred to an inpatient rehabilitation facility (50.0% vs CLTI alone, 40.9%, P < 0001).…”

Poor prognosis after lower‐limb amputation irrespective of diabetes status in patients undergoing hemodialysis

“…Revascularization is the cornerstone of PAD treatment in patients undergoing hemodialysis and the general population [7]. However, the life prognosis, limb salvage rate, and amputation-free survival rate are poorer in patients undergoing dialysis who require revascularization [17]. This may be due to the high rates of restenosis observed after lower-limb EVT [31,32].…”

“…Lower‐limb amputation in patients undergoing hemodialysis is associated with an extremely poor prognosis and deterioration of activities of daily living [12–15]. Several pathologies are associated with lower‐limb amputation, including chronic kidney disease, cerebrovascular disease, coronary artery disease, and diabetes mellitus [16], with the latter being one of the most important risk factors [17]. Nonetheless, a previous study from the Netherlands found no correlation between diabetes status and mortality after lower‐limb amputation in patients with end‐stage renal disease [13].…”