Impact of Renal Insufficiency on Mortality in Advanced Lower Extremity Peripheral Arterial Disease

Abstract

Renal insufficiency predicts mortality among patients who are treated for myocardial infarction and congestive heart failure, but its clinical significance in advanced peripheral arterial disease has not been evaluated. A national cohort of 5787 male veterans who received an initial diagnosis of rest pain, ischemic ulceration, or gangrene between January 1, 2000, and September 30, 2002, and had at least one serum creatinine measurement within 3 mo before diagnosis were identified. Sixty-two percent (n ‫؍‬ 3561) of cohort members had normal or mildly reduced renal function (GFR >60 ml/min per 1.73 m 2 ), 30% (n ‫؍‬ 1742) had moderate renal insufficiency (GFR 30 to 59 ml/min per 1.73 m 2 ), and 8% (n ‫؍‬ 484) had severe renal insufficiency or renal failure (GFR <30 ml/min per 1.73 m 2 ) but were not on dialysis. The percentages of patients who presented with gangrene or ischemic ulceration rather than rest pain increased with declining renal function (70, 77, and 87%; P < 0.001), as did 1-yr mortality risk (17, 27, and 44%; P < 0.001). After adjustment for demographic and clinical characteristics, patients with a GFR of 30 to 59 ml/min per 1.73 m 2 (odds ratio, 1.32; 95% confidence interval, 1.13 to 1.53) and <30 ml/min per 1.73 m 2 (odds ratio, 2.97; 95% confidence interval, 2.39 to 3.69) had a significantly increased odds of death within 1 yr of cohort entry. Both moderate and severe renal insufficiency are associated with an increased odds of death in patients with critical limb ischemia. Death rates were particularly high among those with a GFR <30 ml/min per 1.73 m 2 . This finding may be partly explained by their more frequent presentation with ischemic ulceration or gangrene rather than rest pain.

Impact of diabetes and glycaemic control on peripheral artery disease in Japanese patients with end-stage renal disease: long-term follow-up study from the beginning of haemodialysis

“…Interestingly, higher HbA 1c levels when beginning haemodialysis were associated with an increased risk of PAD and amputation in patients with diabetes mellitus. A previous report has suggested that the 1 year mortality rate increases with more advanced stages of chronic kidney disease in PAD patients with critical limb ischaemia [17]. Our findings could therefore contribute to the risk stratification of patients starting on haemodialysis therapy.…”

Prevalence and risk factors for renal artery stenosis and chronic kidney disease in Japanese patients with peripheral arterial disease

“…6,24,25 O'Hare et al 24 found that CKD was a strong independent predictor of mortality in patients with CLI and that the mortality risk was highest among patients with eGFR o30 ml min -1 per 1.73 m 2 . It has also been shown that eGFR is an independent predictor of death and limb loss after infrainguinal bypass.…”

Combined Effect of Chronic Kidney Disease and Peripheral Arterial Disease on All-Cause Mortality in a High-Risk Population

“…These individuals may present with critical limb ischemia, which is associated with lower successful revascularization rates and higher mortality (24 -27); however, the mortality data on PAD in the earlier stages of CKD is still limited. One recent study by O'Hare et al (28) reported that moderate to severe predialysis CKD significantly increases mortality in patients with advanced PAD; however, that study was limited by its short follow-up (1 yr) and that the PAD population contained only those with advanced PAD (rest pain, ischemic ulceration, or gangrene). In this study, we hypothesized that the risk for death is higher in patients with both CKD and PAD than in those with CKD or PAD alone.…”