Surgical revascularization versus amputation for peripheral vascular disease in dialysis patients: a cohort study

Logar, Christine M.; Pappas, Lisa M.; Ramkumar, Nirupama; Beddhu, Srinivasan

doi:10.1186/1471-2369-6-3

Cited by 26 publications

(23 citation statements)

References 20 publications

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“…This may reflect the very high perioperative mortality rate associated with LEA. The 30-day mortality after major amputation has been reported to be as high as 16% in patients on dialysis (21). Our study confirms that diabetes-related LEAs are associated with high 5 and 10-year mortality rates (5, 22–24).…”

Section: Discussionmentioning

confidence: 99%

Foot Complications and Mortality

McEwen¹,

Ylitalo

Munson³

et al. 2016

Journal of the American Podiatric Medical Association

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Background Our objective was to study the impact of foot complications on 10 year mortality independent of other demographic and biological risk factors in a racially and socioeconomically diverse managed care population with access to high-quality medical care. Methods We studied 6,992 patients with diabetes in Translating Research Into Action for Diabetes (TRIAD), a prospective observational study of diabetes care in managed care. Foot complications were assessed using administrative claims data. The National Death Index was searched for deaths over 10 years of followup (2000–2009). Results Charcot neuroosteoarthropathy (CN) and diabetic foot ulcer with debridement (DFU) were associated with an increased risk of mortality; however, the associations were not significant in fully adjusted models. Lower extremity amputation (LEA) was associated with an increased risk of mortality in both unadjusted (HR 3.21, 95% CI 2.50–4.12) and fully adjusted models (HR 1.84, 95% CI 1.28–2.63). When we examined the associations between LEA and mortality stratified by sex and race, risk was increased in men (HR 1.96, 95% CI 1.25–3.07), Hispanics (HR 5.17, 95% CI 1.48–18.01), and Whites (HR 2.18, 95% CI 1.37–3.47). In sensitivity analyses, minor LEA tended to increase the risk of mortality (HR 1.48, 95% CI 0.92–2.40) and major LEA was associated with a significantly higher risk of death at 10 years (HR 1.89, 95% CI 1.18–3.01). Conclusions In this managed care population with access to high-quality medical care, LEA remained a robust independent predictor of mortality. The association was strongest in men and differed by race.

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Section: Discussionmentioning

confidence: 99%

Foot Complications and Mortality

McEwen¹,

Ylitalo

Munson³

et al. 2016

Journal of the American Podiatric Medical Association

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“…We also found that, regardless of the patient's history of PVD, amputations were far more common than revascularization procedures during the course of dialysis. This was not surprising given that amputations are often the first procedure in patients with ESRD and PVD and that revascularizations in these patients are associated with poor outcomes, including subsequent amputation and mortality (11,24 -26); however, amputations are also associated with increased mortality in dialysis patients (27,28).…”

Section: Discussionmentioning

confidence: 99%

Peripheral Vascular Disease–Related Procedures in Dialysis Patients

Plantinga

Fink

Coresh

et al. 2009

Clinical Journal of the American Society of Nephrology

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Background and objectives: Peripheral vascular disease (PVD) is prevalent among dialysis patients, and many dialysis patients undergo PVD-related procedures. We aimed to examine the risk factors for and prognosis after such procedures in the dialysis setting.Design, setting, participants, & measurements: In a national prospective cohort study of 1041 incident dialysis patients, we examined the factors that are associated with PVD procedures (lower extremity amputations and bypasses) after the start of dialysis. Adjusted risk for PVD procedures of various factors was estimated using multivariable Cox proportional hazards models. Incidence rates of subsequent cardiovascular events, infectious hospitalizations, PVD-and cardiovascular diseaserelated mortality, and all-cause mortality were compared for those with and without a PVD procedure.Results: Overall, 217 (21%) patients underwent a PVD procedure after the start of dialysis. For those without diabetes, only PVD history (relative hazard [RH] 2.9; 95% confidence interval [CI] 1.3 to 6.6) and increased fibrinogen (RH 1.2; 95% CI 1.0 to 1.5) predicted PVD procedures. For those with diabetes, increased serum phosphate (RH 1.2; 95% CI 1.1 to 1.4), along with decreased albumin, increased C-reactive protein and fibrinogen, and lower SBP, was associated with risk for PVD procedures. Of those who had a procedure compared with those who did not, 68 versus 30% experienced a subsequent cardiovascular event, 85 versus 66% an infectious hospitalization, 11 versus 2% a PVD-related death, and 81 versus 59% all-cause death (mean follow-up 3.0 yr).Conclusions: Prognosis after PVD procedures is poor, and providers should be aware that risk factors for PVD procedures may differ by diabetes status.

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“…29 A close temporal association between the first recorded foot ulcer and the onset of renal replacement therapy has been reported. [33][34][35] The risk of death is high both early after amputation (within 30 days) and within the first year. 31 However, only patients on dialysis are at an increased risk of amputation after a revascularization procedure.…”

Section: Discussionmentioning

confidence: 99%

“…30 Revascularization procedures, which in addition to saving the legs are associated with lower mortality than amputation at all levels of renal function, are less frequent in patients with stages 3 to 5 of chronic kidney disease or on dialysis than those with estimated glomerular filtration rate 460 mL/min per 1.72 m 2 . 34 Male sex, diabetes, previous diagnosis of peripheral vascular disease, high mean predialysis systolic pressure, and high serum phosphorus concentration are predictors of amputation in HD patients. 32 Mortality after amputation is high in dialysis patients.…”

Section: Discussionmentioning

confidence: 99%

Death during hospitalization in patients on chronic hemodialysis

Behl

Sun

Agaba

et al. 2010

Hemodialysis International

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Mortality from various causes is higher in patients on chronic hemodialysis (HD) than in the general population. There is evidence suggesting that some of the deaths in HD patients are preventable. To identify potentially preventable causes of death, we analyzed deaths that occurred in HD patients during hospitalization over a period of 15 years. We performed a retrospective cohort analysis of 410 patients on HD for at least 6 months between 1995 and 2009 (included), who had all their hospitalizations in the same hospital. The patients were classified into 3 groups: Those who died during hospitalization (group A, n=120), those who died away from the hospital (group B, n=135), and those who were alive at the end of the observation period (group C, n=155). Continuous variables were compared between groups by the Kruskall-Wallis statistic. Logistic regression was used to identify predictors of dying during the observation period and predictors of death in the hospital. For the whole HD group of 410 patients, only 9 (2.2%) were women. 59% of the patients had diabetes mellitus. Age at the onset of HD was 65.8 ± 11.5 years and the duration of HD was 34.4 ± 27.9 months. Group A patients had a higher annual rate and duration of hospitalization and a higher Charlson comorbidity index than either of the other 2 groups, and, in comparison with patients in group C, were older at the end of observation and had a shorter duration of HD. Cardiac disease (19.2%), vascular access complications (18.3%), peripheral vascular disease (16.7%), infections (15.8%), trauma (11.7%), central nervous system disease (7.5%), respiratory failure (4.2%), malignancy (3.3%), and gastrointestinal disease (3.3%) were the causes of the last hospitalization in group A. Compared with the patients who died during hospitalization without discontinuing HD, group A patients who discontinued HD had a longer duration of their last hospitalization (52.7 ± 77.7 vs. 14.3 ± 23.8 days, P<0.001). Discontinuation of HD occurred in 80% of the hospitalizations for respiratory failure, 75% of the hospitalizations for malignancy, 57% of the hospitalizations for trauma, and 56% of the hospitalizations for central nervous system disease. Logistic regression identified a high Charlson index, advanced age, and short duration of HD as predictors of death, and an absence of diabetes, high Charlson index, prolonged annual duration of hospitalization, and short distance of the patient's domicile from the dialysis unit as predictors of death in the hospital. A substantial number of hospitalizations leading to the death of HD patients are caused by potentially preventable conditions, including vascular access complications, peripheral vascular disease, and trauma. Implementation of measures preventing these hospitalizations is a worthwhile undertaking.

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Surgical revascularization versus amputation for peripheral vascular disease in dialysis patients: a cohort study

Abstract: Background: Surgical treatment of peripheral vascular disease (PVD) in dialysis patients is controversial.

Cited by 26 publications

References 20 publications

Foot Complications and Mortality

Foot Complications and Mortality

Peripheral Vascular Disease–Related Procedures in Dialysis Patients

Death during hospitalization in patients on chronic hemodialysis

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