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Nakhaei P, Hamouda M, Malas MB. The Double Burden: Deciphering Chronic Limb-Threatening Ischemia in End-Stage Renal Disease. Ann Vasc Surg 2024:S0890-5096(24)00151-1. [PMID: 38599491 DOI: 10.1016/j.avsg.2023.12.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 12/12/2023] [Indexed: 04/12/2024]
Abstract
BACKGROUND Chronic limb-threatening ischemia (CLTI) in patients with end-stage renal disease (ESRD) poses significant challenges in clinical management due to its unique pathology and poor treatment outcomes. This review calls for a tailored classification and risk assessment for these patients to guide better revascularization choices with early minor amputation as a first-line strategy in advanced stages. METHODS This review consolidates key findings from recent literature on CLTI in ESRD, focusing on disease mechanisms, treatment options, and patient outcomes. It evaluates the literature to clarify the decision-making process for managing CLTI in ESRD. RESULTS CLTI in ESRD patients often results in worse clinical outcomes, such as nonhealing wounds, increased limb loss, and higher mortality rates. While the literature reveals ongoing debates regarding the optimal revascularization method, recent retrospective studies and meta-analyses suggest potential benefits of endovascular treatment (EVT) over open bypass surgery (OB) in reducing mortality and wound complications, with comparable amputation-free survival rates. CONCLUSIONS The selection of revascularization methods in ESRD patients with CLTI is complex, necessitating individualized strategies. The importance of early detection and timely intervention is critical to decelerate disease progression and improve revascularization outcomes. There is a shift in these treatment strategies toward less invasive endovascular procedures, acknowledging the limitations these patients face with open revascularization surgeries. Considering early minor amputations after revascularization could prevent worse consequences, reflecting a shift in the approach to managing CLTI in ESRD patients.
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Affiliation(s)
- Pooria Nakhaei
- Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego, San Diego, CA
| | - Mohammed Hamouda
- Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego, San Diego, CA
| | - Mahmoud B Malas
- Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego, San Diego, CA.
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2
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Kumada Y, Kawai N, Ishida N, Nakamura Y, Takahashi H, Ohshima S, Ito R, Izawa H, Murohara T, Ishii H. Combined Prognostic Value of Preprocedural Protein-Energy Wasting and Inflammation Status for Amputation and/or Mortality after Lower-Extremity Revascularization in Hemodialysis Patients with Peripheral Arterial Disease. J Clin Med 2023; 13:126. [PMID: 38202133 PMCID: PMC10779791 DOI: 10.3390/jcm13010126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 12/03/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024] Open
Abstract
Protein-energy wasting is associated with inflammation and advanced atherosclerosis in hemodialysis patients. We enrolled 800 patients who had undergone successful lower-extremity revascularization, and we investigated the association among the Geriatric Nutritional Risk Index (GNRI) as a surrogate marker of protein-energy wasting, C-reactive protein (CRP), and their joint roles in predicting amputation and mortality. They were divided into lower, middle, and upper tertiles (T1, T2, and T3) according to GNRI and CRP levels, respectively. Regarding the results, the amputation-free survival rates over 8 years were 47.0%, 56.9%, and 69.5% in T1, T2, and T3 of the GNRI and 65.8%, 58.7%, and 33.2% for T1, T2, and T3 of CRP, respectively (p < 0.0001 for both). A reduced GNRI [adjusted hazard ratio (aHR) 1.78, 95% confidence interval (CI) 1.24-2.59, p = 0.0016 for T1 vs. T3] and elevated CRP (aHR 1.86, 95% CI 1.30-2.70, p = 0.0007 for T3 vs. T1) independently predicted amputation and/or mortality. When the two variables were combined, the risk was 3.77-fold higher (95% CI 1.97-7.69, p < 0.0001) in patients who occupied both T1 of the GNRI and T3 of CRP than in those who occupied both T3 of the GNRI and T1 of CRP. In conclusion, patients with preprocedurally decreased GNRI and elevated CRP levels frequently experienced amputation and mortality, and a combination of these two variables could more accurately stratify the risk.
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Affiliation(s)
- Yoshitaka Kumada
- Department of Cardiovascular Surgery, Matsunami General Hospital, Kasamatsu 501-6062, Japan; (Y.K.); (N.K.); (N.I.); (Y.N.)
| | - Norikazu Kawai
- Department of Cardiovascular Surgery, Matsunami General Hospital, Kasamatsu 501-6062, Japan; (Y.K.); (N.K.); (N.I.); (Y.N.)
| | - Narihiro Ishida
- Department of Cardiovascular Surgery, Matsunami General Hospital, Kasamatsu 501-6062, Japan; (Y.K.); (N.K.); (N.I.); (Y.N.)
| | - Yasuhito Nakamura
- Department of Cardiovascular Surgery, Matsunami General Hospital, Kasamatsu 501-6062, Japan; (Y.K.); (N.K.); (N.I.); (Y.N.)
| | - Hiroshi Takahashi
- Department of Cardiology, Fujita Health University School of Medicine, Toyoake 470-1192, Japan; (H.T.); (H.I.)
| | - Satoru Ohshima
- Department of Cardiology, Nagoya Kyoritsu Hospital, Nagoya 454-0933, Japan; (S.O.); (R.I.)
| | - Ryuta Ito
- Department of Cardiology, Nagoya Kyoritsu Hospital, Nagoya 454-0933, Japan; (S.O.); (R.I.)
| | - Hideo Izawa
- Department of Cardiology, Fujita Health University School of Medicine, Toyoake 470-1192, Japan; (H.T.); (H.I.)
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan;
| | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi 371-8511, Japan
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Manewell SM, Rao P, Haneman K, Zheng M, Charaf H, Menz HB, Sherrington C, Paul SS. Prevention and management of foot and lower limb health complications in adults undergoing dialysis: a scoping review. J Foot Ankle Res 2023; 16:81. [PMID: 37986004 PMCID: PMC10659051 DOI: 10.1186/s13047-023-00679-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/30/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND Foot and lower limb health complications are common among patients undergoing dialysis; but a summary of prevention and management evidence is not available. The aim of this scoping review was to summarise study characteristics and the nature of results regarding strategies to prevent and manage peripheral arterial disease (PAD), foot ulceration, amputation, associated infection and associated hospital admission in adults undergoing dialysis. METHODS MEDLINE, Embase, CINAHL and AMED databases were searched for longitudinal experimental and observational studies. Eligible studies included adults undergoing dialysis (≥10 dialysis patients, with separate results or ≥ 75% of the cohort). Any interventions relating to PAD, foot ulceration, amputation, associated infection, and associated hospital admission were included. RESULTS The review included 212 studies, of which 199 were observational (94%) and 13 were experimental (6%). Sixteen studies (8%) addressed the prevention of foot and lower limb health complications, 43 (20%) addressed management, and 153 (72%) addressed both. The main intervention type in each study was surgery (n = 159, 75%), care from one or more health professionals (n = 13, 6%), screening by a health professional (n = 10, 5%), medication (n = 9, 4%) and rehabilitation (n = 5, 2%). No studies were identified where exercise, offloading or education were the main intervention. Results for PAD were reported in 137 (65%) studies, foot ulceration in 54 (25%), amputation in 171 (81%), infection in 7 (3%), and admission in 26 studies (12%). Results for more than one foot or lower limb outcome were reported in 141 studies (67%), with each study reporting on average two outcomes. Results varied and spanned positive, negative, and neutral outcomes following intervention. CONCLUSIONS Identified studies frequently aimed to both prevent and manage foot and lower limb health complications. A variety of interventions were identified and studies often reported results for more than one foot or lower limb health outcome. Findings from this review can be used to guide future research, with a goal to support improved patient outcomes.
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Affiliation(s)
- Sarah M Manewell
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, NSW, Camperdown, Australia.
- Podiatry Department, Sydney Local Health District, NSW Health, Camperdown, Australia.
| | - Purnima Rao
- Podiatry Department, Sydney Local Health District, NSW Health, Camperdown, Australia
| | - Keren Haneman
- Podiatry Department, Sydney Local Health District, NSW Health, Camperdown, Australia
| | - Minjia Zheng
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, NSW, Camperdown, Australia
| | - Hady Charaf
- Faculty of Podiatric Medicine, School of Health Sciences, Western Sydney University, NSW, Campbelltown, Australia
| | - Hylton B Menz
- School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Cathie Sherrington
- Institute for Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney/Sydney Local Health District, NSW, Camperdown, Australia
| | - Serene S Paul
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, NSW, Camperdown, Australia
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Cheng TW, Farber A, Kalish JA, King EG, Rybin D, Siracuse JJ. The Effect of Chronic and End Stage Renal Disease on Long-term Outcomes after Infrainguinal Bypass. Ann Vasc Surg 2023:S0890-5096(23)00241-8. [PMID: 37149216 DOI: 10.1016/j.avsg.2023.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/11/2023] [Accepted: 04/14/2023] [Indexed: 05/08/2023]
Abstract
OBJECTIVES Patients undergoing infrainguinal bypass for chronic limb threatening ischemia (CLTI) with renal dysfunction are at an increased risk for perioperative and long-term morbidity and mortality. Our goal was to examine perioperative and 3-year outcomes after lower extremity bypass for CLTI stratified by kidney function. METHODS A retrospective, single-center analysis of lower extremity bypass for CLTI was performed between 2008 and 2019. Kidney function was categorized as normal (estimated glomerular filtration rate (eGFR) ≥60ml/min/1.73m2), chronic kidney disease (CKD) (eGFR15-59ml/min/1.73m2), and end stage renal disease (ESRD) (eGFR<15ml/min/1.73m2). Kaplan-Meier and multivariable analysis were performed. RESULTS There were 221 infrainguinal bypasses performed for CLTI. Patients were classified by renal function as normal (59.7%), CKD (24.4%), and ESRD (15.8%). Average age was 66 years and 65% were male. Overall, 77% had tissue loss with 9%, 45%, 24%, and 22% being Wound, Ischemia, and foot Infection (WIfI) stages 1-4, respectively. The majority (58%) of bypass targets were infrapopliteal and 58% used ipsilateral greater saphenous vein. The 90-day mortality and readmission rates were 2.7% and 49.8%, respectively. ESRD, compared to CKD and normal renal function, respectively, had the highest 90-day mortality (11.4% vs. 1.9% vs. .8%, P=.002) and 90-day readmission (69% vs. 55% vs. 43%, P=.017). On multivariable analysis, ESRD, but not CKD, was associated with higher 90-day mortality (OR 16.9, 95% CI 1.83-156.6, P=.013) and 90-day readmission (OR 3.02, 95% CI 1.2-7.58, P=.019). Kaplan Meier 3-year analysis showed no difference between groups for primary patency or major amputation, however ESRD, compared to CKD and normal renal function, respectively, had worse primary-assisted patency (60% vs. 76% vs. 84%, P=.03) and survival (72% vs. 96% vs. 94%, P=.001). On multivariable analysis, ESRD and CKD were not associated with 3-year primary patency loss/death, but ESRD was associated with higher primary-assisted patency loss (HR 2.61, 95% CI 1.23-5.53, P=.012). ESRD and CKD were not associated with 3-year major amputation/death. ESRD was associated with higher 3-year mortality (HR 4.95, 95% CI 1.52-16.2, P=.008) while CKD was not. CONCLUSION ESRD, but not CKD, was associated with higher perioperative and long-term mortality after lower extremity bypass for CLTI. Although ESRD was associated with lower long-term primary-assisted patency, there were no differences in loss of primary patency or major amputation.
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Affiliation(s)
- Thomas W Cheng
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Jeffrey A Kalish
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Elizabeth G King
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Denis Rybin
- Department of Biostatistics, Boston University, School of Public Health, Boston, MA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA.
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Iwai T, Yamaguchi T, Ueshima D, Tobita K, Mizuno A, Fujimoto Y, Miyazaki R, Shimura T, Goto R, Murata N, Anzai H, Higashitani M. Differences in major limb outcomes by indication for lower extremity endovascular revascularization in patients receiving hemodialysis. Heart Vessels 2023; 38:488-496. [PMID: 36322238 DOI: 10.1007/s00380-022-02195-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 10/20/2022] [Indexed: 03/07/2023]
Abstract
The incidence of lower extremity artery disease (LEAD) in patient receiving hemodialysis is remarkably higher than the general population. The treatment strategy and prognosis for LEAD patients differs depending on whether a patient has intermittent claudication (IC) or critical limb-threatening ischemia (CLTI). However, the distinction between the prognosis in HD-dependent patients with IC and CLTI has not been fully elucidated. This study is to determine whether indication of PAD has a distinct impact on major adverse cardiovascular and cerebrovascular events (MACCE) and limb events in patients receiving hemodialysis. The current study included 2321 prospectively enrolled patients from the Tokyo taMA peripheral vascular intervention research ComraDE registry (UMIN-CTR no. UMIN000015100) between September 2014 and December 2016. Out of the enrolled patients, 1644 were not receiving hemodialysis (non-HD patients) and 603 were receiving hemodialysis (HD patients). A composite of all-cause death, myocardial infarction, and stroke events defined as MACCE; while limb events were defined as a composite of unscheduled major amputation, unscheduled major lower limb surgery, acute limb ischemia, unscheduled endovascular treatment, and target lesion revascularization. Propensity score matching was applied among the non-HD and HD patients, in whole group, IC subgroup, and CLTI subgroup. Kaplan-Meier analysis was used for the analysis of outcomes for the whole group, IC subgroup, and the CLTI subgroup. CLTI accounted for 75.5% of the HD patients, whereas IC was 63.4% in the non-HD patients. The HD patients exhibited more frequent below-the-knee lesions than those in the non-HD patients in both IC (p = 0.01) and CLTI (p < 0.001) subgroups. Overall, HD patients exhibited a significantly higher rate of MACCE at 24 months. This trend was similar for limb events in whole group and CLTI subgroup. In contrast, no significant differences in outcomes for limb events were found in IC subgroup. Although, prognosis after EVT in HD patients were significantly worse than non-HD patients, comparable outcome with non-HD patients was observed in the patients treated for IC. Clinical trial registration: This study was registered in the University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR No. UMIN000015100).
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Affiliation(s)
- Takamasa Iwai
- Department of Cardiovascular Medicine, National Cerebral & Cardiovascular Center, Suita, Japan
| | - Tetsuo Yamaguchi
- Department of Cardiovascular Center, Toranomon Hospital, 2-2-2, Toranomon, Minato-Ku, Tokyo, 105-8470, Japan.
| | - Daisuke Ueshima
- Department of Cardiology, Kameda Medical Center, Chiba, Japan
| | - Kazuki Tobita
- Department of Cardiovascular Medicine, Shonan Kamakura General Hospital, Kamakura , Kanagawa, Japan
| | - Atsushi Mizuno
- Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan
| | - Yo Fujimoto
- Department of Cardiovascular Center, Toranomon Hospital, 2-2-2, Toranomon, Minato-Ku, Tokyo, 105-8470, Japan
| | - Ryoichi Miyazaki
- Department of Cardiology, Musashino Red Cross Hospital, Tokyo, Japan
| | - Tsukasa Shimura
- Department of Cardiology, Yokohama City Minato Red Cross Hospital, Kanagawa, Japan
| | - Ryo Goto
- Department of Cardiology, Shuuwa General Hospital, Saitama, Japan
| | - Naotaka Murata
- Department of Cardiology, Tokyo Medical University, Tokyo, Japan
| | - Hitoshi Anzai
- Department of Cardiology, Ota Memorial Hospital, Gunma, Japan
| | - Michiaki Higashitani
- Department of Cardiology, Tokyo Medical University Ibaraki Medical Center, Ibaraki, Japan
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Shah SK, Neal D, Berceli SA, Segal M, Cooper MA, Huber TS, Upchurch GR, Scali ST. National Treatment Patterns and Outcomes for Hospitalized Patients with Chronic Limb-Threatening Ischemia and End-Stage Kidney Disease. Vasc Endovascular Surg 2022; 57:357-364. [PMID: 36541126 DOI: 10.1177/15385744221146868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Chronic limb-threatening ischemia (CLTI) can be associated with dismal outcomes but there are limited real-world data to further define the impact of end-stage kidney disease (ESKD) on outcomes nationally in this subset of patients. We sought to characterize national patterns of inpatient treatment of CLTI and compare outcomes in patients without ESKD. Methods The National Inpatient Sample was queried from 2015-2018 for all hospital admissions including treatment for CLTI. Mixed-effects linear and logistic regression models were used to estimate the effect of ESKD on outcomes and treatment choice. Results We identified 11 652 hospital admissions with CLTI alone and 2705 with CLTI + ESKD. Hospital admissions with CLTI + ESKD patients included patients who were younger (66 vs 69 years, P < .0001), less likely to be white (39% vs 63%, P < .0001), and more likely to reside in lower income large metropolitan areas. Admissions for CLTI + ESKD patients had a lower likelihood of open arterial reconstruction (OR .40, P < .0001) and a higher likelihood of endovascular revascularization or major limb amputation (OR 1.70, P < .0001). Admissions for CLTI + ESKD also had a 4.5- and 1.5-fold higher odds of in-hospital death and complications. These findings were associated with a longer LOS ( P < .0001), increased probability of discharge to rehabilitation facility (50% vs 41%, P < .0001), and greater hospital charges (median, $107 K vs $85 K, P < .0001). Conclusions Compared to hospital admissions for patients without ESKD, admissions for patients with CLTI + ESKD demonstrated distinctive demographic characteristics, a lower likelihood of open revascularization and a higher likelihood of endovascular revascularization and major limb amputation. Chronic limb-threatening ischemia + ESKD hospital admissions showed worse overall outcomes and greater resource utilization compared to CLTI admissions without ESKD.
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Affiliation(s)
- Samir K. Shah
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL, USA
| | - Dan Neal
- Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Scott A. Berceli
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL, USA
| | - Mark Segal
- Division of Nephrology, Hypertension, and Renal Transplantation, University of Florida, Gainesville, FL, USA
| | - Michol A. Cooper
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL, USA
| | - Thomas S. Huber
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL, USA
| | - Gilbert R. Upchurch
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL, USA
| | - Salvatore T. Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL, USA
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