Relationship between kidney disease and endothelial function in peripheral artery disease

Vascular peroxidase 1 is independently associated with worse kidney function in patients with peripheral artery disease

BACKGROUND

Oxidative stress is involved in cardiovascular disease such as peripheral artery disease (PAD). Vascular Peroxidase 1 (VPO1), a novel heme-containing peroxidase mainly expressed in the cardiovascular system, aggravates oxidative stress. Evidence in humans is limited. Current work aims to measure VPO1 in patients suffering from PAD, and to evaluate the association of VPO1 with conventional markers of cardiovascular risk factors (CVRF), including the estimated glomerular filtration rate (eGFR) and albuminuria categories.

METHODS

This study is part of a longitudinal observational study. At baseline, 236 PAD-patients were included. VPO1 plasma levels (ng/mL) were measured by commercially available ELISA kits. A two-sided p level of < 0.05 was considered statistically significant.

RESULTS

In the cross-sectional analysis (n = 236), VPO1 associated with ageing (p = 0.035) as well as with eGFR and albuminuria category, the markers of chronic kidney disease (CKD)-progression (p = 0.042). The longitudinal 18-months follow-up analysis (n = 152) demonstrated that baseline VPO1 predicts rapid kidney function decline (RKFD) (n = 49), defined as more than - 3 mL/min/1.73m2 eGFR loss per year, (OR per one SD VPO1 1.60 (1.11-2.30); p = 0.009). This association between VPO1 and kidney function withstood the multivariable adjustment for traditional CVRF including baseline eGFR and urine albumin-to-creatinine ratio (UACR), (adjOR per one SD VPO1 1.73 (1.14-2.61); p = 0.046).

CONCLUSION

This study is first to reveal that VPO1 is independently associated with declining kidney function in patients with PAD. VPO1 shows a tighter association to kidney function than to other CVRF. This finding points to VPO1 as a potential target protein to assess CKD-progression.

Albuminuria rather than glomerular filtration rate is associated with vascular endothelial function in patients with type 2 diabetes

AIMS

Albuminuria and reduced glomerular filtration rate (GFR) are manifestations of diabetic kidney disease and are both shown to be associated with cardiovascular outcomes. However, the differential association of albuminuria and reduced GFR with endothelial dysfunction, an early feature of atherosclerotic vascular damage, remains unclear. In this study, we investigated the association between albuminuria or estimated GFR (eGFR) and flow-mediated dilatation (FMD), a marker of endothelial function, in patients with type 2 diabetes.

METHODS

This study included 633 patients with type 2 diabetes. The FMD of the brachial artery was measured by ultrasonography. Albuminuria was evaluated by urinary albumin-to-creatinine ratio (ACR).

RESULTS

The mean FMD and eGFR, and the median value of ACR were 6.7%, 66.5 mL/min/1.73m² and 12.5 mg/g creatinine, respectively. Impaired FMD was found in patients with advanced stages of chronic kidney disease based on both GFR and albuminuria categories. Multivariate analysis after adjusting for potential confounders revealed that ACR, but not eGFR, was significantly and inversely associated with FMD.

CONCLUSIONS

Albuminuria is associated with FMD, independently of traditional cardiovascular risk factors in patients with type 2 diabetes. This study suggests a close relationship between albuminuria, rather than reduced GFR, and endothelial dysfunction in type 2 diabetes.

Midterm Outcomes of Common Femoral Endarterectomy Combined with Inflow and Outflow Endovascular Treatment for Chronic Limb Threatening Ischaemia

OBJECTIVE

To assess mid term outcomes of common femoral endarterectomy combined with an inflow and outflow endovascular revascularisation procedure in patients with chronic limb threatening ischaemia (CLTI).

METHODS

This was a prospective study. All patients who, for the first time, underwent planned one stage hybrid common femoral artery (CFA) endarterectomy combined with an inflow and/or outflow endovascular revascularisation procedure to achieve limb salvage in patients with CLTI due to multilevel disease were included between January 2015 and May 2017. Demographics, and clinical and lesion characteristics for each patient were reported. The primary outcome was primary patency. Secondary outcomes were technical success, peri-operative morbidity and mortality, assisted primary patency, secondary patency, clinically driven target lesion revascularisation and amputation free survival.

RESULTS

Three groups were created according to the endovascular treatment zone: group 1 (inflow, n = 60); group 2 (outflow, n = 46); and group 3 (combined inflow and outflow, n = 53). CFA endarterectomy was a fixed step in all cases. The overall technical success was 98%. The peri-operative complication rate was 14% and the mortality rate was 2%. Patients in group 3 demonstrated a significantly lower primary patency rate (53.9% ± 7.1%; p < .001) at 24 months but improved secondary patency rate of (94.0% ± 3.4%). Based on the outcomes of the Cox regression multivariable analysis, lesion length (hazard ratio [HR] 1.10, 95% confidence interval [CI] 1.06-1.14; p < .001), chronic total occlusion (CTO) (HR 0.50, 95% CI 0.25-0.98; p = .046), peripheral artery calcium scoring system (PACSS) grade 4 (HR 2.44, 95% CI 1.27-4.68; p = .008), incomplete revascularisation (HR 3.32, 95% CI 1.64-6.73; p = .001), and dyslipidaemia (HR 0.50, 95% CI 0.27-0.93; p = .031) were the only significant independent predictors of loss of primary patency.

CONCLUSION

Common femoral endarterectomy combined with an inflow and outflow endovascular revascularisation procedure in patients with CLTI is safe, with acceptable patency rates, despite the need for secondary interventions. Dyslipidaemia, lesion length, CTO, PACSS grade 4, and incomplete revascularisation are independent predictors of primary patency loss. The current study analysis supports the recommendation to stage the procedure based on patient risk and degree of limb threat.

In-hospital outcome of peripheral vascular intervention in dialysis-dependent end-stage renal disease patients

BACKGROUND

The impact of end-stage renal disease (ESRD) on peripheral vascular intervention (PVI) outcome remains incompletely elucidated.

OBJECTIVES

We sought to compare the outcome of PVI in dialysis patients with those with normal kidney function.

METHODS

Using weighted data from the National Inpatient Sample database between 2002 and 2014, we identified all peripheral artery disease (PAD) patients aged ≥18 years that underwent PVI. Multivariate logistic regression analysis was performed to examine in-hospital outcomes.

RESULTS

Of 1,186,192 patients who underwent PVI, 1,066,830 had normal kidney function (89.9%) and 119,362 had ESRD requiring dialysis (10.1%). Critical limb ischemia was more prevalent in dialysis patients (63.2 vs. 34.0%, p < .001). Compared with normal kidney function group, ESRD requiring dialysis was associated with higher in-hospital mortality (1.5 vs. 4.2%, adjusted OR: 2.13 [95% CI: 2.04-2.23]) and longer length of hospital stay (median 3 days, Interquartile range [IQR] (0-6) vs. 7 days, IQR (4-18); p < .001). Dialysis patients had higher incidence of major adverse cardiovascular events (composite of death, myocardial infarction, or stroke; 14.3 vs. 9.8%, p < .001) and net adverse cardiovascular events (composite of MACE, major bleeding, or vascular complications; 40.8 vs. 29.1%, p < .001). ESRD patients less frequently underwent open bypass (5.6 vs. 8.5%, p < .001) and more frequently had major amputation (10.3 vs. 3.0%, p < .001) compared with normal kidney function group.

CONCLUSION

PAD patients on dialysis who underwent PVI have higher rates of mortality and adverse outcomes as compared to those with normal kidney function.

Serum resistin is associated with impaired endothelial function and a higher rate of adverse cardiac events in patients with peripheral artery disease

OBJECTIVE

Resistin is a hormone that has been associated with metabolic syndrome and cardiovascular disease. The role of resistin in patients with peripheral artery disease (PAD) has not been fully explored. This study seeks to understand the relationship between serum resistin, vascular function, and cardiovascular outcomes in patients with PAD.

METHODS

There were 106 patients with PAD who were recruited between 2011 and 2016. Patients attended a baseline visit during which a comprehensive vascular physiology assessment including medical and surgical history, radial artery tonometry, and flow mediated-vasodilation (FMD) was completed. A blood sample was drawn, and serum resistin was assayed using enzyme-linked immunosorbent assay kits. Using the time of study enrollment as the time of origin, incident major adverse cardiac events (MACEs) were identified by subsequent chart review and defined as a composite end point of myocardial infarction, coronary revascularization, transient ischemic attack, stroke, or death from a cardiac cause.

RESULTS

Patients had a mean age of 68 ± 8 years, were largely white (75%), and had comorbidities commonly associated with PAD including hypertension (92%), hyperlipidemia (87%), coronary artery disease (37%), and diabetes mellitus (38%). After stratification by resistin quartile, higher resistin quartiles were significantly associated with an older age, a greater number of pack-years smoked, and a lower estimated glomerular filtration rate. Despite similar comorbidities and medication use, endothelial function, as measured by FMD, was significantly lower with increasing resistin quartile (I, 9.1% ± 3.3%; II, 7.1% ± 3.5%; III, 5.8% ± 4.0%; IV, 5.6% ± 3.5%; P = .002). In multivariable linear regression, higher resistin quartiles (III and IV) were associated with lower FMD relative to quartile I after adjusting for several patient characteristics, medications, and comorbidities (III, -2.26 [95% confidence interval (CI), -4.51 to -0.01; P = .05]; IV, -2.53 [95% CI, -4.87 to -0.20; P = .03]). During a median follow-up period of 36 months (interquartile range, 29-45 months), 21 patients experienced the primary end point. In a Cox proportional hazards model adjusted for smoking status, coronary artery disease, and age, each 1 ng/mL increase in resistin was associated with a 10% increased risk of MACEs (hazard ratio, 1.10; 95% CI, 1.00-1.20; P = .04).

CONCLUSIONS

In patients with PAD, higher levels of resistin were associated with impaired endothelial function and an increased rate of MACEs. These results suggest that resistin may be a marker or effector of impaired vascular physiology and adverse cardiac outcomes in patients with PAD. Further research is needed to determine the potential mechanisms by which resistin may impair endothelial function and increase MACEs in this population.

The impact of chronic kidney disease on lower extremity bypass outcomes in patients with critical limb ischemia

OBJECTIVE

Patient selection for open lower extremity revascularization in patients with chronic kidney disease (CKD) remains a clinical challenge. This study investigates the impact of CKD on early graft failure, postoperative complications, and mortality in patients undergoing lower extremity bypass for critical limb ischemia.

METHODS

The National Surgical Quality Improvement Program database was queried for all patients with critical limb ischemia from 2012 to 2015 who underwent lower extremity bypass using the targeted vascular set. The glomerular filtration rate was calculated using the Chronic Kidney Disease Epidemiology Collaboration Study equation. CKD categories were determined from the National Kidney Foundation Kidney Disease Outcomes Quality Initiative staging criteria. Patients were classified into three groups: CKD stages 3 or lower (mild to moderate CKD), CKD stages 4 or 5 (severe CKD), and on hemodialysis (HD). Multiple variable analysis was used to examine graft failure, mortality, and postoperative complications.

RESULTS

The Surgical Quality Improvement Program database identified 6978 patients who underwent infrainguinal lower extremity arterial bypass during the study period. There were 6101 patients (87.4%) with mild to moderate CKD, 327 (4.7%) with severe CKD, and 550 (7.9%) on HD. Patients with severe CKD and on HD were more likely to have revascularization for tissue loss (54.9% vs 68.8% and 74.7%; P < .01). Patients with severe CKD and those on HD had higher rates of early graft failure, postoperative myocardial infarction, and rates of reoperation. Multiple variable analysis confirmed these results showing that HD was associated with postoperative myocardial infarction, readmission, and increased mortality. It also demonstrated that severe CKD was associated with graft failure (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.12-2.50; P = .01), postoperative myocardial infarction (OR, 2.16; 95% CI, 1.35-3.45; P < .01), and readmission (OR, 1.38; 95% CI, 1.06-1.80; P = .02). Other factors associated with graft failure include functional status (OR, 1.39; 95% CI, 1.08-1.80; P = .01), African American race (OR, 1.72; 95% CI, 1.39-2.13; P < .01), and distal bypass (OR, 1.33; 95% CI, 1.09-1.61; P < .01).

CONCLUSIONS

CKD is a significant predictor of perioperative morbidity after lower extremity bypass. Patients with severe CKD have worse postoperative outcomes without increased mortality. Those on HD have worse survival and postoperative outcomes.

One-Year Results of First-Line Treatment Strategies in Patients With Critical Limb Ischemia (CRITISCH Registry)

PURPOSE

To examine the outcomes of all first-line strategies for the treatment of critical limb ischemia (CLI), identify factors that influenced the treatment choice, and determine the risk of amputation or death after each treatment.

METHODS

CRITISCH ( ClinicalTrials.gov identifier NCT01877252) is a multicenter, national, prospective registry evaluating all available treatment strategies applied in 1200 consecutive CLI patients in 27 vascular centers in Germany. The recruitment started in January 2013 and was completed in September 2014. Treatment options were endovascular revascularization (642, 53.5%), bypass surgery (284, 23.7%), femoral artery patchplasty (126, 10.5%) with or without concomitant peripheral intervention, conservative treatment (118, 9.8%), and primary major amputation (30, 2.5%). The primary endpoint of this study was amputation-free survival (AFS). The Society of Vascular Surgery's suggested objective performance goal (OPG) for AFS (71%) was used as the effectiveness criterion. Multivariable regression methods were employed to identify variables that influenced the treatment selection and AFS after each treatment; results are presented as the hazard ratio (HR) and 95% confidence interval (CI).

RESULTS

The 12-month AFS estimates following endovascular therapy, bypass grafting, femoral patchplasty, and conservative treatment were 75%, 72%, 73%, and 72%, respectively. Factors influencing treatment choice were age, chronic kidney disease (CKD), diabetes, smoking, prior vascular procedures in the index leg, TransAtlantic Inter-Society Consensus II C/D lesions, and absence of runoff vessels. Cox regression analysis identified CKD (HR 2.07, 95% CI 1.26 to 3.41, p=0.004), the use of a prosthetic bypass conduit (HR 1.97, 95% CI 1.23 to 3.14, p=0.004), and previous vascular intervention in the index limb (HR 1.52, 95% CI 0.94 to 2.43, p=0.085) as independent risk factors for diminished AFS after bypass surgery. CKD (HR 1.47, 95% CI 1.09 to 1.99, p=0.012) and Rutherford category 6 (HR 1.81, 95% CI 1.30 to 2.52, p<0.001) compromised the performance of endovascular revascularization.

CONCLUSION

CRITISCH registry data revealed that all first-line treatment strategies selected and indicated by the treating physicians met the suggested OPGs. CKD was an important determinant of patient prognosis after treatment regardless of the revascularization method.