Ankle-arm blood pressure index as a predictor of mortality in hemodialysis patients

Granulocyte Colony-Stimulating Factor Improves Endothelial Progenitor Cell-Mediated Neovascularization in Mice with Chronic Kidney Disease

Patients with chronic kidney disease (CKD) have a higher prevalence of peripheral arterial disease (PAD), and endothelial progenitor cells (EPCs) play a pivotal role. We examined the impact of granulocyte colony-stimulating factor (G-CSF) on EPC function in response to tissue ischemia. Eight-week-old male C57BL/6J male mice were divided into sham operation and subtotal nephrectomy (SNx) groups, received hindlimb ischemic operation after seven weeks, then randomly received G-CSF or PBS intervention for four weeks with weekly follow-ups. SNx mice had significantly reduced limb reperfusion, decreased plasma EPC mobilization, and impaired angiogenesis in ischemic hindlimbs compared to the control group. However, G-CSF increased IL-10 and reversed these adverse changes. Additionally, ischemia-associated protein expressions, including IL-10, phospho-STAT3, VEGF, and phospho-eNOS, were significantly downregulated in the ischemic hindlimbs of SNx mice versus control, but these trends were reversed by G-CSF. Furthermore, in cultured EPCs, G-CSF significantly attenuated the decrease in EPC function initiated by indoxyl sulfate through IL-10. Overall, we discovered that G-CSF can improve EPC angiogenic function through a hypoxia/IL-10 signaling cascade and impede neovascular growth in response to ischemia of SNx mice. Our results highlight G-CSF's potential to restore angiogenesis in CKD patients with PAD via EPC-based methods.

Peripheral arterial disease in hemodialysis patients 10 years later

BACKGROUND AND OBJECTIVE

Patients with chronic kidney disease (CKD) on hemodialysis present high cardiovascular comorbidity. Peripheral arterial disease (PAD) is associated with higher mortality and the interest in its early detection and treatment is increasing. The objective of this study is to determine the frequency and severity of symptomatic PAD, and to establish its relationship with mortality in HD patients that have received treated early and compare them with a cohort of our center already reported.

MATERIAL AND METHODS

Retrospective study on a cohort of incident patients since 2014 and followed up until December 2019. Demographic data, cardiovascular risk, the presence of symptomatic PAD at baseline and during follow-up were collected. Trophic lesions were graded using the Rutherford scale.

RESULTS

Initially, there were 91 patients and 7 cases that were not included in the study were lost to follow-up. Age 64 ± 16 years, men 51.6% (47/91). The percentage of baseline PAD was 10.7% (9/84). During a median follow-up of 35 months (20-57), the diagnosis of PAD increased to 25% (21/84). Half of the patients with PAD 52.38% (11/21) obtained a score greater than 3 in the Rutherford Clinical Classification, which corresponds to severe disease. 13/21 patients required reoperation due to recurrence of symptoms (61.9% of cases with PAD). The development of PAD was significantly associated with: an elevated index of Charlson (3.9±2.1 vs. 7.7 ± 3.5; P = 0.001),being male (19 vs. 2; P = 0.001), diabetic (no: 7; yes: 15; P = 0.001) and with a history of chronic ischemic heart disease (no: 13; yes: 8; P = 0.001), 38.1% (8/21) had ischemic heart disease in patients who developed PAD, while in the absence of PAD the presence of ischemic heart disease was 9.5% (6/63). Furthermore, more than half (66.7% [14/21]) of those who developed PAD were diabetic. Univariate analysis showed that age, C reactive protein, albumin, and number of surgical interventions, but not PAD, were associated with mortality. In the multivariate analysis adjusted for other factors, only C reactive protein was related to overall survival Exp β: 2.17; P = 0.011; CI (1.19-3.97). Regarding cardiovascular mortality, in the multivariate Cox analysis, only PAD was related to mortality of cardiovascular origin Exp β: 1.73; P = 0.006; CI (1.17-2.56).

CONCLUSIONS

A significant number of patients on hemodialysis develop PAD requiring peripheral vascular surgery. PAD was not associated with overall mortality in our cohort, but it did show an association with cardiovascular mortality. Prospective studies with a larger sample size are necessary. New surgical treatments and Follow-up by vascular surgeons could improve the severity of PAD and the long-term prognosis.

Significance of nutrition in hemodialysis patients with peripheral arterial disease evaluated by skin perfusion pressure

Background

Peripheral artery disease (PAD) is a serious complication in hemodialysis (HD) patients. Low skin perfusion pressure (SPP) is a useful marker for detecting PAD. Malnutrition is an important cause of intractable complications. We examined the relationship between low SPP and various indicators of nutritional status.

Methods

A total of 120 patients on maintenance HD were enrolled for SPP measurement. SPP was measured at the soles of both feet during HD, and patients were divided into low SPP (L-SPP) and normal SPP (N-SPP) groups by 50 mmHg. The following values were determined by averaging four blood samples taken before SPP measurements every 3 months for one year: hemoglobin, total protein, albumin (Alb), total cholesterol, urea nitrogen, creatinine (Cr), potassium, calcium, phosphate, intact parathyroid hormone, iron (Fe), transferrin saturation (T-SAT), and C-reactive protein (CRP). We calculated the percent Cr production rate, dialysis index (Kt/V), normalized protein catabolic rate (nPCR), geriatric nutritional risk index (GNRI), and estimated salt intake using the required formulas. In addition, the age, body mass index, and presence of diabetes mellitus (DM) were compared between both groups along with all other measurements. Data were expressed as the mean ± standard deviation or median with interquartile range as appropriate. Differences in continuous variables between the two groups were analyzed by Student’s t-test or Wilcoxon’s rank-sum test, as appropriate. Multivariate logistic analysis and receiver operating curve (ROC) analysis were performed for significant variables. The results were expressed as odds ratios with respective 95% confidence intervals (CIs).

Results

The enrolled patients were 82 men and 38 women, with a mean age of 66.9 ± 13.3 years and HD duration of 4.76 (2.13–12.28) years (median interquartile range). Twenty patients belonged to the L-SPP group, suggesting PAD. Comparison between the L-SPP and N-SPP groups showed significant differences in age, Cr, Fe, T-SAT, CRP, nPCR, GNRI, DM, and estimated salt intake. When the GNRI, estimated salt intake, CRP, and DM were applied as independent variables for multiple logistic regression analysis, the GNRI (odds ratio: 0.857, 95% CI 0.781–0.941, p = 0.001), CRP (2.406, 1.051–3.980, p = 0.035), and DM (9.194, 2.497–33.853, p = 0.001) were found to be significant for L-SPP, and a cutoff level of 92.1 (sensitivity 80%, specificity 72%, AUC: 0.742, 95% CI 0.626–0.858, p = 0.001) in the GNRI obtained by ROC was consistent with the risk index in the elderly presented previously.

Conclusions

SPP measurement is an essential tool for detecting high-risk PAD in maintenance HD, which is affected by malnutrition, DM, and inflammation. The GNRI is important for the determination of malnutrition.

Positive correlation of serum indoxyl sulfate level with peripheral arterial disease in hemodialysis patients

OBJECTIVES

Indoxyl sulfate, known for its cardiovascular toxicity, is associated with vascular and coronary artery diseases and increased mortality. Peripheral arterial disease, defined by low ankle-brachial index, is associated with increased mortality in patients on hemodialysis. The present study aimed to determine the relationship between the serum indoxyl sulfate level and peripheral arterial disease in patients on maintenance hemodialysis.

METHODS

The present cross-sectional, single-center study included 75 patients on maintenance hemodialysis. Serum indoxyl sulfate levels were determined by high-performance liquid chromatography-mass spectrometry. Ankle-brachial index values were measured using an automated oscillometric device. Patients with ankle-brachial indexes of < 0.9 were categorized into the low ankle-brachial index group.

RESULTS

In the study cohort, 12 of the 75 patients (16.0%) had low ankle-brachial indexes. The rates of diabetes mellitus (p = 0.010) as well as the serum levels of C-reactive protein (p < 0.001) and indoxyl sulfate (p < 0.001) were higher in the low ankle-brachial index group than the normal ankle-brachial index group. The multivariable logistic regression analysis revealed that serum levels of indoxyl sulfate (odds ratio = 1.123, 95% confidence interval 1.011-1.249, p = 0.031) and C-reactive protein (each 0.1 mg/dL increase, odds ratio = 1.169, 95% confidence interval 1.018-1.343, p = 0.027) were independently associated with peripheral arterial disease in patients on maintenance hemodialysis.

CONCLUSIONS

Serum indoxyl sulfate levels were associated with peripheral arterial disease in patients on maintenance hemodialysis.

Prevalence and risk factors of peripheral artery disease in a population with chronic kidney disease in Australia: A systematic review and meta-analysis

There is a lack of clarity and guidance for screening peripheral artery disease (PAD) in persons with chronic kidney disease (CKD) and end stage kidney disease (ESKD) despite this group being at excess risk of cardiovascular disease (CVD). In this current study, we performed a systematic review and meta-analysis to examine the prevalence and risk factors for PAD in persons with CKD in Australian cohorts. We used the inverse variance heterogeneity meta-analysis with double arcsine transformation to summarize the prevalence of PAD (with 95% CIs). Nine studies and 18 reports from the Australia and New Zealand dialysis and transplant registry with 36 cohorts were included in the review. We found a substantially higher PAD prevalence in cohorts based on an ankle-brachial index (ABI) or toe systolic pressure (TBI) than cohorts based on self-reported history. Higher PAD prevalence was observed in ESKD persons than CKD persons without dialysis (PAD diagnosis based on ABI or TBI: 31% in ESKD persons and 23% in CKD persons, PAD diagnosis based on self-reported history: 17% in ESKD persons and 10% in CKD persons). Older age, Caucasian race, cerebrovascular disease and haemodialysis were associated with the presence of PAD in ESKD persons. Our findings indicated a considerable proportion of PAD in CKD and ESKD persons particularly in those with ESKD. To develop and provide an adequate plan to clinically manage CKD patients with PAD, evidence of cost-effectiveness and clinical benefit of early detection of PAD in persons with CKD in Australia is recommended for future studies.

Obesity-Related Indices Are Associated with Peripheral Artery Occlusive Disease in Patients with Type 2 Diabetes Mellitus

Type 2 diabetes mellitus (DM) is an increasing global health issue. Peripheral artery occlusive disease (PAOD) is a common complication of diabetes, and it is a complex and costly disease. The association between type 2 DM and obesity is well known, however, the relationship between obesity and PAOD in patients with type 2 DM has yet to be elucidated. Therefore, the aim of this study was to examine associations between obesity-related indices and PAOD in patients with type 2 DM. A total of 1872 outpatients with type 2 DM were recruited from two hospitals in southern Taiwan. An ankle–brachial index (ABI) < 0.9 in either leg was considered to indicate the presence of PAOD. The following obesity-related indices were investigated: conicity index (CI), waist–hip ratio (WHR), body roundness index (BRI), waist-to-height ratio (WHtR), abdominal volume index, a body shape index (ABSI), visceral adiposity index (VAI), lipid accumulation product (LAP), body adiposity index, body mass index and triglyceride–glucose index. Overall, 4.1% of the enrolled patients had an ABI < 0.9. High values of the following obesity-related indices were significantly associated with a low ABI: WHtR (p = 0.045), VAI (p = 0.003), CI (p = 0.042), BRI (p = 0.021) and ABSI (p = 0.043). Furthermore, WHR (area under the curve (AUC) = 0.661), CI (AUC = 0.660) and LAP (AUC = 0.642) had the best performance (all p < 0.001) to predict PAOD. In conclusion, high WHtR, BRI, CI, VAI and BAI values were associated with a low ABI in the enrolled patients, and WHR, CI and LAP were the most powerful predictors of PAOD.

Peripheral Vascular Disease in Diabetic Peritoneal Dialysis Patients

In the present article, we review current knowledge of the epidemiology, diagnosis, and treatment of peripheral vascular disease in patients with end-stage renal disease. The main focus is placed on diabetic patients receiving peritoneal dialysis, but studies on patients receiving hemodialysis are also reviewed, because most reports involve this patient group, and the number of reports on peripheral vascular disease in PD patients alone is limited.

Plasma Leucine-Rich α-2-Glycoprotein 1 Predicts Cardiovascular Disease Risk in End-Stage Renal Disease

Plasma leucine-Rich α-2-glycoprotein 1 (LRG1) is an innovative biomarker for inflammation and angiogenesis. Many adverse pathophysiological changes including inflammation, atherosclerosis, and premature mortality is associated with End-stage renal disease (ESRD). However, whether levels of plasma LRG1 correlate with the co-morbidities of ESRD patients is unknown. Plasma LRG1 and high-sensitivity C-reactive protein (hsCRP) were analyzed by ELISA in 169 hemodialysis patients from the Immunity in ESRD (iESRD) study. Patient demographics and comorbidities at the time of enrollment were recorded. Peripheral blood monocyte and T cell subsets were assessed by multicolor flow cytometry. In the univariate analysis, a higher level of LRG1 was associated with the presence of cardiovascular disease (CVD) and peripheral arterial occlusive disease (PAOD). In multivariate logistic regression models, higher LRG1 tertile was significantly associated with PAOD (odds ratio = 3.49) and CVD (odds ratio = 1.65), but not with coronary artery disease, history of myocardial infarction, or stroke after adjusting for gender, diabetes, hemoglobin, albumin, calcium-phosphate product, and level of hsCRP. In addition, the level of LRG1 had a positive correlation with IL-6, hsCRP, and also more advanced T cell differentiation. The association suggests that LRG1 participates in the progression of atherosclerosis by inducing inflammation. Therefore, the role of LRG1 in coexisting inflammatory response should be further investigated in the pathogenesis of cardiovascular morbidity and mortality in patients with ESRD.

Hypothyroidism is associated with all-cause mortality in a national cohort of chronic haemodialysis patients

AIM

The prevalence of hypothyroidism is high in haemodialysis (HD) patients and hypothyroidism increases all-cause mortality in HD patients. Comorbidities are common in HD patients and are associated with both mortality and hypothyroidism. The aim of the study is to explore the effect of the interactions of comorbidities and hypothyroidism on all-cause mortality in HD patients.

METHOD

Patients with hypothyroidism (ICD-9-CM 244.0, 244.1, and 244.9) and matched patients without hypothyroidism in the Registry for Catastrophic Illness Patient Database of Taiwan Health Insurance from 2000 to 2010 were analyzed. The association of hypothyroidism and risk of all-cause mortality was analyzed using Cox proportional hazard regression.

RESULT

Nine hundred and eight HD patients with hypothyroidism and 3632 sex-, age-, gender- matched HD patients without hypothyroidism were analyzed. Hypothyroidism was associated with increased all-cause mortality with an adjusted hazard ratio of 1.22 [95% confidence interval (CI): 1.10-1.36, P < 0.001]. TRT may decrease mortality associated with hypothyroidism (P < 0.001). There was a significant interaction (P = 0.04) between diabetes and hypothyroidism. There was no significant interaction found in hypothyroidism and the following comorbidities: hyperlipidaemia, hypertension, chronic obstructive pulmonary disease, coronary artery disease, stroke, peripheral arterial disease, asthma, congestive heart failure and cancer.

CONCLUSION

Hypothyroidism is associated with increased all-cause mortality in chronic HD patients. The interaction of hypothyroidism and diabetes, but not other common comorbidities in HD patients, has an effect on mortality risks.

Far-infrared therapy improves ankle brachial index in hemodialysis patients with peripheral artery disease

Ankle brachial index (ABI) is a diagnostic tool for peripheral artery disease (PAD), which is an important issue in hemodialysis (HD) patients. We enrolled 198 maintenance HD patients in this study. PAD is defined as ABI ≤ 0.90. Only PAD patients received far-infrared (FIR) therapy using the WS TY101 FIR emitter for 40 min during each HD session, three times weekly for 6 months. The ABI was measured at the bilateral lower extremities for 4 times [pre-dialytic timing (0 min) and 40 min after the initiation of HD session at both day 0 and 6 months after the FIR therapy]. The primary outcome is the change in ABI. There were 51 out of 198 patients with PAD. In comparison with the period without FIR therapy in the 51 PAD patients, 6 months of FIR therapy significantly improved the ABI of the right/left side for 0 min (from 0.77 ± 0.19 to 0.81 ± 0.20, p = 0.027/0.79 ± 0.20 to 0.81 ± 0.17, p = 0.049), 40 min during HD (from 0.73 ± 0.23 to 0.83 ± 0.19, p < 0.001/from 0.77 ± 0.21 to 0.83 ± 0.18, p < 0.001), and the incremental change between 0 and 40 min (from - 0.04 ± 0.14 to 0.05 ± 0.13, p = 0.007/from - 0.05 ± 0.13 to 0.03 ± 0.11, p = 0.012), respectively. In conclusion, the application of FIR therapy for 40 min, three times weekly for 6 months, has improved the ABI of both lower extremities, thus providing a new strategy of PAD treatment in HD patients.

Relationship between Systemic Vascular Characteristics and Retinal Nerve Fiber Layer Loss in Patients with Type 2 Diabetes

Retinal nerve fiber layer (RNFL) loss in diabetic patients is especially common regardless of diabetic retinopathy (DR). The correlations between nonglaucomatous RNFL loss and systemic characteristics in diabetic patients have aroused interests in many aspects. 167 subjects with type 2 diabetes who underwent evaluation for arterial stiffness and cardiovascular autonomic function using heart rate variability (HRV) were included in this study. Arterial stiffness was measured using cardio-ankle vascular index (CAVI) and ankle-brachial index (ABI). Multivariate regression analysis was performed to determine factors influencing the presence of RNFL loss according to age. Factors determining the superior location of diabetic RNFL loss were also investigated. CAVI were worse in patients with RNFL loss, especially in those with old age (≥50 yrs) (p = 0.037). Influential factor of RNFL defect in old group was ABI (p = 0.007). However, in young group (<50 yrs), HRV parameter (low-frequency/high-frequency ratio) determined the presence of RNFL loss (p = 0.040). Significant determinants of superior RNFL defect in old subjects were CAVI and ABI (p = 0.032 and p = 0.024). For young diabetic patients, autonomic dysfunction may have relationship with RNFL loss, but as patients get older, arterial stiffness could aggravate vascular autoregulation and diabetic RNFL loss. RNFL loss in diabetes may be correlated with systemic vascular conditions.

Abnormally Low or High Ankle-Brachial Index Is Associated With the Development of Diabetic Retinopathy in Type 2 Diabetes Mellitus

Although some studies have reported an association between peripheral artery disease (PAD) and diabetic retinopathy (DR) in patients with diabetes, whether or not a causal relationship exists is unknown. The aim of this study was to investigate whether PAD, as indicated by an abnormally low or high ankle-brachial index (ABI), is associated with the development of DR in patients with type 2 diabetes mellitus (DM) without DR. We enrolled 414 (221 men and 193 women) patients with type 2 DM who underwent ABI measurements at our outpatient clinic. PAD was defined as an abnormally low (<0.9) or high (≥1.3) ABI in either leg, and DR was defined as being non-proliferative or proliferative. Of the enrolled patients, 69 (16.7%) had an ABI <0.9 or ≥1.3. The median follow-up period was 23 (15–40) months, during which 74 (17.9%) patients developed DR. In multivariate analysis, an ABI <0.9 or ≥1.3 was independently associated with the development of DR (vs. ABI ≥0.9 to <1.3; hazard ratio, 2.186; 95% confidence interval, 1.261 to 3.789; p = 0.005). An abnormal ABI was associated with the development of DR in our patients with type 2 DM without DR.

Ankle-Brachial Index as a Predictor of Mortality in Hemodialysis: A 5-Year Cohort Study

Background

Abnormal ankle-brachial index (ABI) has been found to be a strong predictor of mortality in some hemodialysis populations in studies with relatively short periods of follow-up, lower than 2 years.

Objective

This study aimed to assess the predictive value of abnormal ABI as a risk factor for death among patients on maintenance hemodialysis after a 5-year follow-up.

Methods

A total of 478 patients on hemodialysis for at least 12 months were included in the study. ABI measurement was performed using a mercury column sphygmomanometer and portable Doppler. Patients were divided into 3 groups according to ABI (low: <0.9; normal: 0.9 to 1.3; and high: >1.3) and followed for a 60-month period.

Results

The prevalence rates of low, normal and high ABI were 26.8%, 64.6% and 8.6%, respectively. The 5-year survival rate was lower in the groups with low ABI (44.1%, P<0.0001) and high ABI (60.8%, P= 0.025) than in the group with normal ABI (71.7%). Cox regression was used to evaluate the association between ABI and mortality, adjusting for potential confounders. Using normal ABI as reference, a low, but not a high ABI was found to be an independent risk factor for all-cause mortality (HR2.57; 95% CI, 1.84-3.57 and HR 1.62; 95% CI, 0.93-2.83, respectively).

Conclusions

long-term survival rates of patients with either low or high ABI were lower than the one from those with normal ABI. However, after adjustment for potential confounders, only low ABI persisted as an independent risk factor for all-cause mortality among hemodialysis patients.

Development and Validation of the Modified Charlson Comorbidity Index in Incident Peritoneal Dialysis Patients: A National Population-Based Approach

Background

The utility of applying the Charlson comorbidity index (CCI) to peritoneal dialysis (PD) patients is disputed because the relative weight of each comorbidity in PD patients may be different from those in other chronic diseases. We aimed to develop and validate a modified CCI in incident PD patients (mCCI-IPD) for better risk stratification and prediction of mortality.

Methods

The mCCI-IPD was developed using data from all Korean adult incident PD patients between 2005 and 2008 ( n = 7,606). Multivariate Cox regression was used to determine new weights for the individual comorbidities in the CCI. The prognostic performance of the mCCI-IPD was validated in an independent cohort ( n = 664) through c-statistics and continuous net reclassification improvement (cNRI).

Results

A total of 75.5% of the patients in the development cohort had 1 or more comorbidities. The Cox proportional hazards model provided reassigned severity weights for the 11 comorbidities that significantly predicted mortality. In the validation cohort, the CCI and mCCI-IPD scores were both correlated with survival and showed no differences in their c-statistics. However, multivariate analyses using cNRI revealed that the mCCI-IPD provided a 38.2% improvement in mortality risk assessment compared with the CCI (95% confidence interval [CI], 15.3 – 61.0; p < 0.001). These significant reclassification improvements were observed consistently in subjects with events (cNRIEvent, 28.2% [95% CI, 6.9 – 49.5; p = 0.009]) and without events (cNRINon-event, 10.0% [95% CI, 1.7 – 18.2; p = 0.019]).

Conclusions

Compared with the CCI, the mCCI-IPD showed better performance in mortality prediction for incident PD patients. Therefore, this tool may be used as a preferred index for statistical analysis and clinical decision-making.

Association of peripheral arterial disease with all-cause and cardiovascular mortality in hemodialysis patients: a meta-analysis

Background

Recent studies have shown an association between peripheral arterial disease (PAD) and increased risk of mortality in hemodialysis (HD) patients; however, the estimates vary widely and are inconsistent. It is necessary to elucidate the degree of mortality risk for PAD patients in HD population.

Methods

PubMed, EMBASE, Web of Science and Cochrane Library (from inception to September 4th, 2016) were systematically searched for cohort studies assessing the association between PAD and mortality in HD patients. We calculated the pooled risk ratios (RRs) with 95% confidence intervals (CI) of all-cause and cardiovascular (CV) mortality using random effects models. Subgroup analyses were conducted to explore the source of heterogeneity.

Results

The search identified 2,973 potentially eligible records and 10 studies (n = 32,864) were included. Our meta-analysis revealed that PAD significantly increased the risk of all-cause mortality (RR 2.15, 95 % CI 1.67–2.77, n = 32,864) and CV mortality (RR 2.99, 95 % CI 1.66-5.38, n = 31,794) in HD patients after multivariate adjustment. Subgroup analyses showed the study design and follow-up time might be two sources of heterogeneity.

Conclusion

PAD may be a prognostic marker of all-cause and CV mortality in HD patients. More attention should be paid to diagnosis and management of PAD in HD patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s12882-016-0397-1) contains supplementary material, which is available to authorized users.

Role of Cilostazol Therapy in Hemodialysis Patients with Asymptomatic Peripheral Arterial Disease: A Retrospective Cohort Study

Background. Peripheral arterial disease (PAD) and its relevant complications are more common in hemodialysis (HD) patients, while the evidence regarding antiplatelet therapy in CKD patients is scarce. We retrospectively analyzed the efficacy of cilostazol on outcomes in HD patients with asymptomatic PAD (aPAD). Methods. This cohort study enrolled 217 HD patients (median follow-up time: 5.75 years). Associations between cilostazol use and the outcomes were evaluated by time-dependent Cox regression analysis. Results. During follow-up, 39.5% (47/119) patients used cilostazol for aPAD and 31.8% (69/217) patients died. Cilostazol users had significantly lower CVD and all-cause mortalities (adjusted HR [95% CI]: 0.11 [0.03, 0.51] and 0.2 [0.08, 0.52]) than nonusers. Both death risks were nonsignificantly higher in cilostazol users than in HD patients without aPAD. The unadjusted and adjusted HR [95% CI] of CVD death risk were 0.4 [0.07, 2.12] and 0.14 [0.02, 0.8] for patients with aPAD during follow-up and were 0.74 [0.16, 3.36] and 0.19 [0.04, 0.93] for those with aPAD at initial. Conclusions. In HD patients with aPAD, lower CVD and all-cause mortality rates were observed in low-dose cilostazol user. Further evidences from large-scale prospective study and randomization trial are desired to confirm the effect of cilostazol.

Effects of Lipid Abnormalities on Arteriosclerosis and Hemostatic Markers in Patients under Hemodialysis

Vascular events caused by arteriosclerosis are the major cause of death in patients under hemodialysis (HD). Arteriosclerosis is associated with lipoprotein abnormalities such as increased serum levels of low-density lipoprotein (LDL), especially of modified LDL (M-LDL) and oxidized LDL (Ox-LDL). We examined the relationship between markers of arteriosclerosis, hemostasis, and lipid metabolism in patients with chronic renal failure, hyperlipidemia, and healthy volunteers. In patients under HD, the serum levels of total cholesterol, LDL, and triglyceride (TG) were decreased, but the serum levels of M-LDL were increased compared to HL and healthy volunteers. In patients with CRF, the serum levels of OxLDL in patients under HD were lower than in those under continuous ambulatory peritoneal dialysis or conservative therapy. The plasma levels of antithrombin and protein C were significantly lower and the plasma levels of thrombomodulin were significantly higher in patients under HD compared to those under conservative therapy. These data show that patients under HD were more in hypercoagulable state than those under conservative therapy. Among patients under HD, only the plasma levels of von Willebrand factor were significantly increased in patients with more than 30 U/L of Ox-LDL compared to those with less than 30 U/L of Ox-LDL. There was no significant difference in the tests of arteriosclerosis among M-LDL values and OxLDL values. These findings suggest that abnormalities of lipid are not the main risk factor for arteriosclerosis disease in patients under HD.

Prognostic Impact of Aortic Calcification Index and Ankle-Arm Blood Pressure Indexin Patients under Hemodialysis

The mortality rate is high in patients receiving hemodialysis (HD), atherosclerotic diseases being the major cause of death. As marker of clinical outcome, a prospective examination of atherosclerotic tests and atherosclerotic risk factors in patients receiving HD was performed. On April 2000, 84 patients receiving HD were followed up until April 2002. At entry to the study, several atherosclerotic tests, including ankle-arm blood pressure index (API), aortic calcification index (ACI), and atherosclerotic risk factors, were performed. In 36 patients with old thrombotic events, 26 had new thrombotic events. Of 48 patients without previous thrombotic events, 15 had new thrombotic events. During 2 years, 41 patients had new thrombotic events and 15 patients died due to thrombotic disorders. The HD durations were significantly longer in non-survivors than survivors and the body mass index was lower in non-survivors than survivors. There was a significant difference in the values of ACI and API between survivors and non-survivors, and between patients with and without thrombotic events. These findings suggest that the ACI and API have a prognostic value because they might predict the occurrence of thrombosis.

Cardiac event risk stratification in patients with end-stage renal disease: Sub-analysis of the B-SAFE study

BACKGROUND

The aim of this study was to investigate whether 123I-labelled β-methyl iodophenyl-pentadecanoic acid (BMIPP) imaging as an abnormal myocardial fatty acid metabolism indicator better predicted fatal and non-fatal cardiac events than conventional predictors [e.g. peripheral artery disease (PAD) and diabetes mellitus (DM)] in haemodialysis patients.

METHODS

In a sub-analysis of the BMIPP SPECT Analysis for Decreasing Cardiac Events in Haemodialysis Patients (B-SAFE) study, 677 asymptomatic patients with ≥1 cardiovascular risk factor and without known coronary artery disease were followed for 3 years. The amount of radioactivity in each 17-left ventricular segment was graded visually and assigned a score from 0 (normal) to 4 (absent). Its total values were designated as baseline summed BMIPP scores. Outcome measures were composite cardiac events.

RESULTS

Cardiac events correlated with age, PAD [hazard ratio (HR): 2.15; p=0.003], DM (HR: 1.76; p=0.006) and summed BMIPP scores (4-8, HR: 1.82; p<0.001; ≥9, HR: 3.49; p<0.001). Cardiac event-free rates decreased with increasing summed BMIPP scores, PAD and DM. Areas under the receiver operating curves (AUCs) indicated that a BMIPP-based model (AUC: 0.656) was more predictive than DM or PAD models (AUC: 0.591); a model with all three was most predictive (AUC: 0.708). The three-year cardiac event-free rates significantly decreased in patients with PAD and/or DM in all summed BMIPP score categories.

CONCLUSIONS

Abnormal myocardial fatty acid metabolism strongly predicts cardiac events in haemodialysis patients; those with PAD or DM are at high risk for cardiac events.

Link between Peripheral Artery Disease and Heart Rate Variability in Hemodialysis Patients

Peripheral artery disease (PAD) and low heart rate variability (HRV) are highly prevalent in hemodialysis patients, and both are associated with increased cardiovascular morbidity and mortality. This study aims to examine the suggested relationship between PAD and HRV, and the relationship of parameters before and after hemodialysis. This study enrolled 161 maintenance hemodialysis patients. PAD was defined as ABI < 0.9 in either leg. HRV was performed to assess changes before and after hemodialysis. The change in HRV (△HRV) was defined as post-hemodialysis HRV minus pre-hemodialysis HRV. Patients’ clinical parameters were collected from the dialysis records. All HRV parameters except high frequency (HF) % were lower in patients with PAD than patients without PAD, though not achieving significant level. In patients without PAD, HF (P = 0.013), low frequency (LF) % (P = 0.028) and LF/HF (P = 0.034) were significantly elevated after hemodialysis, whereas no significant HRV parameters change was noted in patients with PAD. Serum intact parathyroid hormone was independently associated with △HF (β = -0.970, P = 0.032) and △LF% (β = -12.609, P = 0.049). Uric acid level (β = -0.154, P = 0.027) was negatively associated with △LF/HF in patients without PAD. Our results demonstrated that some of the HRV parameters were significantly increased after hemodialysis in patients without PAD, but not in patients with PAD, reflecting a state of impaired sympatho-vagal equilibrium. Severity of secondary hyperparathyroidism and hyperuricemia contributed to lesser HRV parameters increase after hemodialysis in patients without PAD.

Abnormally Low or High Ankle-Brachial Index Is Associated with Proliferative Diabetic Retinopathy in Type 2 Diabetic Mellitus Patients

Although some studies have reported that low ankle-brachial index (ABI) is associated with diabetic retinopathy (DR) in diabetic patients, it remains controversial as to which stage of DR. The aim of this study is to assess whether peripheral artery disease (PAD), indicated by abnormally low or high ABI, is associated with different stages of DR in patients with type 2 diabetes mellitus (DM), and further evaluate the risk factors. A total of 2001 (858 men and 1143 women) patients with type 2 DM who underwent ABI measurement in an outpatient clinic were enrolled. PAD was defined as ABI < 0.9 or ≧ 1.3 in either leg. DR was classified as non-DR, nonproliferative DR and proliferative DR stages. The clinical data were analyzed and the risk factors for abnormal ABI were determined by multivariate logistic regression analysis. The prevalence of ABI < 0.9 or ≧ 1.3 was 3.0%. Multivariate forward logistic regression analysis identified proliferative DR (vs. non-DR) was associated with abnormal ABI (odds ratio, 1.718; 95% confidence interval, 1.152 to 2.562; p = 0.008), but nonproliferative DR was not. Furthermore, the presence of coronary artery disease, cerebrovascular disease, declining renal function and patients without diuretics use were associated with abnormal ABI in patients with proliferative DR. Our study in patients of type 2 DM demonstrated that PAD was associated with proliferative DR. We emphasize the recommendation of performing the ABI test in this population at risk.

Peripheral artery disease and chronic kidney disease: clinical synergy to improve outcomes

Persons with CKD are at a higher risk of developing peripheral artery disease (PAD) and its adverse health outcomes than individuals in the general population who have normal renal function. Classic atherosclerosis risk factors (eg, age, smoking, diabetes, hypertension, and hyperlipidemia) are common in patients with CKD, but CKD also imposes additional unique risk factors that promote arterial disease (eg, chronic inflammation, hypoalbuminemia, and a procalcific state). Current nephrology clinical practice is adversely affected by PAD diagnostic challenges, the complexities of managing 2 serious comorbid diseases, delayed vascular specialist referral, and slow PAD treatment initiation in patients with CKD. Persons with CKD are less likely to be provided recommended "optimal" PAD care. The knowledge that both limb and mortality outcomes are significantly worse in patients with CKD, especially those on dialysis, is not just a biologic fact but can serve as a care delivery call to action. Nephrologists can facilitate positive change. This article proposes that patients with PAD and CKD be strategically comanaged by care teams that encompass the skills to create and use evidence-based care pathways. This proposed collaborative multidisciplinary approach will include vascular medicine specialists, nephrologists, wound specialists, and mid-level providers. Just as clinical care quality metrics have served as the base for ESRD and acute MI quality improvement, it is time that such quality outcomes metrics be initiated for the large PAD-CKD population. This new system will identify and resolve key gaps in the current care model so that clinical outcomes improve within a cost-effective care frame for this vulnerable population.

Ankle-brachial blood pressure index predicts cardiovascular events and mortality in Japanese patients with chronic kidney disease not on dialysis

The ankle-brachial blood pressure index (ABPI) has been recognized to have a predictive value for cardiovascular (CV) events and mortality in general or dialysis populations. However, the associations between ABPI and those outcomes have not been fully investigated in predialysis patients. The present study aimed to clarify the relationships between ABPI and both CV events and mortality in Japanese chronic kidney disease (CKD) patients not on dialysis. In this prospective observational study, we enrolled 320 patients with CKD stages 3-5 who were not on dialysis. At baseline, ABPI was examined and a low ABPI was defined as <0.9. CV events and all-cause deaths were examined in each patient. A Cox proportional hazards model was applied to determine the risk factors for CV events, as well as for mortality from CV and all causes. The median follow-up period was 30 months. CV events occurred in 56 patients and all-cause deaths occurred in 48, including 20 CV deaths. Multivariate analysis showed that age and low ABPI were risk factors for CV events. It was demonstrated that age, a history of cerebrovascular disease and low ABPI were determined as independent risk factors for CV mortality. In addition, age, body mass index and low ABPI were independently associated with all-cause mortality. In patients with CKD, low ABPI during the predialysis period is independently associated with poor survival and CV events, suggesting the usefulness of measuring ABPI for predicting CV events and patient survival in CKD.

Association of brachial-ankle pulse wave velocity, ankle-brachial index and ratio of brachial pre-ejection period to ejection time with left ventricular hypertrophy

BACKGROUND

Arterial stiffness, peripheral artery disease and left ventricular systolic dysfunction contributed to left ventricular hypertrophy (LVH). Using an ABI-form device, we can obtain brachial-ankle pulse wave velocity (baPWV), ankle-brachial index (ABI) and the ratio of brachial pre-ejection period to ejection time (bPEP/bET), which are markers for arterial stiffness, peripheral artery disease and left ventricular systolic function, respectively. The aim of this study was to assess whether "BAP score" calculated from the 3 measures of baPWV, ABI and bPEP/bET is associated with LVH.

METHODS

A total of 1,146 patients were included in the study. BAP score was calculated based on a point system in which 1 point was assigned for baPWV above the median value of 1670 cm/s, ABI < 0.9 or ≥ 1.3 in either leg and bPEP/bET > 0.38.

RESULTS

There was a significant trend for a stepwise increase in the left atrial diameter, left ventricular mass index (LVMI) and the prevalence of LVH and a stepwise decrease in the left ventricular ejection fraction corresponding to advancement in BAP score from 0 to 3. In addition, increased BAP score is significantly associated with increased LVMI and LVH.

CONCLUSIONS

Our results demonstrated increased BAP score was related to increased LVMI and LVH independent of traditional risk factors such as old age, diabetes, hypertension, obesity, anemia, hyperlipidemia and chronic kidney disease. Therefore, the BAP score obtained from the same examination might be useful and convenient in identifying patients with increased LVMI and LVH.

The impact of diabetes mellitus on peritoneal dialysis: the Turkey Multicenter Clinic Study

PURPOSE

It is well established that diabetic peritoneal dialysis (PD) patients have a higher mortality rate than the other PD population. This study was designed to determine the overall predictors of survival and compared mortality and morbidity between diabetic and non-diabetic Turkish PD patients.

METHODS

We conducted a multicenter retrospective study with 915 PD patients [217 had diabetes mellitus (DM)]. Serum albumin, PTH, HbA1c, co-morbid diseases, dialysis adequacy (Kt/V), and peritoneal transport characteristics as well as peritonitis episodes and ultrafiltration failure during the follow-up period were recorded.

RESULTS

DM patients were older and had more co-morbidities than non-DM patients. Peritonitis rates were higher in DM patients (one episode per 35.9 patient months) compared to non-DM patients (one episode per 41.5 patient months) (p < 0.001). On Kaplan-Meier analysis, patient survival was significantly lower in DM patients with the 2-, 3- and 5-year patient survival rates of 90.8%, 87.8% and 78.2% in non-diabetics and 80.9%, 70.4% and 61.2% in diabetics, respectively. On Cox regression analysis, DM (HR 1.5, p = 0.022), age (HR 1.03, p < 0.001), baseline serum albumin (HR 0.39, p < 0.001), heart failure (HR 0.038, p = 0.038), peripheral artery disease (HR 1.83, p = 0.025) and amputation (HR 4.1, p = 0.009) at baseline were significant predictors of overall mortality.

CONCLUSIONS

Patient survival is lower in diabetic compared to non-diabetic patients on PD. Peritonitis rates were also higher in diabetic PD patients. DM, older age, albumin level and cardiovascular co-morbidities are predictors of mortality.

End-stage renal disease and limb salvage

The prevalence of peripheral arterial disease and both traditional and nontraditional vascular risk factors are more common in patients with end-stage renal disease who are undergoing hemodialysis than the general population. Patients undergoing hemodialysis may also be at risk for peripheral arterial disease via nonvascular risk factors and the hemodialysis treatment itself. Unfortunately, because peripheral arterial disease and its risk factors in hemodialysis patients have not been thoroughly ascertained, evaluation of potential treatments has been limited. Given the high potential of morbidity and impaired quality-of-life related to peripheral arterial disease in patients with end-stage renal disease, additional studies are needed to evaluate both quality of life and potential screening for peripheral arterial disease, its risk factors, and treatments to identify areas for improvement in this vulnerable population.

Effects of the ankle-brachial blood pressure index and skin perfusion pressure on mortality in hemodialysis patients

OBJECTIVE

Clinically, the ankle-brachial blood pressure index (ABI) and skin perfusion pressure (SPP) are used to screen for subclinical peripheral artery disease. However, the association between the SPP and mortality in hemodialysis patients has not been previously reported. We investigated these factors and compared the ABI and SPP in patients receiving hemodialysis.

METHODS

A total of 102 patients receiving maintenance hemodialysis were enrolled in this study. The ABI was determined using an ABI-form (Colin, Japan). The SPP was measured using a SensiLase(TM) PAD3000 (Kaneka, Osaka, Japan).

RESULTS

The mean follow-up period was 3.2 ± 1.4 years. A multivariate Cox analysis identified a low ABI (p=0.019) and a low SPP (p=0.047) as being independent predictors of mortality. A receiver operating characteristic (ROC) analysis of the ABI revealed a cutoff point of 1.1 and an area under the curve (AUC) of 0.79, with a sensitivity of 90% and a specificity of 62%. A ROC analysis of the SPP revealed a cutoff point of 54.0 mmHg and an AUC of 0.71, with a sensitivity of 55% and a specificity of 84%.

CONCLUSION

Both low ABI and SPP values were found to be independent risk factors for mortality among hemodialysis patients. The cutoff point for ABI as a predictor of mortality was 1.1, while that for SPP was 54.0 mmHg.

Association of chronic kidney disease and peripheral artery disease with inappropriate left ventricular mass

Inappropriate left ventricular mass index (LVM) may develop as a response to particular hemodynamic and metabolic alterations. Inappropriate LVM and peripheral artery disease (PAD) characterized by abnormally low or high ankle-brachial index (ABI) are common in chronic kidney disease (CKD) patients, in whom there may be a close and cause-effect relationship. The aim of this study is to assess whether CKD and abnormal ABI has an independent and additive association with inappropriate LVM. A total of 1110 patients were included in the study. Inappropriate LVM was defined as observed LVM more than 28% of the predicted value. The ABI was measured using an ABI-form device. PAD was defined as ABI <0.9 or >1.3 in either leg. Multivariate analysis showed that patients with estimated glomerular filtration rate (eGFR) <45 ml/min/1.73 m² (odds ratio [OR], 1.644; P = 0.011) and PAD (OR, 2.082; P = 0.002) were independently associated with inappropriate LVM. The interaction between eGFR <45 ml/min/1.73 m² and PAD on inappropriate LVM was statistically significant (P = 0.044). Besides, eGFR<45 ml/min/1.73 m² (change in observed/predicted LVM, 19.949; P<0.001) and PAD (change in observed/predicted LVM, 11.818; P = 0.003) were also significantly associated with observed/predicted LVM. Our findings show that eGFR <45 ml/min/1.73 m² and PAD are independently and additively associated with inappropriate LVM and observed/predicted LVM. Assessments of eGFR and ABI may be useful in identifying patients with inappropriate LVM.

Smoking in dialysis patients: a systematic review and meta-analysis of mortality and cardiovascular morbidity

BACKGROUND

Cigarette smoking is associated with increased cardiovascular morbidity and mortality in the general population, but the effect of smoking on these outcomes in the dialysis population is less well studied.

STUDY DESIGN

Systematic review and meta-analysis of cohort studies.

SETTING & POPULATION

Adults treated with long-term hemodialysis or peritoneal dialysis. SELECTION CRITERIA FOR INCLUDED STUDIES: Cohort studies of unselected dialysis patients reporting the association between smoking status and cardiovascular morbidity and/or mortality.

PREDICTOR

Smoking status (determined using patient report).

OUTCOMES

(1) All-cause or cardiovascular mortality; (2) incident cardiovascular events.

RESULTS

We identified 34 studies that fulfilled all inclusion criteria. Of these, 26 studies provided data for smoking and mortality and 10 (n = 6,538) were included in a meta-analysis. The pooled HR for all-cause mortality in smokers compared with nonsmokers was 1.65 (95% CI, 1.26-2.14; P < 0.001). 11 studies provided data for smoking and incident cardiovascular events; 5 (pooled n = 845) were included in a meta-analysis. The pooled HR for composite cardiovascular events in smokers compared with nonsmokers was 1.01 (95% CI, 0.98-1.05; P = 0.4).

LIMITATIONS

Data for these meta-analyses were heterogeneous. Few individual studies assessed smoking as the primary variable of interest.

CONCLUSIONS

Active smoking is associated with a significant increase in all-cause mortality in dialysis patients, although there was no corresponding increased risk of cardiovascular events.

Plasma albumin levels correlate with decreased microcirculation and the development of skin defects in hemodialyzed patients

OBJECTIVES

Difficulty healing wounds and skin defects is a frequent problem in patients on chronic hemodialysis (HD) because of malnutrition, inflammation, and atherosclerosis (MIA) syndrome. The aim of the present study was to estimate the influence of peripheral blood flow changes during HD on the development of foot defects and its relationship to plasma albumin levels.

METHODS

Peripheral skin blood flow was measured using a laser Doppler line scanner in 10 different areas of the dorsal part of the instep and the toes of each foot before and during HD with ultrafiltration (897 +/- 465 mL/procedure) in 31 HD patients (10 female, 21 male; age 36-79 y, body mass index = 28 +/- 5.0). No skin defects or apparent acute disease or infection were detected in any patient at the time of laser Doppler line scanner measurement. The feet of the patients were clinically re-examined carefully over the next 18 mo.

RESULTS

We found a significant and constant decrease of skin blood flow during the HD procedure (P < 0.001). Skin blood flow was significantly correlated with serum albumin level both before HD (r = 0.36, P = 0.05) and during HD (r = 0.47, P = 0.007). Skin defects developed in 11 patients, with significantly lower skin blood flow during the 18-mo follow-up period. A significantly larger number of patients who had normal perfusion remained defect-free in comparison to patients with critical perfusion (93% versus 38%, P = 0.002, Kaplan-Meier analysis).

CONCLUSION

Skin blood flow may be impaired in HD patients. The apparent malnutrition and inflammation in HD patients are likely responsible for the decreased skin blood flow and the development of the difficulty to heal skin defects and wounds.

Surrogate markers of cardiovascular disease in CKD: what's under the hood?

Although clinical cardiovascular outcomes, such as heart attack, stroke, and sudden cardiac death, have a dramatic onset, they result from prolonged exposure to an ever-growing array of risk factors. Several noninvasive procedures are available to assess the cumulative effect of these exposures with the goal of more precisely estimating a person's cardiovascular risk. These include ankle-brachial index, which provides an estimation of obstruction in major-vessel lumen caliber; carotid ultrasound, which evaluates carotid intima-media thickness and plaque, visibly quantifying atherosclerotic burden; aortic pulse wave velocity, which provides a measure of large-artery stiffness; and echocardiography, which measures left ventricular mass, providing a measure of subclinical hypertensive heart disease. In this narrative review, we discuss the role of each of these measures, with a particular emphasis on patients with chronic kidney disease.

Association of peripheral artery disease and long-term mortality in hemodialysis patients

BACKGROUND

Peripheral artery disease (PAD) is a common complication in hemodialysis patients. The ankle-brachial blood pressure index (ABI) has been widely used to screen for subclinical PAD. In the present study, we investigated the association between ABI and long-term (up to 8.8 years) mortality among hemodialysis patients.

METHODS

A total of 86 consecutive patients receiving maintenance hemodialysis who underwent an ABI examination between 2001 and 2003 were retrospectively enrolled in this study. Patients with an ABI of less than 0.9 were considered as having PAD; those with an ABI of more than 0.9 in both legs were considered as being free from PAD. We examined the relationship between mortality and several risk factors.

RESULTS

During the follow-up period, 43 deaths were recorded. In the univariate regression analysis, the mortality hazard ratio (HR) of patients with PAD was 1.67 (95% confidence interval [CI], 1.18-2.28). Other predictive variables for mortality included male gender, age, and diabetes mellitus (P = 0.006, P = 0.024, and P = 0.023, respectively). A multivariate Cox analysis identified PAD and male gender as independent predictors of mortality (P = 0.033 and P = 0.028, respectively). The impact of age and diabetes mellitus on mortality was no longer significant in the multivariate analysis.

CONCLUSION

After a relatively long-term observation period, a multivariate analysis indicated that PAD acted independently of other risk factors, including advanced age and the presence of diabetes mellitus. ABI measurements can be used to identify high-risk hemodialysis patients requiring intensive follow-up care.

Detection of peripheral artery disease by duplex ultrasonography among hemodialysis patients

BACKGROUND AND OBJECTIVES

Peripheral arterial disease (PAD) is a known predictor of cardiovascular morbidity and mortality among hemodialysis patients. Although ankle-brachial BP index (ABI) is a simple and reliable test for PAD screening, its sensitivity has been suggested to decrease among dialysis patients.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We performed a cross-sectional outpatient cohort study to examine prevalence of PAD among hemodialysis patients using duplex ultrasonography of the lower extremity artery. We also evaluate the influence of increased arterial stiffness on impaired accuracy of ABI for PAD screening.

RESULTS

Of 315 total patients, 23.8% had PAD. PAD was associated with younger age, diabetes, current smoking, atherosclerotic comorbidities, increased total cholesterol levels, increased triglyceride levels, and lower Kt/V. The receiver operating characteristic analysis (area under the receiver operating characteristic curve = 0.846) showed that sensitivity and specificity of ABI values for PAD were 49.0 and 94.8%, respectively. An ABI cut-off value of 1.05 resulted in the best sensitivity (74.5%) and specificity (84.4%). There was a significant difference in sensitivity of ABI levels <0.9 for detecting PAD among patients in different brachial-ankle pulse wave velocity quartiles. In patients with the highest brachial-ankle pulse wave velocity quartile, PAD was most prevalent (46.5%), and ABI had the highest accuracy in detecting PAD (area under the curve, 0.933).

CONCLUSIONS

These results suggest that duplex ultrasonography was a useful tool for screening asymptomatic PAD among hemodialysis patients and that the diagnostic value of ABI for PAD was affected by various factors.

Significant correlation between ankle-brachial index and vascular access failure in hemodialysis patients

BACKGROUND AND OBJECTIVES

Vascular access failure (VAF) is associated with increased morbidity and mortality in hemodialysis patients. The most common cause of VAF is stenosis at the arteriovenous anastomosis because of abnormal neointimal proliferation and extracellular matrix deposition. These two changes are also observed in the classic atheroma, which means atherosclerotic lesions and venous stenosis in VAF may share some similar pathogenic mechanisms. The ankle-brachial index (ABI) is a reliable marker for atherosclerosis. The aim of this study was to evaluate the relationship between ABI <0.9 and VAF.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

All routine hemodialysis patients in one regional hospital were included except for six patients refusing ABI examinations and four patients with atrial fibrillation. Finally, 225 patients formed our study group. The study subjects were observed from arteriovenous access creation until the first episode of VAF. The mean observation period was 42.2 +/- 42.8 mo. The relative VAF risk was analyzed by Cox-regression methods with adjustments for demographic and comorbid conditions.

RESULTS

VAF episodes were recorded in 111 patients. In multivariate analysis, ABI <0.9 (hazard ratio, 1.893; P = 0.039), vascular access type of arteriovenous graft (P = 0.004), and serum triglyceride level (P = 0.043) were positively associated with VAF, and serum parathyroid hormone level (P = 0.043) was negatively associated with VAF.

CONCLUSIONS

Our findings show that ABI <0.9 is significantly correlated with increased VAF. Screening hemodialysis patients by means of ABI may help to identify a high-risk group for VAF.