Prevalence, clinical characteristics, and predictors of peripheral arterial disease in hemodialysis patients: a cross-sectional study

Minimum-incision transsubclavian transcatheter aortic valve replacement with balloon-expandable valve for dialysis patients

BACKGROUND

Dialysis patients undergoing transcatheter aortic valve replacement (TAVR) face increased risk and have poorer outcomes than non-dialysis patients. Moreover, TAVR in dialysis patients using an alternative approach is considered extremely risky and little is known about the outcomes. We routinely perform minimum-incision transsubclavian TAVR (MITS-TAVR), which is contraindicated for transfemoral (TF) TAVR. This study aimed to evaluate the outcomes of MITS-TAVR compared with those of TF-TAVR in dialysis patients.

METHODS

This single-center, observational study included 79 consecutive dialysis patients who underwent MITS-TAVR (MITS group, n = 22) or TF-TAVR (TF group, n = 57) under regional anesthesia.

RESULTS

The rates of peripheral artery disease (MITS vs. TF, 72.7 % vs. 26.3 %; p < 0.01), shaggy aortas (MITS vs. TF, 63.6 % vs. 5.26 %; p < 0.01), and tortuous aortas (MITS vs. TF, 13.6 % vs. 1.75 %; p = 0.031) were significantly higher in the MITS group. The 30-day mortality was 2.53 % and comparable between the two groups (MITS vs. TF, 4.54 % vs. 1.75 %; p = 0.479). In the MITS group, 14 patients had ipsilateral dialysis fistulas, and three patients had patent in situ ipsilateral internal thoracic artery grafts; however, no vascular complications were observed. Kaplan-Meier survival curves for the two groups showed no significant difference in the survival rate (at 2 years; MITS vs. TF, 77.3 % vs. 68.8 %; p = 0.840) and freedom from cardiovascular mortality (at 2 years; MITS vs. TF, 90.9 % vs. 96.5 %; p = 0.898). The multivariable Cox proportional hazard model also indicated that survival in the MITS group was not significantly different from that in the TF group (hazard ratio 1.48; 95 % confidence interval, 0.77-2.85, p = 0.244). The patency rate of ipsilateral dialysis fistula was 100 % during follow-up.

CONCLUSION

The outcome of MITS-TAVR was comparable to that of TF-TAVR in dialysis patients, despite the higher risk of patient characteristics.

Predictors of major adverse lower limb events in patients with tissue loss secondary to critical limb-threatening ischemia

BACKGROUND

Chronic limb-threatening ischemia (CLTI) is the end-stage of peripheral arterial disease (PAD) posing a high risk for limb loss and mortality. This study aims to evaluate and list possible predictors of major adverse limb events (MALEs) in CLTI patients with tissue loss.

METHODS

This retrospective study included all Rutherford-Becker stage 5 or 6 patients who required foot debridement and revascularization in our department from January 2016 to December 2018. The limbs were classified according to the TASC II, GLASS and WiFI grading systems. The primary composite outcome was MALEs at 2 years. The secondary outcomes included all-cause mortality, primary patency, freedom from reintervention, and major amputation. Kaplan-Meier estimates were used to determine the event rates, and Cox proportional hazards model with the index MALE as a time-dependent covariate was used to search for MALEs predictors.

RESULTS

Of 241 included patients, 19 underwent open surgeries (7.9 %) 207 had endovascular interventions (85.9 %) and 15 required a hybrid approach (6.2 %). On univariate analysis, patients who experienced MALEs (n = 111) more often required hemodialysis (25 vs 15; p = .02), presented with more complex lesions (TASC D on femoropopliteal (p = .05) or below the knee (BTK) arteries (p = .006) with increasing infra-inguinal GLASS Stage (p < .0001)), a history of index limb open (p = .009) or endovascular (p = .049) revascularization, an occluded tibial artery (p = .002 for the posterior tibial and p = .052 for the anterior tibial), or a "desert foot" (p = .02). The CRP level was also higher at admission (p = .001). Technical success of BTK revascularization significantly reduced MALEs (p < .0001) along with the number of patent BTK vessels (p = .0007). Independent predictors of MALEs included hemodialysis (HR = 2.00; 95%CI: 1.14 to 3.39), pulsatile arterial pressure (HR = 1.01; 95%CI: 1.00 to 1.03) and the infra-inguinal GLASS Stage (HR = 2.50; 95%CI: 1.17 to 5.82). We could not correlate our results with the WiFI scores for amputation risk and revascularization benefit.

CONCLUSION

For patients with CLTI at the stage of trophic disorders, with or without a history of index limb revascularization, the GLASS successfully predicted MALEs. Hemodialysis and high pulsatile arterial pressure increased the risk of MALEs. The WiFI score did not demonstrate its interest in this subgroup of patients.

Race and Area of Deprivation Index Predict Outcomes of Endoscopic Sinus Surgery for Chronic Sinusitis

OBJECTIVE

The purpose of this study is to characterize the presentation, outcomes, and barriers to care for White and non-White patients undergoing endoscopic sinus surgery (ESS).

BACKGROUND

ESS is often successful in providing long-term relief for patients suffering from chronic rhinosinusitis (CRS). Literature that uses robust measures of socioeconomic status (SES) and barriers to care to assess ESS outcomes is limited.

METHODS

A retrospective matched cohort study of patients who underwent ESS for CRS between 1/1/2015 and 6/1/2021 at a single tertiary care academic center was conducted. White and non-White patients were matched 1-to-1 by sex and age (± 5 years). SES was evaluated using the area of deprivation index (ADI).

RESULTS

Of the 298 patients included in the study, 149 are White and 149 are non-White, 111 (37.2%) have CRS with nasal polyposis (CRSwNP), 141 (47.3%) had allergic rhinitis, 90 (30.2%) had asthma and 22 (7.4%) required revision ESS. Non-White patients were 3.62 times more likely to present with CRSwNP (95% confidence interval [CI] 2.2-5.96) and had 2.87 times increased odds for requiring revision ESS than age and sex-matched White patients (95% CI 1.090-7.545). The median ADI for non-White (6.00) patients was higher than for White patients (3.00) (P < .001) and 21.5% more non-White patients presented with Medicaid (P < .001).

CONCLUSION

Non-White patients undergoing ESS for CRS are more likely to present from areas with fewer resources and be underinsured. Using robust measures of SES, such as ADI, may allow for care to be tailored to patients with barriers to care.

Outcomes of lower extremity peripheral arterial interventions in patients with and without chronic kidney disease or end-stage renal disease

INTRODUCTION

Peripheral arterial disease (PAD) is a progressive vascular condition characterized by the narrowing or blockage of arteries, primarily attributed to atherosclerosis. PAD's prevalence in the general population is estimated at approximately 5.9%. Notably however, among patients with chronic kidney disease (CKD), PAD's prevalence is substantially higher, ranging from 17% to 48%. This review paper emphasizes the pervasiveness of PAD and its intricate relationship with CKD and end-stage renal disease (ESRD). It demonstrates the importance of early detection, proactive screening, and understanding the formidable challenges associated with treating heavily calcified lesions.

EVIDENCE ACQUISITION

Comprehensive literature searches encompassed the PubMed/MEDLINE, Cochrane Library, and Embase databases, in order to identify studies involving lower extremity peripheral arterial interventions in patients both with and without CKD or ESRD. The search spanned the timeframe from January 2001 to July 2023. The search strategy included vocabulary terms concerning peripheral artery disease, lower extremities, revascularization, chronic kidney disease, and end-stage renal disease.

EVIDENCE SYNTHESIS

Initial searches were used to identify articles based on title. Exclusion criteria was then applied, and any redundant articles were removed. The articles abstracts were then reviewed, and relevant articles were selected. Once selected the articles were thoroughly reviewed including the references to find other relevant articles that were missed during the initial search process. In total 28 articles were selected and included for review of clinical data in regard to PAD outcomes in patients with advanced kidney disease.

CONCLUSIONS

The findings highlight the need for personalized approaches in diagnosing and treating PAD in CKD and ESRD patients. Interdisciplinary collaboration, such as those between nephrologists, vascular surgeons, and interventional radiologists, is vital to optimize outcomes. Further research should focus on innovative, tailored interventions to enhance limb preservation, reduce mortality, prolong patency, and cut healthcare costs.

The Relationship Between Bone Metabolism and Peripheral Artery Disease in Patients on Hemodialysis: The Potential Role of Osteocalcin

Introduction

To examine the factors associated with PAD, with a specific focus on bone metabolism factors such as osteocalcin.

Methods

This cross-sectional study examined factors about demographic, clinical, and laboratory parameters including bone metabolism biomarkers in hemodialysis patients. The ankle-brachial index (ABI) was measured in all patients, with PAD diagnosed as an ABI <0.9.

Results

Out of the 71 patients, PAD was found in 23 individuals. These patients had an average age of 63.5±13.0 years, with 59.2% being male. Compared to non-PAD patients, those with PAD were older, had a lower proportion of males, and had a higher prevalence of diabetes and coronary artery disease. Among the factors related to bone metabolism, only osteocalcin exhibited a significant increase in the PAD group compared to the non-PAD group.

Conclusion

PAD in patients on hemodialysis was independently linked to high levels of osteocalcin in the bloodstream, indicating the presence of bone metabolism disorders.

Association between Flow-Mediated Dilation and Skin Perfusion Pressure with Peripheral Artery Disease in Hemodialysis Patients

Flow-mediated dilation (FMD) is used to noninvasively assess the health of blood vessels and it has been shown to have a similar predictive ability for cardiovascular disease to traditional risk factors. Skin perfusion pressure (SPP) refers to the blood pressure required to restore capillary or microcirculatory flow after controlled occlusion and the return of flow. SPP has been shown to be an important measurement when making clinical decisions for patients with limb ischemia and to be a predictor of the likelihood of wound healing. Peripheral artery disease is common in hemodialysis (HD) patients. However, little is known about the association between FMD or SPP and peripheral artery disease. The aim of this study was to evaluate the association between FMD and SPP with brachial-ankle pulse wave velocity (baPWV) and ankle-brachial index (ABI) in HD patients in Taiwan, an area with a high rate of ESRD. This study was conducted at a regional hospital in southern Taiwan. ABI and baPWV values were measured using an ABI automated device. FMD and SPP were measured using ultrasound and a microvasculature blood flow monitor, respectively. Eighty patients were enrolled in this study. Compared to the patients with an ABI ≥ 0.95, those with an ABI < 0.95 had lower SPP of the feet (dorsal and plantar portions, both p < 0.001). After multivariable adjustments, low triglycerides (p = 0.033) and high calcium–phosphate product (p = 0.018) were significantly associated with low FMD. Further, low ABI (p = 0.001) and low baPWV (p = 0.036) were significantly associated with low SPP of dorsal portions. Old age (p = 0.005), low high-density lipoprotein cholesterol (p = 0.016), and low ABI (p = 0.002) were significantly associated with low SPP of plantar portions. This study demonstrated an association between FMD and SPP with peripheral artery disease in HD patients. Patients with low ABI and baPWV had a high risk of low SPP of the feet. However, there was no significant correlation between FMD and ABI or baPWV.

Management of diabetes mellitus in dialysis patients: Obstacles and challenges

BACKGROUND AND AIMS

Diabetic kidney disease (DKD) is a major health issue that is associated with an increased risk of morbidity and mortality. The treatment of DKD is challenging given changes in blood glucose homeostasis, unclear accuracy of glucose metrics, and altered kinetics of the blood glucose-lowering medications. There is uncertainty surrounding the optimal glycemic target in this population although recent epidemiologic data suggest that HbA1c ranges of 6-8%, as well as 7-9%, are associated with increased survival rates among diabetic dialysis patients. Furthermore, the treatment of diabetes in patients maintained on dialysis is challenging, and many blood glucose-lowering medications are renally metabolized and excreted hence requiring dose adjustment or avoidance in dialysis patients.

METHOD

ology: PubMed, Google Scholar, and Medline were searched for all literature discussing the management of diabetes in dialysis patients.

RESULTS

The literature was discussed under many subheadings providing the latest evidence in the treatment of diabetes in dialysis patients.

CONCLUSION

The management of diabetes in dialysis is very complex requiring a multi-disciplinary team involving endocrinologists and nephrologists to achieve targets and reduce morbidity and mortality.

Outcomes of Lower Extremity Endovascular Revascularization: Potential Predictors and Prevention Strategies

Peripheral artery disease (PAD) is a manifestation of atherosclerosis, which may affect arteries of the lower extremities. The most dangerous PAD complication is chronic limb-threatening ischemia (CLTI). Without revascularization, CLTI often causes limb loss. However, neither open surgical revascularization nor endovascular treatment (EVT) ensure long-term success and freedom from restenosis and revascularization failure. In recent years, EVT has gained growing acceptance among all vascular specialties, becoming the primary approach of revascularization in patients with CLTI. In clinical practice, different clinical outcomes after EVT in patients with similar comorbidities undergoing the same procedure (in terms of revascularization technique and localization of the disease) cause unsolved issues that need to be addressed. Nowadays, risk management of revascularization failure is one of the major challenges in the vascular field. The aim of this literature review is to identify potential predictors for lower extremity endovascular revascularization outcomes and possible prevention strategies.

Prognostic Significance of Abnormal Ankle-Brachial Index Among Long-term Hemodialysis Patients in Kinshasa, the Democratic Republic of the Congo

OBJECTIVE

Early identification of atherosclerosis using a non-invasive tool like ankle-brachial index (ABI) could help reduce the risk for cardiovascular disease among long-term hemodialysis patients. The study objective was to assess the frequency and impact of abnormal ABI as a marker of subclinical peripheral artery disease (PAD) in chronic hemodialysis patients.

METHODS

This was a historic cohort study of kidney failure patients on long-term hemodialysis for at least 6 months. The ABI, measured with two oscillometric blood pressure devices simultaneously, was used to assess subclinical atherosclerosis of low limb extremities. Abnormal ABI was defined as ABI <0.9 or >1.3 (PAD present). Survival was defined as time to death. Independent factors associated with abnormal ABI were assessed using multiple logistic regression analysis. Kaplan-Meier method (log-rank test) was used to compare cumulative survival between the two groups; a P value <0.05 was statistically significant.

RESULTS

Abnormal ABI was noted in 50.6% (n=43) of the 85 kidney failure patients included in the study; 42.4% (n=36) had a low ABI, and 8.2% (n=7) had a high ABI. Factors associated with PAD present were cholesterol (adjusted odds ratio [AOR], 1.02; 95% confidence interval [CI], 1.01-1.04; P=0.019), inflammation (AOR, 9.44; 95% CI, 2.30-18.77; P=0.002), phosphocalcic product (AOR, 6.25; 95% CI, 1.19-12.87; P=0.031), and cardiac arrhythmias (AOR, 3.78; 95% CI, 1.55-7.81, P=0.009). Cumulative survival was worse among patients with PAD present (log-rank; P=0.032).

CONCLUSION

The presence of PAD was a common finding in the present study, and associated with both traditional and emerging cardiovascular risk factors as well as a worse survival rate than patients without PAD.

Early technique failure in peritoneal dialysis patients in a multi-ethnic Asian country

PURPOSE

Early technique failure is a serious complication for peritoneal dialysis (PD) patients. The study aimed to examine the incidence, causes, and risk factors associated with early technique failure.   METHODS: This retrospective study included all incident PD patients in a hospital in Singapore from 2013 to 2017. The primary outcome was early technique failure, which was defined as transfer to hemodialysis for ≥ 30 days or death, within the first year of PD initiation. Secondary outcomes were death, technique failure due to PD infection, and death-censored technique failure.

RESULTS

Overall, 517 patients were included in the study. Of these, 98 patients (19.0%) developed early technique failure. The common causes of early technique failure were death (41.8%) and infection (40.8%). Peripheral vascular disease was significantly associated with a higher hazard of early technique failure [hazard ratio (HR) 1.95, 95% confidence interval (CI) 1.04-3.63] and death (HR 3.75, 95% CI 1.71-8.21), whilst glomerulonephritis as a cause of end-stage kidney disease (compared with hypertension) was associated with a lower hazard of early technique failure (HR 0.38, 95% CI 0.18-0.77) and death (HR 0.08, 95% CI 0.02-0.37). Male gender was associated with early technique failure due to PD infection (HR 2.55, 95% CI 1.32-4.95). No specific factor was associated with death-censored early technique failure.

CONCLUSION

Technique failure in the first year of PD initiation occurs in one-fifth of PD patients and is associated with peripheral vascular disease and cause of end-stage kidney disease.

Implications of Renal Disease in Patients Undergoing Peripheral Arterial Interventions

Since the first peripheral endovascular intervention (PVI) in 1964, the procedure's technical aspects and indications have advanced significantly. Today, endovascular procedures span the spectrum of presentations from acute limb ischemia to critical limb ischemia and symptomatic limiting claudication. Goals of PVI remain restoring limb perfusion, minimizing rates of amputation and mortality, and sparing the need for the high-risk bypass surgery. Unfortunately, there are no large randomized controlled trials that address the optimal approach to peripheral arterial disease revascularization in chronic kidney disease (CKD) patients.

Association of Pulse Volume Recording at Ankle with Total and Cardiovascular Mortality in Hemodialysis Patients

Pulse volume recording is an accurate modality for detecting arterial occlusion in the lower extremities. There are two indexes of pulse volume recording measured at ankle, percentage of mean arterial pressure (%MAP) and upstroke time (UT). The aim of the study was to examine the ability of %MAP and UT for the prediction of overall and cardiovascular mortality in hemodialysis (HD) patients. In 197 routine HD patients, ankle %MAP, ankle UT, and ankle-brachial index (ABI) were automatically measured by Colin VP-1000 instrument. Fourteen cardiovascular mortality and 29 overall mortalities were documented during 2.7 ± 0.6 years follow-up. In the univariate analysis, in addition to co-morbidities and traditional clinical parameters, increased total mortality was associated with decreased ABI, ABI < 0.9, increased %MAP and UT, %MAP > 50%, and UT > 169 ms (p < 0.041) and increased cardiovascular mortality was associated with increased UT and %MAP > 50% (p < 0.022). After multivariate analysis, increased %MAP and %MAP > 50% (p < 0.047) were still the predictors of total mortality and %MAP > 50% (p = 0.024) was still the predictor of cardiovascular mortality. In HD patients, we found that ankle %MAP and %MAP > 50% could predict total mortality and ankle %MAP > 50% could predict cardiovascular mortality in the multivariate analysis. Hence, assessment of %MAP from pulse volume recording at ankle might be helpful in identifying the high-risk group for poor prognosis in HD patients.