In Practice
Peripheral Artery Disease and CKD: A Focus on Peripheral Artery Disease as a Critical Component of CKD Care

https://doi.org/10.1053/j.ajkd.2012.02.340Get rights and content

The incidence of peripheral artery disease (PAD) is higher in patients with chronic kidney disease (CKD) than in the general population. PAD is a strong independent risk factor for increased cardiovascular disease mortality and morbidity, including limb amputation, in persons with CKD. Diagnosis of PAD in patients with CKD may be challenging in the absence of classic intermittent claudication or the presence of atypical leg symptoms. In addition, pedal artery incompressibility may decrease the accuracy of ankle-brachial index measurement, the most common PAD diagnostic tool. Alternative methods such as toe-brachial index should be used if clinical suspicion persists despite a normal ankle-brachial index value. Aggressive risk-factor modification, including treatment of diabetes, hyperlipidemia, and hypertension and smoking cessation, should be mandatory in all patients. Treatment of all individuals with PAD should include antiplatelet medications and prescribed supervised exercise programs and/or cilostazol for individuals with claudication symptoms. Preventive foot care measures and a multidisciplinary approach involving podiatrists and vascular and wound care specialists should be used to reduce amputations. Revascularization for critical limb ischemia is associated with poor outcomes in patients with CKD with PAD. Future investigation is recommended to evaluate the benefit of earlier treatment strategies in this high cardiovascular disease risk population with CKD.

Section snippets

Case Presentation

A 53-year-old man with end-stage renal disease (ESRD) treated with dialysis has a history of hypertension, dyslipidemia, and diabetes mellitus. He presents to his nephrologist with a 2-year history of nonspecific right-leg pain and a nonhealing ulcer on his foot. At the time of dialysis therapy initiation 3 years ago, his ankle-brachial index (ABI) was 1.2 and further testing was not pursued given the absence of an ulcer and concerns regarding gadolinium and contrast exposure. Computed

Prevalence and Incidence

Data from the National Health and Nutrition Examination Survey (NHANES) showed that PAD affects 15% of US adults older than 70 years.14 In asymptomatic persons 70 years or older or 50-69 years with atherosclerosis risk factors, the PAD Awareness, Risk, and Treatment: New Resources for Survival (PARTNERS) Study found PAD (defined as ABI ≤0.90 or history of lower-extremity revascularization) in 29% of the population, but classic claudication in only 5.5% of patients with PAD newly diagnosed and

Detection of Asymptomatic PAD

Asymptomatic PAD in patients with CKD is a clinically relevant potent marker of a high short-term risk of cardiovascular ischemic events, including myocardial infarction or stroke.46 Early detection may improve both patient and clinician awareness of the potential significance of future exertional leg symptoms or signs of more advanced PAD. This recognition could lead to more intensive risk-factor intervention or initiation of medical therapies to improve limb symptoms and overall

The Treatment of PAD in CKD

The literature for the treatment of PAD in patients with CKD or ESRD is scarce, and current treatment guidelines therefore are based on extrapolation of studies in the general population that unfortunately did not provide information based on level of kidney function (Table 2).

Conclusions

PAD is an underdiagnosed and undertreated disease that is one of the most potent risk markers for cardiovascular morbidity and mortality in patients with kidney disease. Its high prevalence, combined with significant mortality, morbidity, and quality-of-life reduction associated with both diseases, highlights the need for nephrologists to understand the potential benefits of early diagnosis and aggressive management of PAD in patients with CKD/ESRD. Current clinical care guidelines are limited

Acknowledgements

Support: None.

Financial Disclosure: Dr O'Hare has received royalties from UpToDate. Dr Herzog has consulted for Amgen; received research support from the National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; received honoraria from UpToDate; served on the Medical Advisory Board for Fresenius; served on the Board of Trustees for the TruRoche Foundation for Anemia Research; has equity interest in Cambridge Heart, Merck, Boston Scientific, and Johnson &

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    Originally published online May 7, 2012.

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