In PracticePeripheral Artery Disease and CKD: A Focus on Peripheral Artery Disease as a Critical Component of CKD Care
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 &
References (143)
- et al.
A population-based study of the incidence and outcomes of diagnosed chronic kidney disease
Am J Kidney Dis
(2003) - et al.
Aspirin prescription and outcomes in hemodialysis patients: the Dialysis Outcomes and Practice Patterns Study (DOPPS)
Am J Kidney Dis
(2007) - et al.
Atherosclerotic cardiovascular disease risks in chronic hemodialysis patients
Kidney Int
(2000) - et al.
Ankle-arm blood pressure index as a predictor of mortality in hemodialysis patients
Am J Kidney Dis
(1996) - et al.
Cardiovascular disease risk status in elderly persons with renal insufficiency
Kidney Int
(2002) - et al.
Renal insufficiency as a predictor of cardiovascular outcomes and mortality in elderly individuals
J Am Coll Cardiol
(2003) - et al.
Novel and traditional cardiovascular risk factors for peripheral arterial disease in incident-dialysis patients
Adv Chronic Kidney Dis
(2007) - et al.
Combined role of reduced estimated glomerular filtration rate and microalbuminuria on the prevalence of peripheral arterial disease
Am J Cardiol
(2009) - et al.
Albuminuria and peripheral arterial disease: results from the Multi-Ethnic Study of Atherosclerosis (MESA)
Atherosclerosis
(2008) - et al.
Hyperhomocyst(e)inemia and the prevalence of atherosclerotic vascular disease in patients with end-stage renal disease
Am J Kidney Dis
(1999)
A high ankle-brachial index is associated with increased cardiovascular disease morbidity and lower quality of life
J Am Coll Cardiol
The association between elevated ankle systolic pressures and peripheral occlusive arterial disease in diabetic and nondiabetic subjects
J Vasc Surg
Prevalence and risk factors of PAD among patients with elevated ABI
Eur J Vasc Endovasc Surg
The prevalence of peripheral arterial disease and medial arterial calcification in patients with chronic renal failure: requirements for diagnostics
Am J Kidney Dis
Serum creatinine predicts mortality in patients with peripheral artery disease: influence of diabetes and hypertension
Atherosclerosis
Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II)
Eur J Vasc Endovasc Surg
2011 ACCF/AHA focused update of the guideline for the management of patients with peripheral artery disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
Circulation
Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II)
J Vasc Surg
Assessment of arterial disease using digital systolic pressure measurement
Ann Vasc Surg
PAD as a risk factor for mortality among patients with elevated ABI—a clinical study
Eur J Vasc Endovasc Surg
Antithrombotic therapy in peripheral arterial occlusive disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy
Chest
Meta-analysis of results from eight randomized, placebo-controlled trials on the effect of cilostazol on patients with intermittent claudication
Am J Cardiol
Cardioprotective medication is associated with improved survival in patients with peripheral arterial disease
J Am Coll Cardiol
Effects of simvastatin on walking performance and symptoms of intermittent claudication in hypercholesterolemic patients with peripheral vascular disease
Am J Med
Effect of simvastatin versus placebo on treadmill exercise time until the onset of intermittent claudication in older patients with peripheral arterial disease at six months and at one year after treatment
Am J Cardiol
Effect of simvastatin on ischemic signs and symptoms in the Scandinavian Simvastatin Survival Study (4S)
Am J Cardiol
Blood pressure control in type 2 diabetes mellitus
Am J Kidney Dis
Smoking and cardiovascular outcomes in dialysis patients: the United States Renal Data System Wave 2 Study
Kidney Int
Effectiveness of a smoking cessation program for peripheral artery disease patients: a randomized controlled trial
J Am Coll Cardiol
ACCF/AHA/ACR/SCAI/SIR/SVM/SVN/SVS 2010 performance measures for adults with peripheral artery diseaseA report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures, the American College of Radiology, the Society for Cardiac Angiography and Interventions, the Society for Interventional Radiology, the Society for Vascular Medicine, the Society for Vascular Nursing, and the Society for Vascular Surgery (Writing Committee to Develop Clinical Performance Measures for Peripheral Artery Disease). Developed in collaboration with the American Association of Cardiovascular and Pulmonary Rehabilitation; the American Diabetes Association; the Society for Atherosclerosis Imaging and Prevention; the Society for Cardiovascular Magnetic Resonance; the Society of Cardiovascular Computed Tomography; and the PAD Coalition. Endorsed by the American Academy of Podiatric Practice Management
J Vasc Surg
Glycemic control and the risk of death in 1,484 patients receiving maintenance hemodialysis
Am J Kidney Dis
Kidney disease as a risk factor for development of cardiovascular disease: a statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention
Circulation
Association between renal insufficiency and inducible ischemia in patients with coronary artery disease: the Heart and Soul Study
J Am Soc Nephrol
Longitudinal follow-up and outcomes among a population with chronic kidney disease in a large managed care organization
Arch Intern Med
Chronic kidney disease and the risk for cardiovascular disease, renal replacement, and death in the United States Medicare population, 1998 to 1999
J Am Soc Nephrol
Mortality over a period of 10 years in patients with peripheral arterial disease
N Engl J Med
Lower-extremity peripheral arterial disease among patients with end-stage renal disease
J Am Soc Nephrol
Edinburgh Artery Study: prevalence of asymptomatic and symptomatic peripheral arterial disease in the general population
Int J Epidemiol
Intermittent claudicationA risk profile from the Framingham Heart Study
Circulation
Anticoagulant and antiplatelet usage associates with mortality among hemodialysis patients
J Am Soc Nephrol
Rosuvastatin and cardiovascular events in patients undergoing hemodialysis
N Engl J Med
Atorvastatin in patients with type 2 diabetes mellitus undergoing hemodialysis
N Engl J Med
Prevalence of and risk factors for peripheral arterial disease in the United States: results from the National Health and Nutrition Examination Survey
Circulation
Peripheral arterial disease detection, awareness, and treatment in primary care
JAMA
High prevalence of peripheral arterial disease in persons with renal insufficiency: results from the National Health and Nutrition Examination Survey 1999-2000
Circulation
USRDS 2007 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States
Peripheral arterial disease in patients with end-stage renal disease: observations from the Dialysis Outcomes and Practice Patterns Study (DOPPS)
Circulation
[Ankle-arm blood pressure index (AABPI) in hemodialysis patients]
Arch Mal Coeur Vaiss
Chronic Renal Insufficiency Cohort (CRIC) Study: baseline characteristics and associations with kidney function
Clin J Am Soc Nephrol
Kidney function and risk of peripheral arterial disease: results from the Atherosclerosis Risk in Communities (ARIC) Study
J Am Soc Nephrol
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Originally published online May 7, 2012.