Risks and outcomes of critical limb ischemia in hemodialysis patients: a prospective cohort study

Mu-Yang Hsieh, Shao-Yuan Chuang, Chih-Kuo Lee, Chien-Ming Luo, Chi-Hung Cheng, Min-Tsun Liao, Po-Lin Lin, Ten-Fang Yang, Chih-Cheng Wu, Mu-Yang Hsieh, Shao-Yuan Chuang, Chih-Kuo Lee, Chien-Ming Luo, Chi-Hung Cheng, Min-Tsun Liao, Po-Lin Lin, Ten-Fang Yang, Chih-Cheng Wu

Abstract

Background: Peripheral arterial disease (PAD) is more common in patients receiving maintenance hemodialysis than in the general population. Critical limb ischemia (CLI), the most severe form of PAD, is associated with high amputation and mortality risk. However, few prospective studies are available evaluating this disease's presentation, risk factors and outcomes for patients receiving hemodialysis.

Methods: The Hsinchu VA study, a prospective multicentre study, investigated the impact of clinical factors on cardiovascular outcomes of patients receiving maintenance hemodialysis from January 2008 until December 2021. We evaluated the presentations and outcomes of patients with newly diagnosed PAD and the correlations of clinical variables with newly diagnosed CLI.

Results: Of 1136 study participants, 1038 had no PAD on enrolment. After a median follow-up period of 3.3 years, 128 had newly diagnosed PAD. Of these, 65 presented with CLI, and 25 underwent amputation or died from PAD. Patients presenting with CLI had more below-the-knee (52%) and multi-level (41%) disease, and completely occluded segments (41%), and higher risk for amputation or PAD-related death compared with patients without CLI (27.7% vs 9.5%, P = .01). After multivariate adjustment, disability, diabetes mellitus, current smoking and atrial fibrillation were significantly associated with newly diagnosed CLI.

Conclusions: Patients undergoing hemodialysis had higher rates of newly diagnosed CLI than the general population. Those with disabilities, diabetes mellitus, smoking and atrial fibrillation may require careful examination for PAD. Trial registration: Hsinchu VA study, ClinicalTrials.gov identifier: NCT04692636.

Keywords: critical limb ischemia; disability; hemodialysis; peripheral artery disease.

© The Author(s) 2022. Published by Oxford University Press on behalf of the ERA.

Figures

Figure 1:
Figure 1:
Flow diagram of the study participants. A total of 1215 patients were assessed for eligibility; 79 patients were excluded because they refused (n = 20), did not meet the criteria for inclusion (n = 35) or did meet the criteria for exclusion (n = 24). Of 1136 patients enrolled, 1038 patients were native for PAD.
Figure 2:
Figure 2:
Kaplan–Meier curve of incident lower-extremity peripheral artery–related events. The incidence rate of PAD was 4.1/100 PY, CLI 2.4/100 PY, amputation or PAD-related death 0.8/100 PY, and all-cause mortality rate 7.4/100 PY.
Figure 3:
Figure 3:
Kaplan–Meier curve of incident PAD-related amputation or death. Patients presented with CLI had higher risk of amputation or PAD-related death than patients not presented with CLI (27.7% vs 9.5%, P = .01).
Figure 4:
Figure 4:
Subgroup analysis of the effect of disability on critical limb ischemia by Kaplan–Meier curve. In subgroup analysis, disability remained a significant predictor for CLI, even in the group of patients without diabetes or CVD. CVD was defined by the presence of either coronary artery disease, stroke or heart failure.

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