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Peripheral Vascular Disease–Related Procedures in Dialysis Patients: Predictors and Prognosis

Laura C. Plantinga^*, Nancy E. Fink^,, Josef Coresh^,,, Stephen M. Sozio, Rulan S. Parekh, Michal L. Melamed^||, Neil R. Powe^*, and Bernard G. Jaar^,,¶

^* Department of Medicine, San Francisco General Hospital and University of California, San Francisco, California; Departments of Epidemiology and Biostatistics, Bloomberg School of Public Health, and Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland; ^|| Departments of Medicine and Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York; and ^¶ Nephrology Center of Maryland, Baltimore, Maryland

Correspondence: Dr. Bernard G. Jaar,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, 2024 E. Monument Street, Suite 2-500, Baltimore, MD 21287. Phone: 410-614-3994; Fax: 410-614-9793; E-mail: bjaar{at}jhmi.edu

Background and objectives: Peripheral vascular disease (PVD) is prevalent among dialysis patients, and many dialysis patients undergo PVD-related procedures. We aimed to examine the risk factors for and prognosis after such procedures in the dialysis setting.

Design, setting, participants, & measurements: In a national prospective cohort study of 1041 incident dialysis patients, we examined the factors that are associated with PVD procedures (lower extremity amputations and bypasses) after the start of dialysis. Adjusted risk for PVD procedures of various factors was estimated using multivariable Cox proportional hazards models. Incidence rates of subsequent cardiovascular events, infectious hospitalizations, PVD- and cardiovascular disease–related mortality, and all-cause mortality were compared for those with and without a PVD procedure.

Results: Overall, 217 (21%) patients underwent a PVD procedure after the start of dialysis. For those without diabetes, only PVD history (relative hazard [RH] 2.9; 95% confidence interval [CI] 1.3 to 6.6) and increased fibrinogen (RH 1.2; 95% CI 1.0 to 1.5) predicted PVD procedures. For those with diabetes, increased serum phosphate (RH 1.2; 95% CI 1.1 to 1.4), along with decreased albumin, increased C-reactive protein and fibrinogen, and lower SBP, was associated with risk for PVD procedures. Of those who had a procedure compared with those who did not, 68 versus 30% experienced a subsequent cardiovascular event, 85 versus 66% an infectious hospitalization, 11 versus 2% a PVD-related death, and 81 versus 59% all-cause death (mean follow-up 3.0 yr).

Conclusions: Prognosis after PVD procedures is poor, and providers should be aware that risk factors for PVD procedures may differ by diabetes status.