Foot Gangrene in Patients with End-Stage Renal Disease: A Case Control Study

Abstract

The prevalence of peripheral arterial disease (PAD) in patients with end-stage renal disease (ESRD) is high, with an annual risk of amputation estimated at 13%, and indications for limb revascularization in patients combining ESRD with stage IV PAD (foot gangrene) are still controversial. This case-controlled study compared survival, limb salvage, and quality of life in a group of patients hospitalized for foot gangrene according to their renal status (ESRD versus no renal insufficiency). All patients with ESRD hospitalized for foot gangrene (n=16) from 1996 to 2002 were compared with a control group with normal creatininemia (n=24) hospitalized for foot gangrene due to peripheral atherosclerotic arterial disease. The 2 groups were matched for age, sex ratio, and number with diabetes mellitus. After a mean follow-up of 467 ±410 days, patients with ESRD had a more severe prognosis as regards mortality (68.7% vs 12.5%, p=0.0005) and major amputation (31% versus 8%, p=0.09). The ESRD group was characterized by more frequent extensive arterial calcifications (16/16 vs 13/24, p=0.002), owing to a higher level of the calcium phosphorus product (3.54 ±1.2 vs 2.4 ±0.6, p=0.0023), and by impaired microcirculatory perfusion, as indicated by a lower oxygen pressure (TcPO₂) (15.6 ±12 mm Hg vs 26 ±16, p=0.07). ESRD implies a poor prognosis in patients with stage IV peripheral arterial disease.

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References

O’Hare A , Johansen K : Lower-extremity peripheral arterial disease among patients with end-stage renal disease. J Am Soc Nephrol 12:2838-2847, 2001.

Leskinen Y , Salenius JP , Lehtimäki T , et al : The prevalence of peripheral arterial disease and medial arterial calcifications in patients with chronic renal failure: Requirements for diagnostics. Am J Kidney Dis 40:472-479, 2002.

Eggers PW , Gohdes D , Pugh J : Nontraumatic lower extremity amputations in the Medicare end-stage renal disease population. Kidney Int 56:1524-1533, 1999.

Harrington EB , Harrington ME , Schanzer H , et al : End-stage renal disease. Is infrainguinal limb revascularization justified? J Vasc Surg 12:691-696, 1990.

Edwards JM , Taylor LM Jr , Porter JM : Comparison of modern results in patients with and without ESRD. Arch Surg 123:1164-1168, 1988.

Simsir SA , Cabellon A , Kohlman-Trigoboff D , et al : Factors influencing limb salvage and survival after amputation and revascularization in patients with end-stage renal disease. Am J Surg 170:113-117, 1995.

Wassermann RJ , Saroyan M , Rice JC , et al : Infra-inguinal revascularization for limb salvage in patients with end-stage renal disease. South Med J 84:190-192, 1991.

Chang BB , Paty PSK , Shah DM , et al : Results of infrainguinal bypass for limb salvage in patients with end-stage renal disease. Surgery 108:742-747, 1990.

Johnson BL , Glickman MH , Bandyk DF , et al : Failure of foot salvage in patients with end-stage renal disease after surgical revascularization. J Vasc Surg 22:280-286, 1995.

10.

Leers SA , Reifsnyder T , Delmonte R , et al : Realistic expectations for pedal bypass grafts in patients with end-stage renal disease. Vasc Surg 28:976-983, 1998.

11.

Korn P , Hoenig SJ , Skillman JJ , et al : Is lower extremity revascularization worthwhile in patients with end-stage renal disease? Surgery 128:472-479, 2000.

12.

Reddan DN , Marcus RJ , Owen WF , et al : Long-term outcomes of revascularization for peripheral vascular disease in end-stage renal disease patients. Am J Kidney Dis 38:57-63, 2001.

13.

Ramdev P , Rayan SS , Sheahan M , et al : A decade experience with infrainguinal revascularization in a dialysis-dependent patient population. J Vasc Surg 36:969-974, 2002.

14.

Kimura H , Miyata T , Sato O , et al : Infrainguinal arterial reconstruction for limb salvage in patients with end-stage renal disease. Eur J Vasc Endovasc Surg 25:29-34, 2003.

15.

Cheung AK , Sarnak MJ , Yan G , et al : Atherosclerotic cardiovascular disease risks in chronic hemodialysis patients. Kidney Int 58:353-362, 2000.

16.

Foley RN , Parfrey PS , Sarnak MJ : Clinical epidemiology of cardiovascular disease in chronic renal disease. Am J Kidney Dis 32(suppl 1):S112-S119, 1998.

17.

Vayssairat M , Gouny P , Cheynel C , et al : Haemodynamics of patients with severe lower limb arterial disease: The critical aspects of critical ischaemia. Eur J Vasc Endovasc Surg 14:284-289, 1997.

18.

Guérin AP , London GM , Marchais SJ , et al : Arterial stiffening and vascular calcifications in end-stage renal disease. Nephrol Dial Transplant 15:1014-1021, 2000.

19.

Blacher J , Guerin AP , Pannier B , et al : Arterial calcifications, arterial stiffness, and cardiovascular risk in end-stage renal disease. Hypertension 38:938-942, 2001.

20.

Hafner J , Keusch G , Wahl C , et al : Uremic small-artery disease with medial calcification and intimal hyperplasia (so-called calciphylaxis): A complication of chronic renal failure and benefit from hyper-parathyroidectomy. J Am Acad Dermatol 33:954-962, 1995.

21.

Milas M , Bush RL , Lin P , et al : Calciphylaxis and nonhealing wounds: The role of the vascular surgeon in a multidisciplinary treatment. J Vasc Surg 37:501-507, 2003.

22.

Hausberg M , Kosch M , Harmelink P , et al : Sympathetic nerve activity in end-stage renal disease. Circulation 106:1974-1979, 2002.

23.

Demer LL , Tintut Y , Parhami F : Novel mechanisms in accelerated vascular calcification in renal disease patients. Curr Opin Nephrol Hypertens 11:437-443, 2002.

24.

Chertow GM , Burke SK , Raggi P , for the Treat to Goal Working group : Sevelamer attenuates the progression of coronary and aortic calcification in hemodialysis patients. Kidney Int 62:245-252, 2002.

25.

Motro M , Shemesh J : Calcium channel blocker nifedipine slows down progression of coronary calcification in hypertensive patients compared with diuretics. Hypertension 37:1410-1413, 2001.