O'Hare Ann M
VA Medical Center, San Francisco, and Nephrology Division, University of California, San Francisco, 513 Parnassus Avenue, Health Sciences East, Room 672, San Francisco, CA 94143-0532, USA. Ann.O'
Cardiol Clin. 2005 Aug;23(3):225-36. doi: 10.1016/j.ccl.2005.03.006.
PAD has been overlooked in many epidemiologic studies evaluating cardiovascular risk associated with renal disease. Conversely, CKD has not been evaluated as a potential risk factor in epidemiologic studies of PAD. PAD, however,seems to be more prevalent among patients with even moderate CKD than in the general population and is most common among chronic dialysis patients, one third or more of whom have a low ABI. Patients with CKD also seem to be at increased risk for developing claudication and for requiring surgical intervention for lower extremity PAD. Furthermore, even moderate CKD seems to be a risk factor for postoperative death and complications after both lower extremity amputation and revascularization procedures. Conversely, even asymptomatic PAD seems to be a risk factor for death among dialysis patients. In the general population, statins, antiplatelet agents (particularly clopidogrel), antihypertensive agents, and ACE inhibitors all have a proven benefit in reducing cardiovascular events in patients with PAD and in some instances may also reduce PAD events. Available evidence suggests that patients with CKD also experience cardio-vascular risk reduction with statin and ACE-inhibitor therapy, but these therapies have not been shown to reduce PAD events specifically in patients with CKD. Further studies are needed to identify interventions that can specifically reduce the incidence of PAD complications in patientswith CKD. Although it is clear that mortality and complication rates after both lower extremity amputation and revascularization are increased in patients with even moderate CKD, currently available observational studies do not provide clear guidance for surgical decision making in CKD patients with limb-threatening ischemia. Further studies are needed to evaluate the risksand benefits of amputation over revascularizationamong patients with CKD and to investigatereasons for the high mortality associated with these procedures in this patient group. Further studies are also needed to measure the impact of CKD on care processes for PAD with the goal of identifying target areas for improvement.
在许多评估与肾脏疾病相关的心血管风险的流行病学研究中，外周动脉疾病（PAD）一直被忽视。相反，在PAD的流行病学研究中，慢性肾脏病（CKD）尚未被评估为潜在的风险因素。然而，即使是中度CKD患者，PAD的患病率似乎也高于一般人群，并且在慢性透析患者中最为常见，其中三分之一或更多患者的踝臂指数（ABI）较低。CKD患者发生间歇性跛行以及因下肢PAD需要手术干预的风险似乎也会增加。此外，即使是中度CKD似乎也是下肢截肢和血运重建术后死亡及并发症的风险因素。相反，即使是无症状的PAD似乎也是透析患者死亡的风险因素。在一般人群中，他汀类药物、抗血小板药物（尤其是氯吡格雷）、抗高血压药物和血管紧张素转换酶（ACE）抑制剂在降低PAD患者心血管事件方面均已证实有获益，并且在某些情况下还可能减少PAD事件。现有证据表明，CKD患者使用他汀类药物和ACE抑制剂治疗也可降低心血管风险，但这些疗法尚未显示能特异性降低CKD患者的PAD事件。需要进一步研究以确定能够特异性降低CKD患者PAD并发症发生率的干预措施。虽然很明显，即使是中度CKD患者，下肢截肢和血运重建后的死亡率和并发症发生率都会增加，但目前可用的观察性研究并未为患有肢体威胁性缺血的CKD患者的手术决策提供明确指导。需要进一步研究以评估CKD患者截肢与血运重建的风险和获益，并调查该患者群体中与这些手术相关的高死亡率的原因。还需要进一步研究来衡量CKD对PAD护理过程的影响，以便确定可改进的目标领域。
