Guerrero Angeles, Montes Rafael, Muñoz-Terol José, Gil-Peralta Alberto, Toro Javier, Naranjo Macarena, González-Pérez Paloma, Martín-Herrera Carmen, Ruiz-Fernández Ana
Department of Nephrology and 2Department of Neurology, University Hospital Virgen del Rocío, Seville, Spain.
Nephrol Dial Transplant. 2006 Dec;21(12):3525-31. doi: 10.1093/ndt/gfl470. Epub 2006 Aug 29.
Cardiovascular disorders are frequently found among chronic renal failure (CRF) patients due to their higher susceptibility to develop atherosclerosis. However, peripheral arterial disease (PAD), that is associated with a high mortality rate, is not usually assessed in these patients. The aims of this study are to find out the prevalence of PAD affecting lower limbs in a population of CRF patients in stages IV/V, and to assess how much PAD determines the 5-year patient survival.
The study population (44 males and 29 females) was aged 58 +/- 15 years. They suffered from advanced CRF (18.6 +/- 6.1 ml/min creatinine clearance), but they were not on dialysis. These patients were sequentially referred initially to the predialysis unit over a period of 14 months. The vascular lesions were assessed by carotid and transcranial ultrasound, as well as by ankle-brachial index test (ABI). Routine 24 h blood and urine laboratory tests were performed for each patient. Cardiovascular morbidity and cardiovascular disease risk factors were evaluated through personal interview.
Fourteen patients had an ABI index of less than 0.91 (PAD indicative), 11 of them also suffered from intermittent claudication. PAD affected significantly more males (P = 0.001) and diabetics (P = 0.001). Also, PAD prevalence was significantly higher in patients with a previous clinical record of coronary heart disease (P = 0.001), increased clinical record of cerebrovascular disease (P = 0.005), a thickness of the left ventricular posterior wall (P = 0.03) and lower cardiac ejection fraction (P = 0.02). PAD patients had a significantly different protein intake (P = 0.003), calcium-phosphorus product (P = 0.001), risk of coronary heart disease based on the Framingham score (P = 0.001) and 5-year survival rate (P = 0.004). There were no significant differences for PAD patients in terms of body mass index, creatinine clearance, lipid profile, Ca and P. Multivariate risk factor analysis revealed that a previous clinical record of coronary heart disease and diabetes increased the risk of developing PAD, as defined by ABI < 0.91. After 5 years, 21 patients (29%) had died: 64% of patients that suffered PAD (9/14) and 20% of the non-PAD population (12/59). The Cox proportional hazards model demonstrated that older age and a lower ABI increased the risk of death.
The present study, conducted on CRF patients in stages IV and V not undergoing dialysis, showed; (a) that a high percentage of these patients developed PAD (19%) or other vascular pathologies; (b) that there was an associated high mortality rate (29%) after 5 years; (c) that the 5-year mortality rate was significantly higher (P = 0.004) in PAD patients (64 vs 20%).
由于慢性肾衰竭（CRF）患者更容易发生动脉粥样硬化，心血管疾病在这类患者中很常见。然而，通常不会对这些患者评估与高死亡率相关的外周动脉疾病（PAD）。本研究的目的是了解IV/V期CRF患者群体中下肢PAD的患病率，并评估PAD对患者5年生存率的影响程度。
研究人群（44名男性和29名女性）年龄为58±15岁。他们患有晚期CRF（肌酐清除率为18.6±6.1ml/min），但未接受透析治疗。这些患者在14个月的时间里先后被转诊至透析前病房。通过颈动脉和经颅超声以及踝臂指数测试（ABI）评估血管病变。对每位患者进行常规24小时血液和尿液实验室检查。通过个人访谈评估心血管发病率和心血管疾病危险因素。
14名患者的ABI指数低于0.91（提示PAD），其中11人还患有间歇性跛行。PAD在男性（P = 0.001）和糖尿病患者（P = 0.001）中更为常见。此外，既往有冠心病临床记录（P = 0.001）、脑血管疾病临床记录增加（P = 0.005）、左心室后壁厚度（P = 0.03）和心脏射血分数较低（P = 0.02）的患者中，PAD患病率显著更高。PAD患者的蛋白质摄入量（P = 0.003）、钙磷乘积（P = 0.001）、基于弗雷明汉评分的冠心病风险（P = 0.001）和5年生存率（P = 0.004）存在显著差异。PAD患者在体重指数、肌酐清除率、血脂谱、钙和磷方面无显著差异。多因素风险因素分析显示，既往有冠心病临床记录和糖尿病会增加发生ABI<0.91定义的PAD的风险。5年后，21名患者（29%）死亡：PAD患者中有64%（9/14）死亡，非PAD人群中有20%（12/59）死亡。Cox比例风险模型表明，年龄较大和ABI较低会增加死亡风险。
本研究针对未接受透析的IV期和V期CRF患者进行，结果显示：（a）这些患者中有很大比例发生了PAD（19%）或其他血管病变；（b）5年后相关死亡率较高（29%）；（c）PAD患者的5年死亡率显著更高（P = 0.004）（64%对20%）。
