O'Hare Ann M, Bertenthal Daniel, Sidawy Anton N, Shlipak Michael G, Sen Saunak, Chren Mary-Margaret
Department of Medicine, VA Medical Center, San Francisco, San Francisco, CA 94121, USA. ann.o'
Clin J Am Soc Nephrol. 2006 Mar;1(2):297-304. doi: 10.2215/CJN.01070905. Epub 2006 Jan 4.
Although peripheral arterial disease is prevalent in patients with renal insufficiency, little is known about how the disease is managed in this patient group. The management of advanced limb ischemia was examined in a large cohort of male veterans (n = 6227). Patients were classified according to whether they underwent lower extremity revascularization, amputation, or no procedure within the first 6 mo after their first diagnosis of critical limb ischemia, defined as ischemic rest pain, ulceration, or gangrene. The association of renal insufficiency with revascularization and the association of management strategy with mortality within 1 yr of cohort entry were measured. Within 6 mo of initial diagnosis of critical limb ischemia, 39% of patients underwent lower extremity revascularization, 27% underwent major amputation, and 34% did not undergo either procedure. Patients with an estimated GFR 30 to 59 (adjusted odds ratio [OR] 0.84; 95% confidence interval [CI] 0.72 to 0.96), 15 to 29 ml/min per 1.73 m2 (OR 0.47; 95% CI 0.35 to 0.65), 15 ml/min per 1.73 m2 not on dialysis (OR 0.32; 95% CI 0.16 to 0.62), and dialysis patients (OR 0.62; 95% CI 0.47 to 0.84) were less likely to undergo revascularization than those with an estimated GFR > or = 60 ml/min per 1.73 m2. At all levels of renal function, mortality risk was lowest for patients who underwent revascularization. Patients with critical limb ischemia and concomitant renal insufficiency are less likely to be treated with revascularization. However, among patients with renal insufficiency, mortality is lowest for patients who receive a revascularization. Further studies are needed to determine the optimal care for this high-risk patient group.
尽管外周动脉疾病在肾功能不全患者中很常见，但对于该患者群体中这种疾病的管理方式却知之甚少。在一大群男性退伍军人（n = 6227）中研究了晚期肢体缺血的管理情况。根据患者在首次诊断为严重肢体缺血（定义为缺血性静息痛、溃疡或坏疽）后的前6个月内是否接受下肢血管重建、截肢或未进行任何手术进行分类。测量了肾功能不全与血管重建的关联以及队列入组后1年内管理策略与死亡率的关联。在首次诊断严重肢体缺血的6个月内，39%的患者接受了下肢血管重建，27%的患者接受了大截肢，34%的患者未进行任何一种手术。估算肾小球滤过率（GFR）为30至59（校正比值比[OR] 0.84；95%置信区间[CI] 0.72至0.96）、每1.73 m²为15至29 ml/min（OR 0.47；95% CI 0.35至0.65）、未接受透析的每1.73 m²为15 ml/min（OR 0.32；95% CI 0.16至0.62）以及透析患者（OR 0.62；95% CI 0.47至0.84）比估算GFR≥60 ml/min每1.73 m²的患者接受血管重建的可能性更小。在所有肾功能水平上，接受血管重建的患者死亡风险最低。患有严重肢体缺血并伴有肾功能不全的患者接受血管重建治疗的可能性较小。然而，在肾功能不全患者中，接受血管重建的患者死亡率最低。需要进一步研究以确定针对这一高危患者群体的最佳治疗方案。
