Abnormal ankle-brachial index and risk of cardiovascular or all-cause mortality in patients with chronic kidney disease: a meta-analysis

Abstract

Prognostic role of ankle-brachial index (ABI) in patients with chronic kidney disease (CKD) is controversial. We aimed to evaluate whether abnormal ABI was an independent predictor of cardiovascular or all-cause mortality in CKD patients with or without hemodialysis by conducting a meta-analysis. We systematically searched Pubmed and Embase databases for prospective observational studies that investigated baseline abnormal ABI and subsequent cardiovascular or all-cause mortality risk in CKD patients with or without hemodialysis. An ABI value of 0.9 to 1.3 was defined as normal. Pooled hazard risk (HR) with 95% confidence interval (CI) was calculated for the abnormal vs. normal ABI category. Six studies enrolling 5820 patients were identified and analyzed. Overall, abnormal ABI was associated with an increased risk of all-cause mortality (HR 2.26; 95% CI 1.60-3.18) and cardiovascular mortality (HR 3.58; 95% CI 2.53-5.06). Subgroup analysis indicated that patients with abnormally low ABI increased by 2.45-fold all-cause mortality and 5.18-fold cardiovascular mortality. Similarly, an abnormally high ABI increased by 1.94-fold all-cause mortality and 4.04-fold cardiovascular mortality. In addition, the effect of abnormal ABI on all-cause mortality was more pronounced among hemodialysis patients (HR 3.06; 95% CI 2.30-4.07) but not in CKD patients (HR 1.42; 95% CI 0.98-2.05). Abnormally low and high ABI are independently associated with cardiovascular or all-cause mortality risk in maintenance hemodialysis patients. This meta-analysis highlighted an U-shaped relationship between ABI and mortality risk in CKD patients undergoing hemodialysis. However, findings of this meta-analysis were undermined by the small number of included studies.

Ankle‐brachial index, arterial stiffness, and biomarkers in the prediction of mortality and outcomes in patients with end‐stage kidney disease

“…A possible explanation is that elevations of these biomarkers represent the target organ damage and systemic inflammation, which is difficult to be evaluated by ABI alone. Abnormal ABI has been shown to be well correlated with systemic disease burden of atherosclerosis, which is a strong predictor of MACE . On the other hand, accumulating evidence demonstrated that an elevation of cTn is specific to myocardial damage and hs‐CRP reflects systematic atherosclerotic burden and activity even in ESKD patients .…”

“…Abnormal ABI has been shown to be well correlated with systemic disease burden of atherosclerosis, which is a strong predictor of MACE. 6,8 On the other hand, accumulating evidence demonstrated that an elevation of cTn is specific to myocardial damage [24][25][26] and hs-CRP reflects systematic atherosclerotic burden and activity even in ESKD patients. 1,17,27 As multiple organ disorder causes markedly higher systemic adverse events, 2-4 these observations suggest that biomarker approach complements the risk assessment that cannot be identified by ABI alone, and their combination could provide better risk stratification of ESKD patients treated with HD.…”

“…The mechanisms underlying the association between ESKD and MACE include highly prevalent comorbidities such as coronary artery disease, cerebrovascular disease, and peripheral artery disease (PAD) . Accumulating evidence suggests that arterial stiffness and ankle‐brachial index (ABI) are well correlated with atherosclerotic burden and are strong predictors of MACE . Among the various indices of arterial stiffness, brachial‐ankle (ba) pulse wave velocity (PWV) is an established tool for the noninvasive assessment of arterial stiffness in clinical practice .…”

“…[2][3][4] Accumulating evidence suggests that arterial stiffness and anklebrachial index (ABI) are well correlated with atherosclerotic burden and are strong predictors of MACE. [5][6][7][8] Among the various indices of arterial stiffness, brachial-ankle (ba) pulse wave velocity (PWV) is an established tool for the noninvasive assessment of arterial stiffness in clinical practice. 9,10 However, measurements of baPWV can be influenced by the presence of PAD and hemodynamic condition after hemodialysis (HD) session.…”

Cardiovascular changes in patients with mild‐to‐moderate chronic kidney disease compared with healthy subjects: a 5‐year follow‐up study

“…Although hypertension is associated with renal dysfunction (Rao et al, 2008), more rapid progression of CKD and the development of various cardiovascular comorbidities (Go et al, 2004;Botdorf et al, 2011;Segura & Ruilope, 2011), it is common that blood pressure (BP) is inadequately controlled in CKD patients (Peralta et al, 2005;Lee et al, 2017). Biomarkers including an abnormal ankle-brachial index (ABI), arterial stiffness, increased common carotid artery (CCA) diameter and intima-media thickness (CIMT), and left ventricular hypertrophy (LVH) are associated with increased cardiovascular risks and worse prognosis in CKD (Szeto et al, 2007;Chue et al, 2010;Paoletti et al, 2011;Karras et al, 2012;Kozakova et al, 2017;Chen et al, 2017;Major et al, 2018). Biomarkers including an abnormal ankle-brachial index (ABI), arterial stiffness, increased common carotid artery (CCA) diameter and intima-media thickness (CIMT), and left ventricular hypertrophy (LVH) are associated with increased cardiovascular risks and worse prognosis in CKD (Szeto et al, 2007;Chue et al, 2010;Paoletti et al, 2011;Karras et al, 2012;Kozakova et al, 2017;Chen et al, 2017;Major et al, 2018).…”