Abnormal digital brachial index prior to hemodialysis access construction and cardiovascular mortality

Abstract

Introduction An abnormal ankle‐brachial index indicating presence of peripheral arterial disease (PAD) is known to predict mortality in end‐stage renal disease (ESRD). Hand ischemia, reflected by low finger pressures, is also a factor associated with increased mortality in patients undergoing hemodialysis (HD). The Aim of the present study is to determine whether an abnormal digital brachial index in ESRD patients prior to HD access surgery is related to lower survival rates. Methods A digital brachial index (DBI, systolic finger pressure/systolic brachial arterial pressure) was obtained using digital plethysmography in ESRD patients before construction of a primary HD access between January 2009 and December 2018 in a single center. Patients were grouped based on categories of DBI (low <80%, normal 80–99%, high ≥100%). Overall and cardiovascular mortality were assessed with the ERA‐EDTA classification system (ERA‐EDTA codes 11, 14‐16, 18, and 22‐26, 29). Factors potentially influencing survival rates were analyzed using standard statistics. Findings Follow‐up was available in 199 patients (female n = 80; age 70 years ±12; follow‐up index 99% ±1). Overall, 2 and 4 years survival were similar among DBI groups Moreover, 2 and 4 years freedom from cardiovascular death were also not different (low DBI 80% ±8 and 58% ±11; normal DBI 86% ±4 and 75% ±6; high DBI 74% ±6 and 61% ±7). Following correction for age, diabetes mellitus, cardiovascular disease and smoking, a high DBI conferred a significantly increased risk of cardiovascular mortality (HR 2.09 [1.06–4.13], P = 0.03) and a trend toward higher overall mortality (HR 1.69 [0.98–2.93], P = 0.06). Discussion ESRD patients with an abnormally elevated DBI before HD access creation have an increased risk of cardiovascular mortality in the first four postoperative years.

A preoperative modified Allen test result may be associated with long term mortality after hemodialysis access construction

“…1,21,22 Several studies found that hand ischemia as reflected by a low systolic finger pressure (P dig ) was associated with increased mortality rates in HD populations. [6][7][8][9][10] Based on these findings, we hypothesized an association between drop in P dig (∂P dig ) during a MAT and mortality in CKD patients who were scheduled for access surgery. Interestingly, 52% of the individuals demonstrating a ∂P dig > 50 mmHg at the preoperative MAT had died after 4 years compared to just 15% with a ∂P dig < 15 mmHg.…”

“…This finding may reflect lack of compensatory capacity of the vascular system in some of these fragile patients. [6][7][8][9][10] Prior to choosing the optimal type of HD access in an CKD patient, stratification of risk factors is required. For instance, a patient having multiple risk factors and possibly a limited life expectancy may benefit from a permanent indwelling line rather than from an arteriovenous fistula or loop.…”