Impact of diabetes and glycaemic control on peripheral artery disease in Japanese patients with end-stage renal disease: long-term follow-up study from the beginning of haemodialysis

Abstract

Aims/hypothesis End-stage renal disease (ESRD) patients with diabetes have been regarded as being at the highest risk of cardiovascular disease. We therefore investigated the relationship between diabetes and the incidence of peripheral artery disease (PAD) in new haemodialysis patients. Methods We enrolled 1,513 ESRD patients who had just begun haemodialysis therapy. They were divided into two groups: those with (n0739) and those without diabetes (n0774). The endpoint was the development of PAD, defined as ankle brachial pressure index ≤0.9 or toe brachial pressure index <0.7 in patients with an ankle brachial pressure index >0.9. Results According to the Kaplan-Meier method, the 10 year event-free rate for development of PAD and lower limb amputation was significantly lower in the diabetes group than in the non-diabetes group (60.3% vs 82.8%, HR 2.99, 95% CI 2.27, 3.92, p<0.0001 and 93.9% vs 98.9%, HR 5.59, 95% CI 2.14, 14.7, p00.0005 for PAD and lower limb amputation, respectively). In patients with diabetes, quartile analysis of HbA 1c levels showed that the highest quartile group (≥6.8% [51 mmol/mol]) had significant development of PAD and lower limb amputation compared with lower quartile groups (PAD HR 1.63, 95% CI 1.17, 2.28, p00.0038; lower limb amputation HR 2.99, 95% CI 1.17, 7.70, p00.023). Conclusions/interpretation Diabetes was a strong predictor of PAD after initiation of haemodialysis therapy in patients with ESRD. In addition, higher HbA 1c levels were associated with increased risk of developing PAD and requiring limb amputation in such diabetic populations.

Non-traumatic lower limb amputation in patients with end-stage renal failure on dialysis: an Australian perspective

“…44 As previously discussed that DM predisposes to micro-and macro-vascular complications, development of diabetic foot syndrome and also infections, 2,3 it would be ideal for these patients to have a tighter control of their blood sugar levels hence preventing worsening prognosis of foot complications which require LLAs. Our findings are consistent with other studies done previously; Plantinga et al 21 and Ishii et al 16 also found the association between high CRP levels while Plantinga et al's study along with Speckman et al 24 also reported the low levels of albumin amongst amputees, while LockingCustolito et al 17 found that elevated HbA1c was associated with LLAs. Our study was a retrospective chart audit and we were relying on the health professional's accuracy of information documented in patient medical records as well as biochemical pathology data base for our data collection.…”

“…This prevalence is similar and comparable to that in the United States and Canada 17,21,22 however, is much higher than other parts of the world, such as Japan. 16 A closer look at our data revealed that half of the patients attending to the dialysis center were from an aboriginal heritage; however as per the 2011 census only 6.13% of the population of Townsville region is represented by people with an indigenous background. 23 Thus the prevalence of indigenous patients amongst our sample size was much higher than the general population.…”

“…Locking-Custolito et al, Combe et al, Plantinga et al and Ishii and colleagues, also found positive association between presence of DM and LLAs. [15][16][17]21 The strongest association with LLAs, that our study found, was that of history of ulceration. In contrast, previous studies do not associate this as the strongest risk factor.…”

“…These studies have also identified that LLAs are a frequent event in patients on hemodialysis therapy (HD) and that this risk is further increased with the presence of concurrent DM. 12,15 Regarding the prevalence of LLAs in ESRF patients, on dialysis that has been recorded has a wide distribution from as low as 1.72% in Japan 16 to as high as 13.4% in Canada, 17 there is no recorded prevalence from the Australian continent even though Australian data suggests high rates of CVD, DM and ESRF amongst the indigenous population. 18,19 Indigenous Australians have been found to have a 38 times higher risk for LLA secondary to DM as compared to their non-indigenous counterparts.…”

Osteoprotegerin as a marker of atherosclerosis in type 1 and type 2 diabetic patients

“…This could be related to the inclusion of only diabetic patients without any macrovascular complications. In a study carried out by Ishii et al in diabetic and nondiabetic end stage renal disease patients, increased HbA1c levels were found to be related to increased peripheral artery disease (established by ABI) risk, and this study supports our assumption (17). Thus, these findings show that good glycemic control is the most important stage to prevent related complications.…”