Utility of Exercise-Induced Zero TBI Sign in Patients on Maintenance Hemodialysis

Abstract

This is a translation of J Jpn Coll Angiol 2015; 55: 125-129. It is uncertain whether exercise-induced zero toe brachial index sign (e-ZETS) is beneficial to prevent advanced perfusion disturbance in maintenance hemodialysis (HD) patients. In HD patients, we compared the clinical findings and prognoses among 22 toes in a resting zero toe brachial index sign (r-ZETS) group, 22 toes in an e-ZETS group, and 63 toes in a non-e-ZETS group. The hemodynamics of the lower extremities in the e-ZETS group is intermediate between the r-ZETS and non-e-ZETS groups. As the result of a 36-month followup observation, the r-ZETS avoidance rate was significantly lower in the e-ZETS group (63.6%; P <0.001) than the none-ZETS group (98.4%), showing that it was difficult to avoid advanced perfusion disturbance. The e-ZETS in HD patients may appear before r-ZETS, being beneficial as a predictor for advanced perfusion disturbance. (This is a translation of J Jpn Coll Angiol 2015; 55: 125-129.)Keyword: peripheral arterial disease, critical limb ischemia, hemodialysis, toe brachial pressure index, exercise posture and producing a driving force in walking. However, patients on maintenance hemodialysis (HD patients) sometimes undergo great toe amputation due to critical limb ischemia (CLI), resulting in a marked decrease in the activity of daily life. 1) CLI is often treated by revascularization, when revascularization is not indicated, perfusion disorders should be diagnosed as early as possible, and efforts should be made to prevent CLI. Since CLI is closely associated with a poor prognosis, even earlier diagnosis is required.As a diagnostic method for perfusion disorders at the toe level, the ratio of the toe to brachial blood pressure (toe brachial pressure index: TBI) is widely used. Matsui et al. 2) called the state not allowing TBI measurement "the zero TBI sign," and reported that this sign is a good parameter indicating severe perfusion disorders of the toe. This zero TBI sign (resting zero TBI sign: r-ZETS) represents a state in which the toe pressure is below 40 mmHg as the measurement threshold of automatic devices for blood pressure measurement. Findings such as ischemic resting pain, ulceration, or gangrene in addition to such a hemodynamic state lead to CLI. Therefore, r-ZETS is an important factor for the diagnosis of CLI, and measurement for its detection is indispensable.However, in terms of early diagnosis and treatment, measurement for r-ZETS detection is not performed at an appropriate timing. In daily clinical practice, regular TBI measurements are important for the early diagnosis of "the condition as the gateway to severe perfusion disorders including CLI." However, there is no clear TBI cut-off value indicating this condition.In HD patients, the complication rate of severe perfusion disorders is high, and CLI sometimes suddenly develops in the absence of intermittent claudication. Therefore, it is necessary to detect objective signs indicating the gateway to severe perfusion disorders including CLI and take act...