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Lower extremity peripheral artery disease in end-stage renal disease

Ann M O'Hare, MD
Kirsten Johansen, MD
Section Editor
Steve J Schwab, MD
Deputy Editors
Kathryn A Collins, MD, PhD, FACS
Alice M Sheridan, MD


Among patients with end-stage renal disease (ESRD), peripheral artery disease (PAD) is common and is associated with substantial morbidity and mortality [1-12]. However, compared to other atherosclerotic diseases such as coronary and cerebrovascular disease, little is known concerning the epidemiology of lower extremity PAD in this population and limited information is available to guide treatment and preventive strategies.

Lower extremity PAD in patients undergoing maintenance dialysis will be reviewed here. PAD in patients with chronic kidney disease and general issues related to PAD in patients in the general population are discussed separately. (See "Peripheral artery disease in chronic kidney disease" and "Overview of lower extremity peripheral artery disease".)


Among patients with ESRD, estimates of the prevalence of PAD vary in part according to the specific population studied:

In the United States, the overall prevalence of PAD among patients initiating dialysis is approximately 14 to 15 percent [13,14].

Based on the HEMO study and the USRDS database, the prevalence of PAD is approximately 25 percent among chronic hemodialysis patients [15,16].


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Literature review current through: May 2017. | This topic last updated: Mar 09, 2016.
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  1. O'Hare A, Johansen K. Lower-extremity peripheral arterial disease among patients with end-stage renal disease. J Am Soc Nephrol 2001; 12:2838.
  2. Aakhus S, Dahl K, Widerøe TE. Cardiovascular morbidity and risk factors in renal transplant patients. Nephrol Dial Transplant 1999; 14:648.
  3. Eggers PW, Gohdes D, Pugh J. Nontraumatic lower extremity amputations in the Medicare end-stage renal disease population. Kidney Int 1999; 56:1524.
  4. Chertow GM, Normand SL, Silva LR, McNeil BJ. Survival after acute myocardial infarction in patients with end-stage renal disease: results from the cooperative cardiovascular project. Am J Kidney Dis 2000; 35:1044.
  5. Cho YW, Terasaki PI. Impact of new variables reported to the UNOS registry. Clin Transpl 1997; :305.
  6. Lemmers MJ, Barry JM. Major role for arterial disease in morbidity and mortality after kidney transplantation in diabetic recipients. Diabetes Care 1991; 14:295.
  7. Matas AJ, Gillingham KJ, Elick BA, et al. Risk factors for prolonged hospitalization after kidney transplants. Clin Transplant 1997; 11:259.
  8. Rocco MV, Soucie JM, Reboussin DM, McClellan WM. Risk factors for hospital utilization in chronic dialysis patients. Southeastern Kidney Council (Network 6). J Am Soc Nephrol 1996; 7:889.
  9. Fishbane S, Youn S, Flaster E, et al. Ankle-arm blood pressure index as a predictor of mortality in hemodialysis patients. Am J Kidney Dis 1996; 27:668.
  10. O'Hare AM, Johansen KL. Peripheral vascular disease in end-stage renal disease patients. Int J Artif Organs 2002; 25:1123.
  11. O'Hare AM, Feinglass J, Reiber GE, et al. Postoperative mortality after nontraumatic lower extremity amputation in patients with renal insufficiency. J Am Soc Nephrol 2004; 15:427.
  12. Koch M, Trapp R, Kulas W, Grabensee B. Critical limb ischaemia as a main cause of death in patients with end-stage renal disease: a single-centre study. Nephrol Dial Transplant 2004; 19:2547.
  13. USRDS 2004 Annual Data Report: Reference Tables. 2004; 335.
  14. Collins AJ, Hanson G, Umen A, et al. Changing risk factor demographics in end-stage renal disease patients entering hemodialysis and the impact on long-term mortality. Am J Kidney Dis 1990; 15:422.
  15. Cheung AK, Sarnak MJ, Yan G, et al. Atherosclerotic cardiovascular disease risks in chronic hemodialysis patients. Kidney Int 2000; 58:353.
  16. O'Hare AM, Hsu CY, Bacchetti P, Johansen KL. Peripheral vascular disease risk factors among patients undergoing hemodialysis. J Am Soc Nephrol 2002; 13:497.
  17. Rajagopalan S, Dellegrottaglie S, Furniss AL, et al. Peripheral arterial disease in patients with end-stage renal disease: observations from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Circulation 2006; 114:1914.
  18. Lamping DL, Constantinovici N, Roderick P, et al. Clinical outcomes, quality of life, and costs in the North Thames Dialysis Study of elderly people on dialysis: a prospective cohort study. Lancet 2000; 356:1543.
  19. Mäkisalo H, Lepäntalo M, Halme L, et al. Peripheral arterial disease as a predictor of outcome after renal transplantation. Transpl Int 1998; 11 Suppl 1:S140.
  20. Al Zahrani HA, Al Bar HM, Bahnassi A, Abdulaal AA. The distribution of peripheral arterial disease in a defined population of elderly high-risk Saudi patients. Int Angiol 1997; 16:123.
  21. Leskinen Y, Salenius JP, Lehtimäki T, et al. The prevalence of peripheral arterial disease and medial arterial calcification in patients with chronic renal failure: requirements for diagnostics. Am J Kidney Dis 2002; 40:472.
  22. Testa A, Ottavioli JN. [Ankle-arm blood pressure index (AABPI) in hemodialysis patients]. Arch Mal Coeur Vaiss 1998; 91:963.
  23. Ono K, Tsuchida A, Kawai H, et al. Ankle-brachial blood pressure index predicts all-cause and cardiovascular mortality in hemodialysis patients. J Am Soc Nephrol 2003; 14:1591.
  24. Leavey SF, Strawderman RL, Young EW, et al. Cross-sectional and longitudinal predictors of serum albumin in hemodialysis patients. Kidney Int 2000; 58:2119.
  25. Jaar BG, Plantinga LC, Astor BC, et al. Novel and traditional cardiovascular risk factors for peripheral arterial disease in incident-dialysis patients. Adv Chronic Kidney Dis 2007; 14:304.
  26. Lin CS, Chen SJ, Sung CC, et al. Hemodialysis Is Associated With Increased Peripheral Artery Occlusive Disease Risk Among Patients With End-Stage Renal Disease: A Nationwide Population-Based Cohort Study. Medicine (Baltimore) 2015; 94:e1164.
  27. Boaz M, Weinstein T, Matas Z, et al. Peripheral vascular disease and serum phosphorus in hemodialysis: a nested case-control study. Clin Nephrol 2005; 63:98.
  28. Chan CT, Mardirossian S, Faratro R, Richardson RM. Improvement in lower-extremity peripheral arterial disease by nocturnal hemodialysis. Am J Kidney Dis 2003; 41:225.
  29. Manns BJ, Burgess ED, Hyndman ME, et al. Hyperhomocyst(e)inemia and the prevalence of atherosclerotic vascular disease in patients with end-stage renal disease. Am J Kidney Dis 1999; 34:669.
  30. Cheng SW, Ting AC, Wong J. Fasting total plasma homocysteine and atherosclerotic peripheral vascular disease. Ann Vasc Surg 1997; 11:217.
  31. Koskas F, Cluzel P, Deray G, et al. Management of peripheral arterial disease among end-stage renal failure patients. In: Cardiovascular Disease in End-Stage Renal Failure, Loscalzo J, London GM (Eds), Oxford University Press, Oxford 2000. p.421.
  32. Gradman WS, Cohen W, Haji-Aghaii M. Arteriovenous fistula construction in the thigh with transposed superficial femoral vein: our initial experience. J Vasc Surg 2001; 33:968.
  33. Taylor SM, Eaves GL, Weatherford DA, et al. Results and complications of arteriovenous access dialysis grafts in the lower extremity: a five year review. Am Surg 1996; 62:188.
  34. Polkinghorne KR, Atkins RC, Kerr PG. Determinants of native arteriovenous fistula blood flow. Nephrology (Carlton) 2004; 9:205.
  35. Koelemay MJ, Lijmer JG, Stoker J, et al. Magnetic resonance angiography for the evaluation of lower extremity arterial disease: a meta-analysis. JAMA 2001; 285:1338.
  36. Ishii H, Kumada Y, Toriyama T, et al. Cilostazol improves long-term patency after percutaneous transluminal angioplasty in hemodialysis patients with peripheral artery disease. Clin J Am Soc Nephrol 2008; 3:1034.
  37. McMurray SD, Johnson G, Davis S, McDougall K. Diabetes education and care management significantly improve patient outcomes in the dialysis unit. Am J Kidney Dis 2002; 40:566.
  38. Reddan DN, Marcus RJ, Owen WF Jr, et al. Long-term outcomes of revascularization for peripheral vascular disease in end-stage renal disease patients. Am J Kidney Dis 2001; 38:57.
  39. Treiman GS, Oderich GS, Ashrafi A, Schneider PA. Management of ischemic heel ulceration and gangrene: An evaluation of factors associated with successful healing. J Vasc Surg 2000; 31:1110.
  40. Albers M, Romiti M, Bragança Pereira CA, et al. A meta-analysis of infrainguinal arterial reconstruction in patients with end-stage renal disease. Eur J Vasc Endovasc Surg 2001; 22:294.
  41. Jaar BG, Astor BC, Berns JS, Powe NR. Predictors of amputation and survival following lower extremity revascularization in hemodialysis patients. Kidney Int 2004; 65:613.
  42. O'Hare AM, Sidawy AN, Feinglass J, et al. Influence of renal insufficiency on limb loss and mortality after initial lower extremity surgical revascularization. J Vasc Surg 2004; 39:709.
  43. O'Hare AM, Feinglass J, Sidawy AN, et al. Impact of renal insufficiency on short-term morbidity and mortality after lower extremity revascularization: data from the Department of Veterans Affairs' National Surgical Quality Improvement Program. J Am Soc Nephrol 2003; 14:1287.
  44. Vierthaler L, Callas PW, Goodney PP, et al. Determinants of survival and major amputation after peripheral endovascular intervention for critical limb ischemia. J Vasc Surg 2015; 62:655.
  45. Faglia E, Mantero M, Caminiti M, et al. Extensive use of peripheral angioplasty, particularly infrapopliteal, in the treatment of ischaemic diabetic foot ulcers: clinical results of a multicentric study of 221 consecutive diabetic subjects. J Intern Med 2002; 252:225.
  46. Graziani L, Silvestro A, Bertone V, et al. Percutaneous transluminal angioplasty is feasible and effective in patients on chronic dialysis with severe peripheral artery disease. Nephrol Dial Transplant 2007; 22:1144.
  47. Kumada Y, Aoyama T, Ishii H, et al. Long-term outcome of percutaneous transluminal angioplasty in chronic haemodialysis patients with peripheral arterial disease. Nephrol Dial Transplant 2008; 23:3996.
  48. Brümmer U, Condini V, Cappelli P, et al. Spinal cord stimulation in hemodialysis patients with critical lower-limb ischemia. Am J Kidney Dis 2006; 47:842.
  49. Ruggenenti P, Viganò G, Mecca G, et al. Failure of prostacyclin to improve peripheral arterial disease in dialysis patients. Nephron 1990; 54:93.
  50. Dossa CD, Shepard AD, Amos AM, et al. Results of lower extremity amputations in patients with end-stage renal disease. J Vasc Surg 1994; 20:14.
  51. O'Hare AM, Bacchetti P, Segal M, et al. Factors associated with future amputation among patients undergoing hemodialysis: results from the Dialysis Morbidity and Mortality Study Waves 3 and 4. Am J Kidney Dis 2003; 41:162.
  52. Chiriano J, Bianchi C, Teruya TH, et al. Management of lower extremity wounds in patients with peripheral arterial disease: a stratified conservative approach. Ann Vasc Surg 2010; 24:1110.
  53. http://vawwl.va.gov/podiatry/page.cfm?pg=44.
  54. Edwards JM, Taylor LM Jr, Porter JM. Limb salvage in end-stage renal disease (ESRD). Comparison of modern results in patients with and without ESRD. Arch Surg 1988; 123:1164.
  55. Harrington EB, Harrington ME, Schanzer H, Haimov M. End-stage renal disease--is infrainguinal limb revascularization justified? J Vasc Surg 1990; 12:691.
  56. Plantinga LC, Fink NE, Coresh J, et al. Peripheral vascular disease-related procedures in dialysis patients: predictors and prognosis. Clin J Am Soc Nephrol 2009; 4:1637.