title: Influence of renal insufficiency on limb loss and mortality after initial lower extremity surgical revascularization.
abstract: OBJECTIVE
  Limb loss after lower extremity surgical revascularization occurs relatively frequently in patients receiving dialysis. The goal of the present study was to determine whether patients with milder degrees of renal insufficiency are also at risk for this complication.
  
  
  METHODS
  This cohort study was carried out at the Department of Veterans Affairs (VA). The study sample consisted of 9932 patients undergoing an initial surgical revascularization procedure between October 1, 1995, and September 30, 2000, recorded by the VA National Surgical Quality Improvement Program (NSQIP). We examined the occurrence of major amputation within 1 year of lower extremity surgical revascularization by level of renal function.
  
  
  RESULTS
  Eleven percent of study patients underwent major lower extremity amputation within 1 year of NSQIP-documented lower extremity revascularization surgery: 10% (739 of 7335) of patients with normal renal function, 11% (251 of 2210) of patients with moderately reduced renal function, 12% (24 of 205) of patients with severe renal insufficiency, and 29% (53 of 182) of patients receiving dialysis. After adjustment for demographic characteristics and comorbid conditions, only patients receiving dialysis were at significantly increased risk for amputation, compared with patients with normal renal function (odds ratio, 2.46; 95% confidence interval, 1.74-3.47; P<.001). Compared with all other veterans undergoing bypass procedures, patients receiving dialysis were more likely to have a wound infection; a diagnostic code for lower extremity gangrene, infection, or ischemic ulceration; an elevated white blood cell count; and preoperative sepsis at the time of initial revascularization. In addition, they were more likely to have a preoperative hospital stay longer than 1 week, undergo concurrent minor amputation, and undergo an outflow (vs inflow) procedure.
  
  
  CONCLUSIONS
  Only patients receiving dialysis, and not patients with milder degrees of renal insufficiency, appear to be at higher risk for limb loss after revascularization, compared with patients with normal renal function. Further studies are needed to determine why patients receiving dialysis are at a singularly increased risk for limb loss after lower extremity revascularization and whether their more frequent presentation with limb-threatening infection at the time of revascularization reflects late presentation for surgery or a more rapid course of peripheral arterial disease in this patient group.
authors.affiliation: Department of Medicine, Veterans Affairs Medical Center and University of California, San Francisco 94121, USA. Ann.O'Hare@med.va.gov
authors.forename: Ann M
authors.initials: AM
authors.lastname: O'Hare
authors.forename: Anton N
authors.initials: AN
authors.lastname: Sidawy
authors.forename: Joe
authors.initials: J
authors.lastname: Feinglass
authors.forename: Kendra Magee
authors.initials: KM
authors.lastname: Merine
authors.forename: Jennifer
authors.initials: J
authors.lastname: Daley
authors.forename: Shukri
authors.initials: S
authors.lastname: Khuri
authors.forename: William G
authors.initials: WG
authors.lastname: Henderson
authors.forename: Kirsten L
authors.initials: KL
authors.lastname: Johansen
mesh_terms: D000368:Aged; D000671:Amputation, Surgical; D015331:Cohort Studies; D003956:Dialysis / Q000009:adverse effects*; D005260:Female; D005734:Gangrene / Q000209:etiology / Q000601:surgery; D006801:Humans; D007511:Ischemia / Q000209:etiology / Q000601:surgery*; D035002:Lower Extremity / Q000098:blood supply* / Q000473:pathology / Q000601:surgery; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D051437:Renal Insufficiency / Q000150:complications*; D012189:Retrospective Studies; D014656:Vascular Surgical Procedures / Q000401:mortality