title: Impact of renal insufficiency on mortality in advanced lower extremity peripheral arterial disease.
abstract: Renal insufficiency predicts mortality among patients who are treated for myocardial infarction and congestive heart failure, but its clinical significance in advanced peripheral arterial disease has not been evaluated. A national cohort of 5787 male veterans who received an initial diagnosis of rest pain, ischemic ulceration, or gangrene between January 1, 2000, and September 30, 2002, and had at least one serum creatinine measurement within 3 mo before diagnosis were identified. Sixty-two percent (n = 3561) of cohort members had normal or mildly reduced renal function (GFR > or =60 ml/min per 1.73 m(2)), 30% (n = 1742) had moderate renal insufficiency (GFR 30 to 59 ml/min per 1.73 m(2)), and 8% (n = 484) had severe renal insufficiency or renal failure (GFR <30 ml/min per 1.73 m(2)) but were not on dialysis. The percentages of patients who presented with gangrene or ischemic ulceration rather than rest pain increased with declining renal function (70, 77, and 87%; P < 0.001), as did 1-yr mortality risk (17, 27, and 44%; P < 0.001). After adjustment for demographic and clinical characteristics, patients with a GFR of 30 to 59 ml/min per 1.73 m(2) (odds ratio, 1.32; 95% confidence interval, 1.13 to 1.53) and <30 ml/min per 1.73 m(2) (odds ratio, 2.97; 95% confidence interval, 2.39 to 3.69) had a significantly increased odds of death within 1 yr of cohort entry. Both moderate and severe renal insufficiency are associated with an increased odds of death in patients with critical limb ischemia. Death rates were particularly high among those with a GFR <30 ml/min per 1.73 m(2). This finding may be partly explained by their more frequent presentation with ischemic ulceration or gangrene rather than rest pain.
authors.affiliation: Division of Nephrology, Box 111J, Nephrology, VA Medical Center San Francisco, 4150 Clement Street, San Francisco, CA 94121, USA. Ann.O'Hare@med.va.gov
authors.forename: Ann M
authors.initials: AM
authors.lastname: O'Hare
authors.forename: Daniel
authors.initials: D
authors.lastname: Bertenthal
authors.forename: Michael G
authors.initials: MG
authors.lastname: Shlipak
authors.forename: Saunak
authors.initials: S
authors.lastname: Sen
authors.forename: Mary-Margaret
authors.initials: MM
authors.lastname: Chren
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001157:Arterial Occlusive Diseases / Q000175:diagnosis* / Q000401:mortality*; D002423:Cause of Death; D015331:Cohort Studies; D005500:Follow-Up Studies; D005919:Glomerular Filtration Rate; D006801:Humans; D007676:Kidney Failure, Chronic / Q000175:diagnosis / Q000401:mortality*; D007677:Kidney Function Tests; D035002:Lower Extremity; D008297:Male; D008875:Middle Aged; D016491:Peripheral Vascular Diseases / Q000175:diagnosis / Q000401:mortality*; D011237:Predictive Value of Tests; D012044:Regression Analysis; D018570:Risk Assessment; D012720:Severity of Illness Index; D016019:Survival Analysis