Critical factors leading to wound complications in amputated patients: low hematocrit levels

Background: Patients with diabetes-induced lower extremity infection and gangrene suffer from post-amputation wound complications. The aim of this report is to identify critical factors leading to wound complications in amputated patients.Methods: 50 patients with ipsilateral transmetatarsal (TMA) or finger amputation treated in Istanbul University Medical Faculty between 2001 and 2013 were retrospectively reviewed. Amputations were caused by diabetic foot infection. None of the patients had peripheral artery disease (ABPI>1.1).Results: In 9 (18%) patients, revision was required despite appropriate antibiotherapy after amputation. 7 (78%) of these patients were women, 8 (89%) were smokers and hematocrit levels were below 25% in all of them. 4 of the 5 patients (80%) with chronic kidney disease were among the patients in need of revision.Conclusion: The risk of wound complications after amputation is high. These complications increase morbidity and treatment costs. This study showed that low hematocrit value is a risk factor for the development of wound infection after amputation.

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Chronic kidney disease and outcomes of lower extremity revascularization for peripheral artery disease

Atherosclerosis ◽

10.1016/j.atherosclerosis.2019.12.016 ◽

2020 ◽

Vol 297 ◽

pp. 149-156 ◽

Cited By ~ 3

Author(s):

Nathaniel R. Smilowitz ◽

Nipun Bhandari ◽

Jeffrey S. Berger

Keyword(s):

Chronic Kidney Disease ◽

Kidney Disease ◽

Lower Extremity ◽

Peripheral Artery Disease ◽

Peripheral Artery ◽

Artery Disease ◽

Lower Extremity Revascularization

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Abstract 13474: Rivaroxaban Reduces Major Cardiovascular and Limb Events in Patients With the High-risk Triad of Chronic Kidney Disease, Peripheral Artery Disease and Recent Lower Extremity Revascularization: Insights From VOYAGER PAD

Circulation ◽

10.1161/circ.142.suppl_3.13474 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Judith A Hsia ◽

Sonia Anand ◽

Mark R Nehler ◽

Rupert Bauersachs ◽

Manesh R Patel ◽

...

Keyword(s):

Chronic Kidney Disease ◽

High Risk ◽

Kidney Disease ◽

Lower Extremity ◽

Limb Ischemia ◽

Major Amputation ◽

Acute Limb Ischemia ◽

Peripheral Artery ◽

Artery Disease ◽

Lower Extremity Revascularization

Introduction: Chronic kidney disease (CKD) is common among patients undergoing lower extremity revascularization (LER) for peripheral artery disease (PAD) and identifies a population at high risk for adverse outcomes. The VOYAGER PAD trial demonstrated the efficacy of rivaroxaban in PAD patients after LER on a composite of cardiovascular (CV) and limb ischemic events (HR 0.85 vs placebo, 95% CI 0.76-0.96; p=0.009); this analysis examines the prespecified subgroup of patients with CKD. Methods: VOYAGER PAD (NCT02504216) was a double-blind, placebo-controlled trial which randomized PAD patients with recent LER to rivaroxaban 2.5 mg twice daily or placebo on a background of aspirin 100 mg daily. The primary endpoint was a composite of acute limb ischemia, major amputation for vascular cause, myocardial infarction, ischemic stroke or CV death. The primary safety endpoint was TIMI major bleeding. Analysis of the intention-to-treat population utilized Kaplan Meier estimates and Cox proportional-hazards models. Results: Among 6319 VOYAGER patients with baseline estimated glomerular filtration rate (eGFR), 21% were <60 (mostly CKD stage 3) and 79% were ≥60 ml/min/1.73m 2 . During 28-month (median) follow up, patients with CKD had a higher rate of major CV and limb events: placebo group 10.0 events/100 patient-years (95% CI 8.5, 11.8) for eGFR <60 vs 7.4 (95% CI 6.7, 8.2) for eGFR ≥60. Rivaroxaban reduced primary outcome events with no heterogeneity by eGFR category (Figure, p for interaction 0.62). Acute limb ischemia and major amputation were significantly reduced among patients with eGFR<60 (HR 0.55, 95% CI 0.36, 0.86) as well as ≥60 (HR 0.77, 95% CI 0.63, 0.94). TIMI major bleeding was numerically more frequent among patients with CKD with no heterogeneity by treatment group (Figure, p for interaction 0.37). Conclusions: Rivaroxaban reduced major CV and limb events in patients with PAD undergoing LER, including those with CKD, a particularly high-risk population.

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Low serum magnesium as a risk factor for peripheral artery disease in chronic kidney disease: an open verdict

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfaa115 ◽

2020 ◽

Vol 35 (11) ◽

pp. 1831-1833

Author(s):

Martin H de Borst ◽

Jeroen H F de Baaij

Keyword(s):

Chronic Kidney Disease ◽

Risk Factor ◽

Kidney Disease ◽

Peripheral Artery Disease ◽

Serum Magnesium ◽

Peripheral Artery ◽

Artery Disease ◽

Low Serum

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Risk for recurrent cardiovascular disease events among patients with diabetes and chronic kidney disease

Cardiovascular Diabetology ◽

10.1186/s12933-021-01247-0 ◽

2021 ◽

Vol 20 (1) ◽

Author(s):

Demetria Hubbard ◽

Lisandro D. Colantonio ◽

Robert S. Rosenson ◽

Todd M. Brown ◽

Elizabeth A. Jackson ◽

...

Keyword(s):

Myocardial Infarction ◽

Cardiovascular Disease ◽

Chronic Kidney Disease ◽

Health Insurance ◽

High Risk ◽

Kidney Disease ◽

Peripheral Artery ◽

Increased Risk ◽

Patients With Diabetes ◽

Very High

Abstract Background Adults who have experienced multiple cardiovascular disease (CVD) events have a very high risk for additional events. Diabetes and chronic kidney disease (CKD) are each associated with an increased risk for recurrent CVD events following a myocardial infarction (MI). Methods We compared the risk for recurrent CVD events among US adults with health insurance who were hospitalized for an MI between 2014 and 2017 and had (1) CVD prior to their MI but were free from diabetes or CKD (prior CVD), and those without CVD prior to their MI who had (2) diabetes only, (3) CKD only and (4) both diabetes and CKD. We followed patients from hospital discharge through December 31, 2018 for recurrent CVD events including coronary, stroke, and peripheral artery events. Results Among 162,730 patients, 55.2% had prior CVD, and 28.3%, 8.3%, and 8.2% had diabetes only, CKD only, and both diabetes and CKD, respectively. The rate for recurrent CVD events per 1000 person-years was 135 among patients with prior CVD and 110, 124 and 171 among those with diabetes only, CKD only and both diabetes and CKD, respectively. Compared to patients with prior CVD, the multivariable-adjusted hazard ratio for recurrent CVD events was 0.92 (95%CI 0.90–0.95), 0.89 (95%CI: 0.85–0.93), and 1.18 (95%CI: 1.14–1.22) among those with diabetes only, CKD only, and both diabetes and CKD, respectively. Conclusion Following MI, adults with both diabetes and CKD had a higher risk for recurrent CVD events compared to those with prior CVD without diabetes or CKD.

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Unique aspects of peripheral artery disease in patients with chronic kidney disease

Vascular Medicine ◽

10.1177/1358863x18824654 ◽

2019 ◽

Vol 24 (3) ◽

pp. 251-260 ◽

Cited By ~ 5

Author(s):

Nkiruka V Arinze ◽

Andrew Gregory ◽

Jean M Francis ◽

Alik Farber ◽

Vipul C Chitalia

Keyword(s):

Chronic Kidney Disease ◽

Kidney Disease ◽

Peripheral Artery Disease ◽

Clinical Aspects ◽

Peripheral Artery ◽

Health Care Burden ◽

High Prevalence ◽

Novel Biomarkers ◽

Artery Disease ◽

Poor Outcomes

Peripheral artery disease (PAD) represents a major health care burden. Despite the advent of screening and interventional procedures, the long-term clinical outcomes remain suboptimal, especially in patients with chronic kidney disease (CKD). While CKD and PAD share common predisposing factors, emerging studies indicate that their co-existence is not merely an association; instead, CKD represents a strong, independent risk factor for PAD. These findings implicate CKD-specific mediators of PAD that remain incompletely understood. Moreover, there is a need to understand the mechanisms underlying poor outcomes after interventions for PAD in CKD. This review discusses unique clinical aspects of PAD in patients with CKD, including high prevalence and worse outcomes after vascular interventions and the influence of renal allograft transplantation. In doing so, it also highlights underappreciated aspects of PAD in patients with CKD, such as disparities in revascularization and higher peri-procedural mortality. While previous reviews have discussed general mechanisms of PAD pathogenesis, focusing on PAD in CKD, this review underscores a need to probe for CKD-specific pathogenic pathways that may unravel novel biomarkers and therapeutic targets in PAD and ultimately improve the risk stratification and management of patients with CKD and PAD.

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Incremental effects of diabetes mellitus and chronic kidney disease in medial arterial calcification: Synergistic pathways for peripheral artery disease progression

Vascular Medicine ◽

10.1177/1358863x19842276 ◽

2019 ◽

Vol 24 (5) ◽

pp. 383-394 ◽

Cited By ~ 1

Author(s):

Prakash Krishnan ◽

Pedro R Moreno ◽

Irene C Turnbull ◽

Meerarani Purushothaman ◽

Urooj Zafar ◽

...

Keyword(s):

Diabetes Mellitus ◽

Chronic Kidney Disease ◽

Kidney Disease ◽

Peripheral Artery Disease ◽

Arterial Calcification ◽

Peripheral Artery ◽

Fetuin A ◽

Artery Disease ◽

Protein Density ◽

Medial Arterial Calcification

Diabetes mellitus (DM) and chronic kidney disease (CKD) separately are known to facilitate the progression of medial arterial calcification (MAC) in patients with symptomatic peripheral artery disease (PAD), but their combined effect on MAC and associated mediators of calcification is not well studied. The association of MAC and calcification inducer bone morphogenetic protein (BMP-2) and inhibitor fetuin-A, with PAD, is well known. Our aim was to investigate the association of MAC with alterations in BMP-2 and fetuin-A protein expression in patients with PAD with DM and/or CKD. Peripheral artery plaques (50) collected during directional atherectomy from symptomatic patients with PAD were evaluated, grouped into no-DM/no-CKD ( n = 14), DM alone ( n = 10), CKD alone ( n = 12), and DM+CKD ( n = 14). MAC density was evaluated using hematoxylin and eosin, and alizarin red stain. Analysis of inflammation, neovascularization, BMP-2 and fetuin-A protein density was performed by immunohistochemistry. MAC density, inflammation grade and neovessel content were significantly higher in DM+CKD versus no-DM/no-CKD and CKD ( p < 0.01). BMP-2 protein density was significantly higher in DM+CKD versus all other groups ( p < 0.01), whereas fetuin-A protein density was significantly lower in DM+CKD versus all other groups ( p < 0.001). The combined presence of DM+CKD may be associated with MAC severity in PAD plaques more so than DM or CKD alone, as illustrated in this study, where levels of calcification mediators BMP-2 and fetuin-A protein were related most robustly to DM+CKD. Further understanding of mechanisms involved in mediating calcification and their association with DM and CKD may be useful in improving management and developing therapeutic interventions.

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