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Jornal Vascular Brasileiro

Print version ISSN 1677-5449

J. vasc. bras. vol.8 no.4 Porto Alegre Dec. 2009

http://dx.doi.org/10.1590/S1677-54492009000400004 

ORIGINAL ARTICLE

 

Prevalence of peripheral occlusive arterial disease in patients with chronic renal failure

 

 

José Aderval AragãoI; Francisco Prado ReisII; Roberto Ribeiro Borges NetoIII; Marina Elizabeth Cavalcanti de Sant’Anna AragãoIV; Marco Antonio Prado NunesV; Vera Lúcia Corrêa FeitosaVI

IProfessor adjunto, Anatomia Humana, Universidade Federal de Sergipe (UFS), Aracaju, SE. Professor adjunto III, Anatomia Humana, Universidade Tiradentes (UNIT), Aracaju, SE. Doutorando, Curso de Pós-Graduação em Angiologia e Cirurgia Vascular, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP.
IIProfessor titular, Neuroanatomia, UNIT, Aracaju, SE. Coordenador, Laboratório de Morfologia e Biologia Estrutural, Instituto de Tecnologia e Pesquisa, UNIT, Aracaju, SE
IIIAcadêmico de Medicina, UFS, Aracaju, SE
IVMédica, Serviço de Segurança e Medicina do Trabalho, Prefeitura Municipal de Aracaju, SE
VProfessor assistente, Anatomia, UNIT, Aracaju, SE. Doutorando, Curso de Pós-Graduação em Angiologia e Cirurgia Vascular, UNIFESP, São Paulo, SP
VIProfessora associada, Departamento de Morfologia, UFS, Aracaju, SE

Correspondence

 

 


Abstract

Background: Peripheral occlusive arterial disease has been found to be a sensitive marker of systemic atherosclerosis and a predictor of other cardiovascular diseases. In spite of the high prevalence of the cardiovascular diseases, there are few studies about peripheral occlusive arterial disease in patients with chronic renal failure under hemodialysis treatment.

Objective: To determine the prevalence of peripheral occlusive arterial disease in patients with chronic renal failure under hemodialysis treatment at a center of excellence in the State of Sergipe, Brazil.

Methods: A cross-sectional study was conducted from June to November 2008 at a center of excellence for the treatment of patients with chronic renal failure. Those patients with the ankle-brachial index (ABI) ≤ 0.9 were diagnosed as having peripheral occlusive arterial disease.

Results: From a population of 239 individuals with chronic renal failure, 201 were evaluated. Of that, 28 (14%) had peripheral arterial insufficiency with ABI ≤ 0.9. Their age ranged from 24 to 82 years (mean age = 52 years). Hypertension and dyslipidemia were the more frequent risk factors. Among the patients with peripheral occlusive arterial disease, 89% had dyslipidemia; 71% had high blood pressure; and 29% had coronary diseases.

Conclusion: The prevalence of peripheral occlusive arterial disease in patients with chronic renal failure was 14%.

Keywords: Chronic renal failure, peripheral occlusive arterial disease, ankle-brachial index.


 

 

Introduction

Peripheral occlusive arterial disease (POAD) is a gradual pathological process of diminished blood flow. It can be either symptomatic or asymptomatic. The disease leads to less oxygen being transported to tissues, to the point of occluding arteries in the lower limbs. The disease is a leading cause of death in the Western world1-6.

POAD is associated with risk factors (RF) such as age, smoking, diabetes mellitus, systemic hypertension (SHT), dyslipidemia, and a sedentary lifestyle, all of which contribute to the progressive, generalized development of atherosclerotic plaques. Smoking and DM stand out among those factors, since each seems to imply a three- to fourfold increase in risk of POAD7-10. Recently, other factors have been considered: hyperhomocysteinemia, fibrinogen, high C-reactive protein (CRP), and chronic renal failure (CRF)11-19.

High prevalence of cardiovascular disease among CRF patients leads to mortality rates ten times as high as those found in the general population20. Using the ankle-brachial index (ABI), Vinuesa et al.21 found 32 percent prevalence for POAD among pre-dialytic chronic renal failure patients. Using the same diagnostic method, Hiatt11, Selvin & Erlinger12 and Leibson et al.22 found prevalence ranged from 4.3 to 26 percent in the general population.

ABI is a low cost, noninvasive, easy to use method with high degrees of sensitivity and specificity. Under normal conditions, systolic pressure of the lower limbs is equal to, or slightly higher than, that of the upper limbs. When the lower limbs have arterial obstructions, systolic blood pressure at the ankle level drops, decreasing ABI values. An ABI = 0.9 has 90 to 97 percent sensitivity and 98 to 100 percent specificity for detecting arterial stenoses compromising 50 percent of the lumen of one or more high diameter vessels of the lower limbs9,13,18,23,24. Considering the high rate of prevalence, high morbidity and mortality and the influence POAD can have on survival rates for CRF patients, early diagnosis of this pathological process is key.

It is estimated that POAD prevalence ranges from 15 to 20 percent among people 55 years old or more, and that around 70 to 80 percent of patients with POAD are asymptomatic4. However, the prevalence jumps to 30 to 38 percent in 24 percent of patients aged 40 or older who have CRF and are undergoing dialytic treatment11,12,22,25-27. The objective this study was to establish POAD prevalence if CRF patients undergoing hemodialytic treatment.

 

Method

This is a cross-sectional study, performed from June to November 2008, at a reference clinic for hemodialytic treatment CRF patients in the state of Sergipe, Northeastern Brazil. The project was approved by the Universidade Federal de Sergipe Research Ethics Committee under protocol number 3045.0.000.107-08.

Patients were asked to take part of the study one hour before the haemodialysis session. If after reading the informed consent form they agreed to participate, they were included. Patients were excluded if they were under the age of 18, had indigenous ancestry, were pregnant, had an amputated upper or lower limb, or had a bilateral arteriovenous fistula. Information regarding age, gender, coronary disease, smoking, hypertension, haemodialysis time, total cholesterol (TC), high-density lipoprotein cholesterol (HDL-c) and capillary glycemia was collected using forms. Patients were considered diabetic if fasting glycemia > 126 mg/dL or if they were undergoing pharmacological treatment; to have coronary disease if they had positive past history; smoking if currently a smoker; dyslipidemic if they had high TC or low HDL-c; hypertensive if blood pressure (BP) = 140 x 90 mmHg or if using antihypertensive medication. A sphygnomanometer and a portable vascular Doppler system with 10 MHz transducer (DV 600®, WEM Equipamentos Eletrônicos, São Paulo, Brazil) were used to measure systolic blood pressure (SBP) in the upper (brachial artery) and lower (anterior and/or posterior tibial artery) limbs. Patients were classified as having POAD if ABI = 0.928.29.

 

Results

At a reference clinic for hemodialytic treatment CRF patients in the state of Sergipe, Northeastern Brazil, 239 patients with CRF were selected for the study. Of those, 38 were then excluded: 2 because they were not 18 years old or older, three because they had amputated lower limbs, eight because of arteriovenous fistulas in the upper limbs, and 25 because they refused to participate. Patient haemodialysis time ranged from 1 to 151 months, mean average 33.72±29.72 months.

Among the 201 patients, age ranged from 18 to 86 years, mean average 47.55±14.92 years; 129 were male. There were high rates of hypertension and dyslipidemia, regardless of gender (Table 1). HDL-c levels were low for 145 (88%) dyslipidemic patients, 90 (62%) of which were male and 55 (38%) female.

 

 

Smokers, predominantly male (76%), smoked on average 19.8 cigarettes per day. Coronary disease was associated with hypertension in 75 percent of cases (30/40), and with dyslipidemia in 80 percent (32/40). Among dyslipidemic patients, 16 percent (5/32) were hypertensive and had TC > 200 mg/dL, while 84 percent (27/32) had HDL-c < 40 mg/dL for men or < 50 mg/dL for women.

POAD was found in 28 (14%) of the 201 patients, seven of which were women and 21 were men. All participants had variable levels of arterial insufficiency and ABI = 0,9. ABI was normal for 148 (74%) patients, 25 (12%) of which had ABI > 1.4.

The age of POAD patients ranged from 24 to 82 years old, mean average 52.03±17.36 years. Distribution of POAD patients by RF and by gender showed hypertension and dyslipidemia were the most common risk factors (Table 2).

 

 

Correlation between risk factors shows strong association between hypertension and coronary disease. Overall, dyslipidemia had the strongest association with other factors (Table 3). Of 25 dyslipidemic patients, five (20%) had TC > 200 mg/dL and 20 (80%) had altered HDL-c levels, < 40 mg/dL for men and < 50 mg/dL for women.

 

Discussion

POAD can be defined as a manifestation of atherosclerosis in the lower limbs associated with increased morbidity and mortality, limited functioning, and worse quality of life. POAD prevalence depends on diagnostic criteria; it is significantly higher when using ABI than when estimated solely on the basis of intermittent claudication. ABI, as a marker of asymptomatic POAD, provides important information about subclinical atherosclerosis, as well as being a key predictor of cardiovascular events3,30,31.

In most epidemiological studies, POAD prevalence ranges from 3 to 10 percent, increasing circa 15 to 20 percent for patients over 70 years old32. In this study, POAD prevalence among CRF patients undergoing hemodialytic treatment was 14 percent, matching the findings of Hiatt11, Selvin & Erlinger12, Leibson et al.22, and Hasimu et al.33, who report prevalence ranging from 4.3 to 26 percent. According to Vinuesa et al.21, however, the rate of POAD among pre-dialytic chronic renal failure patients is 32 percent.

The most frequent risk factors, such as old age, DM, smoking, dyslipidemia, hypertension and coronary disease, implicated in POAD, are the same reported for coronary and carotid arteriosclerosis, though the relative importance of the various factors is different for peripheral arteriosclerosis11,12,34. Vinuesa et al.21 and Selvin & Erlinger12 report old age as extremely relevant for POAD prevalence. Similar findings have been described by the NHANES sutdy, which found POAD prevalence higher than 15 percent for patients over 70 years old4. In this study, mean age of POAD patients was 52.03±17.36 years.

Current studies recommend research into the link between POAD patients and diabetes, since the association probably increases POAD risk by 1.5 to 4 times25-27. Framingham claims the association to be 20 percent35, while Murabito et al.14 report 68.65 percent. In this study, there is a 25 percent association between POAD and diabetes.

Hiatt8 reports smoking is the most important RF for POAD. In this study, 18 percent of POAD patients were smokers. Gabriel et al.36 report 68.75 percent prevalence, while others37-39 claim approximately half of all POAD patients were smokers. The latter authors also claim that the association can be twice as strong for POAD patients than for coronary artery disease (CAD) patients.

In terms of lipid profile of patients who had CRF associated with POAD, the study found a 14 percent rate of hypercholesterolemia. In studies NHANES and PARTNERS, the rates were 60 and 77 percent, respectively4,13. HDL-c was low for 75 percent of POAD patients in our study; the same was found by Lima et al.40 and Brandão et al.41, who report POAD patients had low HDL-c levels.

SHT is probably the most frequent cardiovascular RF among CRF patients undergoing hemodialytic treatment. Prevalence of hypertension among POAD patients was 71 percent, a finding similar to the 70 percent found by Mittal et al.42, but different from the 86 percent recently reported by Agarwal et al.43.

Among our POAD patients, 29 percent had coronary disease, unlike the rates found by Gabriel et al.36 and Sukhija et al.44, who report rates of 90.76 and 98 percent, respectively. Hasimu et al.33, meanwhile, report a lower rate: 25.4 percent.

 

Conclusion

At a reference clinic for hemodialytic treatment CRF patients in the state of Sergipe, Northeastern Brazil, POAD prevalence was 14 percent, and the most frequent RF were hypertension and dyslipidemia.

 

Acknowledgments

The authors would like to thank Dr. Manuel Pacheco de Andrade, for allowing this study to be performed at Clinese, and Professor Rute Santana Reis, for revising the spelling and organizing data tables.

 

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Correspondence:
José Aderval Aragão
Rua Aloísio Campos, 500
CEP 49035-020 - Aracaju, SE - Brazil
Telephone: +55 (79) 3255.1381, +55 (79) 9989.6767
E-mail: jaafelipe@infonet.com.br

Manuscript received Apr 07 2009, accepted for publication Nov 03 2009.

 

 

There is no conflict of interest concerning the publication of this article.

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