Abstract
Peripheral arterial disease is common in diabetic chronic kidney disease (CKD) and is characterized either by abnormally low or high ankle-brachial index (ABI). Whether low or high ABI carries similar prognostic value is unknown. The association of baseline ABI with all-cause mortality over 40 ± 21 months (mean ± SD) was ascertained in 167 proteinuric diabetics (age 57 ± 7 years; median urine protein-creatinine, 2.5 mg/mg). Association of change in ABI with all-cause mortality was determined in 75 subjects with normal ABI (0.9 – 1.3) at baseline. Among 167 participants, 41% had an abnormal ABI: < 0.9, 18%; and > 1.3 or non-compressible arteries, 23%. Only individuals with low ABI had a significantly higher risk for all-cause mortality (hazards ratio (95% confidence interval), HR: 2.23 (1.07, 4.65)). In subjects with normal ABI at baseline with follow-up measurement (n = 75), vascular disease worsened in 39% over 23 ± 6 months: 17% had either a decrease in ABI by ≥ 0.1 or a final ABI < 0.9, and 21% had a final ABI > 1.3 or non-compressible arteries. Only individuals who had a decrease in ABI over time had a significantly higher risk for death (adjusted HR, 7.41 (1.63, 33.65)). Peripheral arterial disease is not uncommon and progresses rapidly in individuals with diabetes and proteinuria. Low or declining ABI is a strong predictor of all-cause mortality. Routine measurement of ABI is a simple bed-side procedure that may permit easy risk-stratification in diabetic CKD patients.
Highlights
Diabetes is the most common cause of nontraumatic amputation in the United States; this higher risk is, at least in part, secondary to a higher prevalence and severity of peripheral arterial disease in diabetics [1, 2, 3]
Peripheral arterial disease is common in diabetic chronic kidney disease (CKD) and is characterized either by abnormally low or high ankle-brachial index (ABI)
The problem is further accentuated in diabetics with chronic kidney disease (CKD), and both a reduction in glomerular filtration rate and albuminuria are associated with a higher likelihood of peripheral arterial disease [4, 5, 6, 7]
Summary
Diabetes is the most common cause of nontraumatic amputation in the United States; this higher risk is, at least in part, secondary to a higher prevalence and severity of peripheral arterial disease in diabetics [1, 2, 3]. Many diabetics have non-compressible arteries leading to an elevated ABI [22]; whether increase in ABI over time is associated with a higher risk for death has not been tested even in individuals without CKD. Closing these gaps in our knowledge is critical to validate. We undertook this study to test the following two hypotheses: in individuals with diabetes and proteinuria, 1) both low and high ABI are associated with a higher risk for death, and 2) both a decrease and an increase in ABI over time is associated with higher all-cause mortality
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