MON-136 MANAGEMENT AND OUTCOMES OF LIMB-THREATENING ISCHAEMIA IN DIALYSIS-DEPENDENT PATIENTS: EXPERIENCE IN A LARGE NEW ZEALAND RENAL SERVICE

Abstract

Limb-threating ischaemia (LTI) is highly prevalent in dialysis patients worldwide and associated with high mortality and morbidity. Risk factors include diabetes, smoking and also kidney failure-associated factors such as diffuse medial vascular calcification. The rate of lower limb amputation in dialysis populations is 2-5% per annum. Current KDOQI guidelines for the management of peripheral vascular disease are extrapolated from studies in the general population, in whom primary revascularisation is recommended unless they have poor physical function or infection. This may not be the optimal approach for dialysis patients with a higher burden of diffuse vascular disease, catabolic state and complications. Aim: To compare outcomes in chronic dialysis patients receiving primary amputation (PA) versus primary revascularisation (PRV) for LTI at Waikato Hospital, New Zealand. This was a retrospective cohort study. Patients on chronic dialysis aged ≥18 years presenting with their first LTI episode (defined according to consensus guidelines) between 01/01/2008 to 31/12/2015 were included. Their outcomes were followed until 31/12/2017. We excluded patients with previous treatment for peripheral vascular disease prior to the study period, patients managed conservatively, patients declining or deferring amputation, admissions with simultaneous bilateral lower limb ischaemia, non-ischaemic ulcers, and calciphylaxis. Data collected included baseline demographics, cause of end-stage kidney disease (ESKD), co-morbidities, dialysis characteristics and body-mass index. We recorded data on the index admission with LTI, concurrent infection, imaging, treatment(s) and readmissions. Outcomes included major adverse limb events (MALE), patient survival and hospital length of stay. 41 index admissions were identified with 40 patients in total. Patient characteristics were as follows: mean age-60.9 years, Male-61%, Maori-80.5%, diabetic nephropathy as cause of ESKD-85.43%, mean dialysis vintage-34.2 months, dialysis modality-HD-73.2% and PD-26.8%, mean comorbidity index score-7.0, mean BMI-31.2 kg/m2 and mean PTH-68.2 pmol/L. There were 23 PRVs and 18 PAs. After accounting for patient survival, there were 8 index admissions with >1 MALE/year in the PRV group and 1 index admission in the PA group with >1 MALE/year. Median survival was 11.7 months in the PRV group versus 21.4 months in the PA group. Median length of stay for the index admission was 14.9 days in the PRV group versus 17.3 days in the PA group. Early amputation is associated with lower MALE and mortality but increased hospital length of stay, in dialysis dependent patients presenting with limb-threatening ischemia. Larger, prospective observational studies are needed to confirm this association and help develop future guidelines.