Prevalence of peripheral arterial disease in end stage renal disease patients undergoing hemodialysis: A cross-sectional study

Abstract

The chronic renal disease is a principle common medical dilemma in Iraq. Peripheral arterial disease (PAD) is a prevalent infirmity in the hemodialysis people. The aim of present study was to estimate the prevalence of PAD in subjects with end-stage renal disease (ESRD). This cross-sectional study was done between January 2016 and May 2017 on ESRD subjects regularly attending renal dialysis unit in Al-Kindy teaching hospital in Baghdad, Iraq. PAD was diagnosed on the base of the ankle-brachial index (ABI) measured by using a hand-held Doppler ultrasound. Subjects with ABI =0.9 were supposed positive for PAD. A total of 150 ESRD cases were analyzed. The mean age of the subject was 49.52 15 years. Majority of them were males 87(58%). Most of the subjects were hypertensive 100(66.6%), while 39(26%) were diabetic. PAD was present in 79(52.7%) of cases. Intermittent claudication was the main manifestation in patients with PAD 57(72.15%) and only 3(3.8%) of the patients end with an amputation. The study revealed that only older age was significantly and individually linked with PAD, while additional determinants such as male gender, smoking, positive virology, hypertension, diabetes mellitus, hyperlipidemia, and IHD were not significant. We conclude that PAD prevalence is high among subjects with ESRD undergoing hemodialysis. The ABI should be routinely calculated for subjects with ESRD on usual hemodialysis.

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ORIGINAL ARTICLE
474 P J M H S Vol. 12, NO. 1, JAN – MAR 2018
Prevalence of Peripheral Arterial Disease in End Stage Renal
Disease Patients Undergoing Hemodialysis: A Cross-Sectional
Study
HAIDER RAHEEM NEAMAH1, QAYS AHMED HASSAN2, HARITH MOHAMED KAMBER3
ABSTRACT
The chronic renal disease is a principle common medical dilemma in Iraq. Peripheral arterial disease
(PAD) is a prevalent infirmity in the hemodialysis people. The aim of present study was to estimate the
prevalence of PAD in subjects with end-stage renal disease (ESRD). This cross-sectional study was
done between January 2016 and May 2017 on ESRD subjects regularly attending renal dialysis unit in
Al-Kindy teaching hospital in Baghdad, Iraq. PAD was diagnosed on the base of the ankle-brachial
index (ABI) measured by using a hand-held Doppler ultrasound. Subjects with ABI ≤0.9 were
supposed positive for PAD. A total of 150 ESRD cases were analyzed. The mean age of the subject
was 49.52±15 years. Majority of them were males 87(58%). Most of the subjects were hypertensive
100(66.6%), while 39(26%) were diabetic. PAD was present in 79(52.7%) of cases. Intermittent
claudication was the main manifestation in patients with PAD 57(72.15%) and only 3(3.8%) of the
patients end with an amputation. The study revealed that only older age was significantly and
individually linked with PAD, while additional determinants such as male gender, smoking, positive
virology, hypertension, diabetes mellitus, hyperlipidemia, and IHD were not significant. We conclude
that PAD prevalence is high among subjects with ESRD undergoing hemodialysis. The ABI should be
routinely calculated for subjects with ESRD on usual hemodialysis.
Keywords: PAD, ESRD, ABI, chronic kidney disease.
INTRODUCTION
Subjects with chronic kidney disease (CKD)
undergoing hemodialysis have large degrees of lower
limb atherosclerosis, where the prevalence of
peripheral artery disease (PAD) fluctuates from 16.6
to 38.5%, opposed to 4.4 to 29% in the overall
population1,2. Subjects with CKD are extremely
predisposed to exhibiting hastened atherosclerosis,
even in the lack of specific classical cardiovascular
hazard factors. Oftentimes those subjects not only
present traditional hazard factors such as
hypertension, diabetes, or dyslipidemia, but also
other non-traditional factors such as inflammation,
malnutrition, and oxidative tension, which excite and
expand atherosclerosis3-6. Although the association
between myocardial infarction, stroke, and
cardiovascular death with renal dysfunction is well
authorized, there are few data on the prevalence of
PAD in the lower extremities in subjects with CKD7.
---------------------------------------------------------------------
1Lecturer, Section of Cardiovascular Surgery, Department
of Surgery, Al-Kindy College of Medicine, University of
Baghdad, Iraq.
2Assistant professor, Section of Radiology, Department of
Surgery, Al-Kindy College of Medicine, University of
Baghdad, Iraq.
3Lecturer, Section of Urology, Department of Surgery, Al-
Kindy College of Medicine, University of Baghdad,
Correspondence to Dr. Qays Ahmed Hassan E-mail:
qtimeme@yahoo.com, Cell phone: 9647722604163
The common characteristic manifestation of
PAD is intermittent claudication. Rest pain, tissue
loss, and gangrene are among the more extreme
presentations of PAD and it has been a major cause
of lower limb amputation, especially in those with
diabetes8.
Ankle-brachial index (ABI) is a noninvasive
diagnostic test that is simple to do, relevant, and
effective in identifying subclinical PAD. It has also
been proved to be a powerful predictor of
cardiovascular morbidity and death. An ABI<0.9 is
95% sensitive and 100% specific for angiographically
diagnosed PAD for arterial stenosis≥50% in the lower
limbs9,10.
The immediate discovery of PAD recognizes a
gathering of cases who would benefit from vigorous
cardiovascular hazard factor correction and limit the
unfavorable consequences such as pain rest pain, a
danger of tissue necrosis, and also amputation of
legs7-9.
Many researchers have been investigated the
prevalence of PAD in the hemodialysis people.
Nevertheless, no before-mentioned work had been
carried out in Iraq. So we achieved the present study
with an aim to estimate the prevalence of PAD in
end-stage renal disease (ESRD) subjects on
hemodialysis from middle Baghdad.

Haider Raheem Neamah, Qays Ahmed Hassan, Harith Mohamed Kamber
P J M H S Vol. 12, NO. 1, JAN – MAR 2018 475
PATIENTS AND METHODS
This hospital-based cross-sectional study was
conducted at Hemodialysis Unit of Alkindy Teaching
Hospital from January 2016 to May 2017, where 150
cases of hemodialysis subjects were prospectively
investigated. Approval of the regional ethical and
scientific boards was taken before study start.
Consents were gathered from all subjects entered in
this study. Data were assembled applying a
questionnaire sheet and were filled by a close
conversation with subjects. The systolic blood
pressure (SBP) in the posterior tibial artery or
dorsalis pedis artery was recorded and next divided
by the SBP in the brachial artery from the upper limb
to determine the ABI. ABI was measured by using a
hand-held Doppler ultrasound with an appropriately
sized sphygmomanometer cuff for each subject.
Subjects with ABI ≤0.9 was regarded positive for
PAD.
Data were inserted into the statistical package of
social science (SPSS) program version 24 where
descriptive statistics were presented in form of
percentages and tables. For analytic statistics, Chi-
square test was applied to determine if there was any
relationship between ABI groups with specific data
(age, gender, duration of dialysis, smoking,
hypertension, diabetes mellitus, hyperlipidemia, virus,
stroke and ischemic heart disease) where if P-value
< 0.05 was regarded as an important association.
RESULTS
This study reveals that 58% (87) of subjects with
ESRD were males, the mean age of the subjects was
49.52 ± 15, 39.3% (59) were smokers, 66.6% (100)
were hypertensive, 26% (39) were diabetic, 33.3%
(50) of the subjects had coronary artery disease and
13.3% (20) had cerebrovascular disease. The mean
of SBP was 140.53 ± 30.2, the mean of diastolic
blood pressure (DBP) was 77.6± 18 and the pulse
pressure (PP) was 62.9± 27 (Table 1).
The results show that the PAD was diagnosed in
52.7% (79) of subjects, whose manifestations were
mainly intermittent claudication 72.15% (57) and only
3.8% (3) of the cases end with an amputation.
The results show that the mean of ABI of subjects
with PAD was 0.73± 0.13. The discrepancy in the
rate of males in subjects with PAD and without PAD
was not statistically important (P=0.952). The
subject's mean age with PAD was higher significantly
than those without PAD (P=0.038) (Table 2).
PAD prevalence was higher among subjects
with a history of smoking, hypertension, diabetes
mellitus, hyperlipidemia, positive virology, IHD, and
stroke. But all these variables showed no significant
association with PAD as summarized in Table 3.
Table 1. Social and morbidity data of the study sample
(n=150)
Social/morbidity factor
n
Sex: males
87 (58)
Age: years
49.52 ± 15
Diabetes
39 (26)
Hypertension
100 (66.75)
Smoking
59 (39.3)
Coronary heart disease
50 (33.3)
Cerebrovascular disease
20 (13.3)
Hyperlipidemia
27 (18)
Positive virology
78 (52)
SBP mm Hg
140.53 ± 30.2
DBP mm Hg
77.6 ± 18
PP mm Hg
62.9 ± 27
Table 2: Demographic features of subjects with & without
the diagnosis of PAD
Variable
PAD Present
(ABI ≤ 0.9)
(n=79)
PAD Absent
(ABI>0.9)
(n=71)
P value
Age (years)
51.9 ± 13.6
46.8 ± 16
0.038
Male
46(52.9%)
41(47.1%)
0.952
Table 3. Comparison of clinical aspects of subjects with
and without the diagnosis of PAD
Variables
PAD
Present
(ABI ≤ 0.9)
(n=79)
PAD
Absent
(ABI > 0.9)
(n=71)
P
value
Smoking
35(59.3%)
24(33.8%)
0.189
Positive virology
44(56.4%)
34(47.8%)
0.339
Diabetes
mellitus
21(26.6%)
18(25.3%)
0.864
Hypertension
52(65.8%)
48(67.6%)
0.817
Hyperlipidemia
16(20.2%)
11(15.5%)
0.449
IHD
28(35.4%)
22(30.9%)
0.563
Stroke
10(12.6%)
10(14%)
0.798
Claudication
57(72.1%)
5(7%)
0.000
Amputation
3(3.8%)
1(1.4%)
0.365
SBP mm Hg
141.6 ± 29.1
139.3± 31.6
0.636
DBP mm Hg
77.8 ± 19.3
77.3 ± 16.6
0.860
PP mm Hg
63.8 ± 28.1
61.9 ± 25.9
0.681
Duration of
dialysis (y)
2.12 ± 1.24
2.18 ± 1.99
0.863
DISCUSSION
Various worldwide studies had achieved including a
varied prevalence of PAD in the hemodialysis people.
However, the present research work is the primary of
its sort in Iraq, to assess the prevalence of PAD in
the hemodialysis subjects applying ABI. PAD serves
a pointer to a poor prognosis in the hemodialysis
subjects and may assist to distinguish a group at an
extremely great danger that may profit from

Prevalence of Peripheral Arterial Disease in End Stage Renal Disease Patients Undergoing Hemodialysis
476 P J M H S Vol. 12, NO. 1, JAN – MAR 2018
advancing curative interference11. There have been
very few studies investigating PAD risk factors
among patients with ESRD12. The appearance of
PAD really raises the chance of both morbidity
(chronic ischemic ulceration, gangrene, and
amputation) and mortality between ESRD
subjects13,14.
The present study showed that the PAD
prevalence among ESRD subjects undergoing
regular hemodialysis was 52.7%. O'Hare and
Johansen15 noted that PAD is more prevalent among
subjects with ESRD than in the overall community.
Prevalence rates vary from 17 to 48%, depending on
the ESRD group analyzed and the distinguishing
techniques employed. Lim et al16 wrote that the most
popular manifestation of PAD is intermittent
claudication, and these findings are agreeing with this
study since the intermittent claudication prevalence
among PAD subjects was (72.15%) (57 out of 79).
The results of this study revealed that PAD
prevalence was significantly higher in subjects with
intermittent claudication and in subjects with old age.
PAD is often noted in old age subjects in overall
community17. Yet, in hemodialysis subjects; also
youngest can have a big prevalence of PAD due to
uremia effects and dialysis-associated determinants.
However, the present study revealed the prevalence
of PAD remaining higher in elderly subjects. The
cause for not seeing youthful subjects with PAD in
this study may be attributed to that the bulk of our
cases were of old age i.e. age > 40 years and held in
hemodialysis for longer than a two-year continuation.
The popular concept is that PAD is frequent in men in
the general community18-20. The aforementioned
concept was kept also in the present research.
Though, the constant relationship of male sex with
PAD in ESRD people is yet unexplained.
On the other hand, PAD prevalence was not
differing significantly according to diabetes,
hypertension, IHD, stroke, SBP, DBP, BP,
hyperlipidemia, amputation, duration of the dialysis
(year), the presence of the virus, and gender. Selvin
et al21 declared that the most conventional hazard
determinants for atherosclerosis (e.g. old age,
smoking, and diabetes mellitus) are well correlated
with PAD, but the perception of determinants exactly
leading to the evolution of PAD and its sequence in
ESRD subjects is remained actually poor. These
findings were in agreement with this study according
to the age but different according to diabetes and
smoking since there was no strong association
between PAD and diabetes/smoking in the present
study.
Lim et al16 highlighted that PAD is a growing and
frequent under-diagnosed health dilemma. Evaluation
of the PAD prevalence is an essential concern for
estimating health demands and organizing health
settings.
CONCLUSION
Peripheral arterial disease prevalence is high among
subjects with end-stage kidney disease sustaining
hemodialysis. Patient's older age is a risk
determinant for the peripheral arterial disease. The
ankle-brachial index should be routinely estimated for
subjects with end-stage kidney disease on usual
hemodialysis.
Acknowledgments: We would desire to appreciate
all occupants of the Department of Radiology and all
the sufferers and treating teams of Nephrology
Department who were instantly included in this work.
Funding source: none
Conflict of interest: The authors declare that they
have no conflict of interest.
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