P1514PERIPHERIAL VASCULAR DISEASE IN DIABETIC PATIENTS ON HEMODIALYSIS - RISK OF HOSPITALIZATION AND MORTALITY IN A LARGE EUROPEAN COHORT
Authors: Brzosko Szymon , Drozdz Maciej , Frazao Joao , Kleophas Werner , Das Partha , Silva Fatima , Jacobson Stefan H 
Published: June 2020

Abstract

Background and Aims
Patients with diabetes mellitus on hemodialysis (HD) are at increased risk of development and progression of vascular calcification, atherosclerosis and peripheral vascular disease (PVD). Presence of PVD constitute a major risk factor for the development of cardiovascular events, such as myocardial infarction, stroke, hospitalization or cardiovascular death. The presence of PVD is also associated with a reduced quality of life and disability. A significant proportion of patients with PVD are asymptomatic with no or few classical symptoms and early detection to prevent progressive disease is therefore very important. Both the ACC/AHA and KDIGO guidelines recommend screening of individuals who are at risk.

Method
We analyzed the frequency of foot complications following implementation of a standardized foot examination in 345 prevalent diabetic hemodialysis patients in 12 DaVita centers; 8 in Poland (n=177 patients) and 4 in Portugal (n=168 patients). The protocol includes: history of ulcers, amputation and examination of the pedal pulses (a dorsalis pedis and a tibialis posterior). Foot complications were classified according to Wagner (grade 0-5). PVD was classified by clinical pulse measurement (normal vs weak or missing). We analyzed associations between foot complications and peripheral pulses with risk of hospitalization and mortality using Cox proportional hazard models.

Results
The mean age in all diabetic HD patients (58% men) was 70.4 (14 SD) yrs. Charlson comorbidity index (CCI) was 8.8 (2.4), Kt/V 1.8 (0.4), s-albumin 39 (4) g/L, Hb 11.1 (1.3) g/dL. A normal pulse in both a dorsalis pedis and both a tibialis posterior was found in 18% and 10% of patients. All other patients had weak or absent pulses. The Wagner classification score was 0 in 79% of patients, 1-3 in 16 % patients and 4-5 in 5 %. All-cause mortality was 31% during the 2 year follow up and 71% of patients had at least one hospital stay In patients hospitalized during follow up, a dors ped was normal/abnormal in 12% and 88% respectively (p&lt;0.05); a tib post was normal/abnormal in 8% and 92%, respectively (p&lt;0.05). There were no associations between Wagner score 0-5 and hospitalization or mortality. In unadjusted Cox models presence of weak or absent pulses in a dorsalis pedis was significantly associated with all-cause mortality RR 2.1 (CI 1.1-4.3; p&lt;0.05). In adjusted analyses including age, sex, Hb, albumin, Kt/V, vascular access, phosphorus, PTH and CCI, only albumin was associated with mortality (RR 0.89, CI 0.84-0.94; p&lt;0.001) and risk of hospitalization (RR 0.92, CI 0.89-0.96; p&lt;0.001).

Conclusion
Diabetic patients on HD have a high prevalence of PVD that warrant close clinical attention. Documentation of peripheral foot pulses for early detection of PVD is simple and suitable to identify patients at high risk of future complications and mortality. This standardized protocol could be the basis of a program to improve overall health outcomes in this vulnerable group of patients.