Abstract
Background: Patients on dialysis have an increased risk of peripheral arterial disease. This nationwide Danish cohort study describes the incidence of lower extremity amputation or revascularization in patients treated with dialysis and explores influence of diabetes mellitus and dialysis modality over time.
Methods: By individual-linkage between nationwide registries, risk of lower extremity amputation or revascularization was compared between two time periods and groups of patients treated with hemodialysis or peritoneal dialysis, with or without diabetes mellitus.
Results: We assessed risk of lower extremity amputation or revascularization in 75 419 patients with diabetes not on dialysis and 10 908 dialysis patients. Compared with the background population, hazard ratio for lower extremity amputation or revascularization associated with diabetes or treated with peritoneal dialysis without diabetes was equal, hazard ratio 12. Patients with diabetes on hemodialysis had hazard ratio 117(104-131) in the period 1997-2004 with lower hazard ratio in the later period, hazard ratio 68(60-77). For patients treated with hemodialysis with no diabetes, hazard ratio was not lower in the second time period; hazard ratio 15(13-18) vs hazard ratio 17(14-20). Hazard ratios of lower extremity amputation or revascularization were not significantly lower in patients with peritoneal dialysis and diabetes in the later period, hazard ratio 38(30-48) vs 30(23-37). For patients on hemodialysis with diabetes a lower hazard ratio was found in the later period. Patients without diabetes had almost the same risk of lower extremity amputation or revascularization over time. Patients on peritoneal dialysis had, compared to patients treated with hemodialysis, lower risk of lower extremity amputation or revascularization.
Conclusions: Patients on dialysis without diabetes had an equal or increased risk of lower extremity amputation or revascularization compared to patients with diabetes not on dialysis. Patients on dialysis with diabetes had higher risk compared to those without diabetes. Risk was higher in patients on hemodialysis compared to patients on peritoneal dialysis. Over time there was a trend towards decreased risk in dialysis patients with diabetes. The Danish programme for yearly evaluation of peripheral ischemia by podiatricians in patients with diabetes may be one of the reasons for the differences seen in risk reduction.