LAUSR

While many guidelines do not specifically identify chronic kidney disease (CKD) as a risk factor for peripheral arterial disease (PAD), the incidence of PAD is higher in patients with CKD. PAD is also an independent risk factor for increased cardiovascular disease mortality and morbidity and limb amputation, in patients with CKD. In this issue of Catheterization and Cardiovascular Interventions, Kabir et al. report clinical outcomes of patients with and without CKD undergoing infrainguinal endovascular revascularization from the multicenter XLPAD registry, which included 3699 patients from 2005 to 2018. Patient's with CKD had a higher incidence of hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease, prior stroke, and heart failure. This finding is not surprising given many of those are risk factors for the development of CKD. The CKD cohort had significantly longer lesion length with greater calcification, and more commonly involved below-the-knee disease compared to non-CKD patients. While this increased disease burden did not affect the technical success of the procedure, patient's with CKD had higher limb amputation at 12-months without difference in target vessel revascularization. Additionally patient's with CKD had significantly lower 12-month survival compared to nonCKD patients. We congratulate the authors on their study which corroborate with previous literature on the negative impact of CKD on PAD outcomes. We see several areas for improvement in the treatment of this patient population. One should screen vigilantly for PAD in CKD patients, for both typical and atypical symptoms. Perhaps early detection in this population would allow for early aggressive risk modification, and initiation of pharmaceutical and endovascular therapies. Additionally, one should realize the limitations of the ankle-brachial index (ABI) is patients with CKD, as the presence of arterial calcification makes the test less reliable. In patients with CKD and high clinical suspicion for PAD, we use the toe-brachial index or arterial duplex ultrasound. Despite the high prevalence of PAD and critical limb ischemia in the CKD patient population, studies suggest that patients with CKD may be offered fewer revascularization procedures than patients without CKD. One reason for this may be concern for contrastinduced nephropathy. Use of carbon dioxide arteriography, or an antegrade study from the common femoral artery, for patient's with distal disease, selectively imaging the tibial may help to provide the same result while minimizing contrast exposure. The poor microvasculature circulation of patient's with CKD is one contributing cause for the higher mortality and limb amputation seen in patient's with CKD despite there being no difference in procedural success and TVR rates between CKD and non-CKD patients. Patient's with CKD have increased inflammation, oxidative stress and uremic toxins, and decreased proangiogenic factors. This is an area in need of further investigation. Lastly, multidisciplinary efforts to improve access to preventive foot care and to identifying those at greatest risk for limb loss may be beneficial. A comprehensive program for diabetes care delivered in the dialysis unit that included foot care was effective at lowering the incidence of PAD and amputation-related admissions. Received: 15 June 2021 Accepted: 18 June 2021