Critical limb ischaemia as a main cause of death in patients with end-stage renal disease: a single-centre study.

BACKGROUND Patients with end-stage renal disease (ESRD) have a high overall mortality rate, particularly due to cardiovascular morbidity. In an era of decline in cardiovascular diseases and early cardiovascular intervention, non-cardiac diseases seem to have a larger impact on overall mortality. METHODS From 1997 to 2003, all incident haemodialysis patients in a single centre were enrolled in this prospective study. Those with clinical signs of vascular disease were examined by coronary or peripheral angiographies. Physicians took the patients' medical histories, examined them and followed them up until the end of the study or death. Causes of death were defined by the physicians. RESULTS In all, 322 patients were enrolled in the study, 38% of whom were diabetic. At the start of dialysis treatment, 38% had coronary artery disease (CAD), defined as >50% stenosis of at least one coronary artery or as definite myocardial infarction, and 14% had critical ischaemia of at least one limb (CLI). In all patients with foot lesions, CLI was defined angiographically, as evidenced by stenosis or rarefication of distal vessels in the legs. Patients who died (n = 121) [due to cardiac causes (n = 25), complications of CLI (n = 22), stroke (n = 10), cachexia following a long-standing, non-malignant disease (n = 6), malignancy (n = 24), infection not related to CLI (n = 18) and other causes (n = 16)] were older (71+/-10 vs 65+/-13 years), more often male [74/121 (61%)] and often diabetic [56/121 (46%)]. CAD was documented in 82/121 (68%). Five-year survivals in patients with no risk and diabetes without CAD or CLI, CAD and CLI were 74%, 73%, 50% and 10%, respectively. Age, CLI and smoking habits independently increased the risk of death (hazard ratios: 1.052, 4.921 and 2.292, respectively). CONCLUSIONS These results indicate that CLI with associated complications is not only an indicator of high mortality in patients with ESRD, but is also one of the main causes of death.