Systematic Review and Meta analysis of Outcomes of Lower Extremity Peripheral Arterial Interventions in Patients with and without Chronic Kidney Disease or End Stage Renal Disease.

OBJECTIVES: Patients with chronic kidney disease (CKD) present with a higher risk of peripheral arterial disease (PAD). While individual studies have documented the association between CKD/ESRD and adverse outcomes in patients undergoing PAD interventions in an era of technological advances in peripheral revascularization, the magnitude of the effect size is unknown. Therefore, we aimed to perform a meta-analysis comparing outcomes of PAD interventions in patients with CKD/ESRD to patients with normal renal function, stratified by intervention type (endovascular vs. surgical), reflecting contemporary practices METHODS: Five databases were analyzed from January-2000 to June-2019 for studies comparing outcomes of lower extremity PAD interventions in patients with CKD/ESRD vs normal renal function. We included both endovascular and open interventions, with indication being either claudication or critical limb ischemia. We analyzed pooled odds ratio (OR) across studies with 95% CI using random effects model. Funnel plot and exclusion sensitivity analyses were used for bias assessment.

RESULTS: Seventeen observational studies with 13,140 patients were included. All included studies except two accounted for unmeasured confounding either by a multivariable regression analysis or by case control matching. Maximum follow up was 114 months (range 0.5-114). Target lesion revascularization (TLR) was higher with CKD/ESRD compared to normal renal function (OR 1.68 (95% CI 1.25-2.27), P=.001). Major amputations (OR 1.97 (95% CI 1.37-2.83),P<.001) and long-term mortality (OR 2.28 (95% CI 1.45-3.58),P<.001) were higher with CKD/ESRD. Higher TLR rates with CKD/ESRD versus normal renal function were only seen with endovascular interventions but were not found to be different for surgical interventions. Statistically significant higher rates of major amputations and long-term mortality were seen with CKD/ESRD compared with normal renal function, regardless of the intervention type.

CONCLUSIONS: Patients with CKD/ESRD undergoing lower extremity PAD interventions have worse outcomes when compared to patients with normal renal function. When stratifying our analyses by endovascular versus open surgical interventions, higher rates of TLR for CKD/ESRD were only seen with endovascular, and not in open surgical approaches. Major amputations and all-cause mortality were higher with CKD/ESRD, irrespective of the indication. Evidence-based strategies to manage this at risk population in PAD are essential.