The Effects Of Uncontrolled Diabetes And Dialysis Dependence On Revascularization For CLTI
Carly G. Sobol, Lauren L. Taylor, Victor K. Heh, PhD, Timur P. Sarac, MD, Mounir J. Haurani, MD, Michael R. Go, MD.
The Ohio State University College of Medicine, Columbus, OH, USA.
Objective: Diabetes (DM) and chronic kidney disease (CKD) both adversely affect outcomes of chronic limb threatening ischemia (CLTI). However, conflicting data exist on the relationship between degree of DM or CKD and CLTI outcomes, and some patients with uncontrolled DM (SVS grade 3) or dialysis dependence (SVS grade 5) may be denied revascularization for fear of worse outcomes compared to in lesser degrees of DM or CKD. We compared revascularization outcomes in patients with uncontrolled versus controlled DM, and in dialysis dependence versus non-dialysis-dependent CKD.
Methods: Data from 2013-2019, including demographics, comorbidities categorized per SVS reporting standards, and clinical outcomes was collected retrospectively from our multidisciplinary limb salvage center. T and chi-square tested differences between groups. Product-limit Kaplan-Meier estimated survival functions.Results:223 limbs in 198 patients had limb salvage attempts, 78% endo and 22% open. 173 patients were diabetic; 90 of these had uncontrolled DM/type 1 DM. There were no differences in rates of severe cardiovascular disease or WIfI stage between the controlled and uncontrolled DM groups. There were no differences in survival, patency, healing, or limb salvage between the two groups. Two- and five-year survival in the controlled DM group was 80.8% and 68.8%, and in the uncontrolled DM group was 79.7% and 62.4% (P=0.6384). Two- and five-year limb salvage in the controlled DM group was 88.3% and 86.0%, and in the uncontrolled DM group was 85.6% and 81.6% (P=0.3596).
212 patients had CKD; 42 of these had dialysis dependence. There were no differences in rates of severe cardiovascular disease or WIfI stage between the non-dialysis CKD and dialysis CKD groups. Dialysis patients had statistically significant decreases in survival and limb salvage compared to non-dialysis-dependent CKD patients. Two- and five-year survival in the non-dialysis CKD group was 83.9% and 69.8%, and in the dialysis group was 76.7% and 51.2% (P=0.0445). Two- and five-year limb salvage in the non-dialysis CKD group was 91.1% and 91.1%, and in the dialysis group was 75.9% and 61.1% (P=0.0013).
Conclusions: Patients with uncontrolled DM do not have worse outcomes than patients with lesser degrees of DM and should not be denied revascularization based solely upon their degree of DM. However, dialysis patients have worse outcomes compared to non-dialysis CKD patients, and caution is advised when offering them revascularization.
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