Percutaneous transluminal angioplasty is feasible and effective in patients on chronic dialysis with severe peripheral artery disease.

BACKGROUND: Peripheral arterial disease (PAD) is common among patients on chronic dialysis. Despite severe clinical manifestations, the indication for bypass surgery is controversial, because of the high morbidity and mortality rate of these patients. The less invasive percutaneous transluminal angioplasty (PTA) is a possible alternative, but data about PTA in dialysis patients are scarce. METHODS: We followed 107 dialysis patients (mean age 67+/-10, 75 males) with 132 ischaemic limbs (97% with critical limb ischaemia and ischaemic foot lesions or rest pain) consecutively treated by PTA. RESULTS: PTA was successful in 97% of cases. Median follow-up was 22 months. Cumulative limb salvage rates at 12, 24, 36 and 48 months were 86, 84, 84 and 62%, respectively. Log-rank test showed an association between major amputation and baseline presence of foot lesions (P=0.04). This association was confirmed by a Cox survival multivariate analysis [hazard ratio (HR)=7.03, 95% confidence interval (CI)=1.1-43.0, P=0.035]. Limb salvage without any new intervention on the same leg was achieved in 70% of the cases, and was associated with the absence of diabetes mellitus (P=0.01), lower number of treated lesions (P=0.04) and proximal level (iliac and/or femoro-popliteal) of PTA (P<0.001). Independent predictors were diabetes mellitus (HR=3.47, 95% CI=1.31-9.17, P=0.01) and proximal PTA (HR=0.28, 95% CI=0.08-0.94, P=0.04). Fifty-three (49%) patients died during follow-up. Patients older than 67 years (the median value in our sample) had a 2.4-fold increase in mortality risk (95% CI=1.4-4.1, P<0.001). CONCLUSIONS: PTA is feasible and effective in dialysis patients with PAD, and should be preferred to other more invasive interventions.

Effects of a vitamin E-bonded membrane and of glutathione on anemia and erythropoietin requirements in hemodialysis patients.

BACKGROUND: The oxidative damage of RBC membranes in hemodialysis (HD) patients increases red blood cell (RBC) susceptibility to hemolysis and impairs cell survival. Reduction of the oxidative stress might lead to better control of anemia and reduction of the erythropoietin (rhEPO) dose. METHODS: We studied 38 stable HD patients, given a mean dose of rhEPO of 104+/-65 U/kg BW/week, at baseline and during antioxidant treatment with either a full or a 50% dose of EPO. Antioxidant treatment involved the combined use of glutathione, GSH (1200 mg i.v. at the end of each dialysis session) and a vitamin E-bonded HD membrane, CL-E. RBC and reticulocyte counts were done monthly. RBC survival (51Cr T/2) was assayed in 18 patients before and after the end of the study. Oxidative status was determined in 10 patients by measuring plasma concentrations of malondyhaldeide-4-hydroxynonenal (MDA-4HNE), reactive oxygen molecular species (ROMs), and oxydized-LDL (oxLDL) as indices of oxidative stress, alpha-tocopherol and total thiols as single antioxidants, and TAS as a marker of total antioxidant plasma activity. RESULTS: Antioxidant treatment significantly reduced the high basal plasma concentrations of MDA4HNE and oxLDL, and significantly increased those of alpha-tocopherol, whereas TAS and thiols were unmodified. These changes lasted after the reduction of EPO. Anemia significantly improved with treatment, due to a significant increase in RBC survival. A close direct linear relationship was detected between plasma levels of vitamin E and hemoglobin. CONCLUSIONS: Adequate control of oxidative stress achieves better control of anemia in HD patients. Since several antioxidant systems are impaired in uremia, the combined use of the CL-E membrane and GSH seems to be the best antioxidant therapy so far, with significant saving of the rhEPO dose.