The impact of chronic kidney disease on lower extremity bypass outcomes in patients with critical limb ischemia

Objective: Patient selection for open lower extremity revascularization in patients with chronic kidney disease (CKD) remains a clinical challenge. This study investigates the impact of CKD on early graft failure, postoperative complications, and mortality in patients undergoing lower extremity bypass for critical limb ischemia. Methods: The National Surgical Quality Improvement Program database was queried for all patients with critical limb ischemia from 2012 to 2015whounderwent lower extremity bypass using the targeted vascular set. The glomerular filtration rate was calculated using the Chronic Kidney Disease Epidemiology Collaboration Study equation. CKD categories were determined from the National Kidney Foundation Kidney DiseaseOutcomesQuality Initiative staging criteria. Patients were classified into three groups: CKD stages 3 or lower (mild to moderate CKD), CKD stages 4 or 5 (severe CKD), and on hemodialysis (HD). Multiple variable analysis was used to examine graft failure, mortality, and postoperative complications. Results: The Surgical Quality Improvement Program database identified 6978 patients who underwent infrainguinal lower extremity arterial bypass during the study period. There were 6101 patients (87.4%) with mild to moderate CKD, 327 (4.7%) with severe CKD, and 550 (7.9%) on HD. Patients with severe CKD and on HD were more likely to have revascularization for tissue loss (54.9% vs 68.8% and 74.7%; P <.01). Patients with severe CKD and those on HD had higher rates of early graft failure, postoperative myocardial infarction, and rates of reoperation. Multiple variable analysis confirmed these results showing that HD was associated with postoperative myocardial infarction, readmission, and increased mortality. It also demonstrated that severe CKD was associated with graft failure (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.12- 2.50; P =.01), postoperative myocardial infarction (OR, 2.16; 95% CI, 1.35- 3.45; P <.01), and readmission (OR, 1.38; 95% CI, 1.06- 1.80; P =.02). Other factors associated with graft failure include functional status (OR, 1.39; 95% CI, 1.08- 1.80; P =.01), African American race (OR, 1.72; 95% CI, 1.39- 2.13; P <.01), and distal bypass (OR, 1.33; 95% CI, 1.09- 1.61; P <.01). Conclusions: CKD is a significant predictor of perioperative morbidity after lower extremity bypass. Patients with severe CKD have worse postoperative outcomes without increased mortality. Those on HD have worse survival and postoperative outcomes.