5. A 45-year-old CKD 5 secondary to diabetic nephropathy received a suitable kidney offer from his brother. He gives a history of calf intermittent claudication after 20 yards. Clinical examination revealed good femoral pulses on both sides, but absent distal pulses.
- How do you manage this case?
Patients with strong symptoms of peripheral arterial disease should be evaluated with a clinical examination in search of the presence of ulcers that must be resolved before transplantation.
Subsequently, performing a non-invasive vascular examination such as arterial Doppler USG is mandatory. In the case of alterations, CT of the abdomen and pelvis should be performed for a better assessment of arterial calcification for planning the surgical procedure, but who knows, maybe indicate intervention through arteriography that should be evaluated by a vascular surgeon.
Patient is at high risk factors for
Peripheral vascular disease and CVD
by hx :
DM , CKD5 on RHD and Intermittent claudications and absent distal pulses :
For PVD :
Duplex on both LLs and iliac vessels if he is not on hemodialysis or the gold standard is to do ( if he was on RHD ) :
CT Angiography on both arteries and veins of Iliac vessels and the both lower limbs in addition to CT abdomen without contrast to detect the degree of arterial calcifications.
And early intervenstion ( angioplasty if needed before kidney transplantation ) .
For Cardiac risk :
This patient is at higher risk for coronary vascular disease as he has (DM , Peripheral vascular disease , CKD5 )
So non-invasive tests for coronary vessels will no to be ideal for this patient like (Myocardial perfusion imaging with exercise –ECHO with exercise –ECHO with dobutamine –CT coronary Angiography )
The best option is coronary angiography to detect if he needs more intervention or not ( Angioplasty with stenting or bypass surgery )
Ref :
Kirk A (2014) Textbook of organ transplantation. Wiley Blackwell, Chichester
.
Mobley CM, Pelletier SJ (2010) Chapter 30. Renal transplantation. In: Minter RM, Doherty GM (eds) Current procedures: surgery. The McGraw-Hill Companies, New York
How do you manage this case?
45 year old patient with diabetic nephropathy with a history and clinical examination of distal peripheral artery disease and according to guidelines, Tx surgery should be postponed till medical management of PVD
PVD is common in ESKD patients especially in diabetics , heavy smokers , and CKD-MBD .
Investigations such as, Ankle brachial index , duplex ultrasonography.and proper evaluation by a vascular surgeon as well as arteriography which is the gold standard .
Management may include angioplasty or even surgical intervention
As well as antiplatelet medications and statins
In view of calf claudication, DM and ESRD, potential recipient require cardiovascular and PVD evaluation
Cardiovascular evaluation:
PVD evaluation:
Pre-operative management:
This patient is diabetic and ckd with sings of peripheral vascular disease (intermittent claudication ,so he may need CT angiogram for abdominal and lower limb vessels to know the outcome of graft perfusion before the transplant
The patient has history of claudication , which is the symptom of peripheral artery disease.
The patient has CKD and he is diabetic, so he is at a high risk for peripheral artery disease.
workup for detection include calculation of the ankle-brachial index,aortoiliac Doppler Ultasound and non-contrast CT of the abdomen and pelvis to assess arterial calcification.
High-grade of aorto-iliac calcific stenosis is a contraindication for allograft transplantation in the ipsilateral iliac fossa, if the patient had previous aorto-iliac intervention with iliac artery stent insertion and the length of soft artery is too short to permit anastomosis.
PVD is associated with high risk of graft loss and high risk for amputation and patient mortality post transplantation
Ø Vascular surgeon involvement is crucial since this patient carries a high risk for Peripheral vascular disease (which is an important cause of allograft ischemia).
Ø His risk factors:
· Gender: male
· Age >50
· DM
· +ve history (intermittent claudication) and
· +ve clinical finding absent distal pulses.
o *Males, diabetics, patients with hypertension, lipid abnormalities, a history of vascular disease elsewhere, and cigarette smoking are at higher risk for peripheral vascular disease.
Ø So Doppler U/S and ABI will not be enough for Peripheral vascular disease assessment: he need non-invasive evaluation of the peripheral vasculature, preferably noncontract CT of the pelvic vasculature. Angiography should be considered if non-invasive studies suggest the presence of large-vessel disease.
Ø If he had significant aortoiliac disease may require intra-abdominal reconstructive arterial surgery and transplantation may be contraindicated.
Ø Medical management should start by aspirin, statin and other medications according to severity.
3. Vascular Evaluation regarding vascular evaluation, practice varies among transplant centers. some transplant centers routinely ask only for an aortoiliac Doppler ultrasound and calculate the ankle-brachial index (ABI), while others screen first with a non-contrast CT of the abdomen/pelvis to assess iliac calcification and a follow-up Doppler ultrasound if there are concerns about flow. Furthermore, recent data suggest that computed tomography angiography (CTA) and magnetic resonance angiography (MRA) become the most sensitive and informative methods for the PAD assessment (3). Arteriography is still considered the gold standard for diagnostic evaluation of PAD which still remains necessary in selected cases (1,2). Back to our case, this patient had a history of muscle claudication which is mostly related to peripheral vascular disease which should be evaluated properly by CT angiography with contrast on abdominal pelvic and lower limb vessels or MRA after referral to vascular and she may need arteriography.
References
1. Tang GL, Chin J, Kibbe MR Advances in diagnostic imaging for peripheral arterial disease. Expert Rev CardiovascTher (2010) 8(10): 1447- 1455.
2. Owen AR, Roditi GH Peripheral arterial disease: the evolving role of non-invasive imaging. Postgrad Med J (2011) 87(1025): 189-198.
3. Ota H, Takase K, Igarashi K, Chiba Y, Haga K, et al MDCT compared with digital subtraction angiography for assessment of lower ex tremity arterial occlusive disease: importance of reviewing cross-sec tional images. AJR Am J Roentgenol . (2004)182(1): 201-209.
Possibly patient has PVD. We can start by non-invasive tests to conform diagnosis, including a Doppler ultrasound of arteries of upper and lower limbs. Aortoiliac disease may be related; the patient is diabetic, has ESRD, and activity is limited to small efforts ;walking twenty yards. So, kidney transplantation is relatively contraindicated.
A multidisciplinary approach is needed for choice of more invasive diagnostic angiography methods for assessment the extent of PVD as well as metabolic control of diabetes, blood pressure, and risk factors like smoking and dyslipidemia.
Statins, anticoagulation / antiplatelet medications, monitored exercises, and other medications optimization of fitness for surgery.
Cardiovascular events need special attention and care ;being the most common cause for mortality.
This patient with history of diabetes and ESKD is at risk of peripheral vascular disease. His claudication shows PVD and needs to evaluate by doppler ultrasonography, assessment of ankle-brachial index and performing CT angiography. There is increased risk for CVD that necessitates its evaluation by EKG, echocardiography and stress test. He should have good control of diabetes and blood pressure, have ideal body weight, no smoking, adequate dialysis and normal product for calcium and phosphate. He should receive proper treatment for PVD such as angioplasty or medications.
This patient should be evaluated by vascular surgeon. Vascular assessment should begin with Doppler ultrasound and accordingly, CT angiography/MRA may be required with possible vascular intervention. A significant disease of peripheral vasculatures including iliac vessels might make transplant surgery difficult or impossible and can aggravate distal leg ischemia due to vascular steal syndrome.
Dudley C, Harden P (2010) Clinical Practice Guidelines, Assessment of the Potential Kidney Transplant Recipient.
How do you manage this case?
· This index case has history of claudication pain and his examination showed absent distal pulses on a back ground of diabetic kidney disease. Accordingly, his symptoms and signs are suggestive of peripheral arterial disease (PVD).
· He requires full assessment with a vascular surgeon as part of the multidiscipline team to reduce the risks of infection and graft failure and determine their suitability for transplantation.
· Diagnostic tests include ankle-brachial index (ABI <0.9 suggests PAD), pelvic X ray to detect vascular calcifications, ultrasound Doppler of the lower limbs and CTA. Additionally, full cardiac assessment is required as PVD is CAD risk equivalent.
· Medical management includes wound care, control of risk factors, involvement in structured exercise programs , blood pressure, diabetes and hypercholesterolemia management. Using anti-platelets(aspirin or clopidogrel), Cilostazol (a phosphodiesterase inhibitor) and control of calcium and phosphate levels.
· Revascularization therapies improve amputation-free survival and chronic limb-threatening ischemia. Options include angioplasty and stenting or bypass surgery. Treatment should be individualized according to the patient preferences, surgeon decision and expected outcomes based on the extent of vascular disease and its severity, the presence of collateral circulation and the risk benefit evaluation.
· References:
1. KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation. Transplantation. April 2020;Volume 104 ,Number 4S.
2. Hernández D, Vázquez T, Armas-Padrón AM, et al. Peripheral Vascular Disease and Kidney Transplant Outcomes: Rethinking an Important Ongoing Complication. Transplantation. 2021 Jun 1;105(6):1188-1202
Thios 45 year old diabetic ESRD male with intact femoral pulses and absent distal pulses:
The patient can proceed for kidney transplant, if
Chadban SJ, Ahn C, Axelrod DA, Foster BJ, Kasiske BL, Kher V, Kumar D, Oberbauer R, Pascual J, Pilmore HL, Rodrigue JR, Segev DL, Sheerin NS, Tinckam KJ, Wong G, Knoll GA. KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation. Transplantation. 2020 Apr;104(4S1 Suppl 1):S11-S103. doi: 10.1097/TP.0000000000003136. PMID: 32301874.
Explore patient compliant to diabetic medications, diet control, life style modification, modifiable risk factors such as smoking.
Optimizing diabetic control to prevent other target organ damage eg diabetic retinopathy, peripheral neuropathy.
screen for associated comorbid for diabetes mellitus mainly cardiovascular disorder.
Once sugar under perfect control may allow to proceed with kidney transplant.
45 Y old Male, DM, ESRD, Ischemic lower limb pains, intact femoral pulses and absent distal pulses.
This patient has bad peripheral vascular disease and is a very high risk of ischemic heart disease as well.
I WILNOT PROCEED FOR KIDNEY TRANPSLANTATION NOW.
1- He needs proper assessment by the vascular team via CT- angiography of aorto-iliac and both lower limbs to find out how extensive is the calcification and stenosis.
I think he might need angioplasty and stenting if possible. If angioplasty is not amenable, he will need medical treatment (statins, anti-platelets).
2- I will refer him for cardiac assessment to rule out IHD as well: ECG, ECHO, MPI, up to coronary angiography if indicated.
3- Control of MBD: calcium, PO4 and PTH levels.
4- Control of DM.

5- MDT to discuss when it will be possible for transplantation which should be the best therapeutic modality for his ESRD.
This patient is having diabetes and peripheral vascular disease.
PVD is associated with an increased risk of amputation (particularly in patients with diabetes), allograft ischemia, significant morbidity, and poor patient survival.
He needs evaluation with Non- contrast CT of Abdomen and pelvis, to look for vascular calcification and suitability of iliac vessels for anostomosis.
Opinion of Vascular Surgeon should also be taken for need peripheral arterial bypass or angioplasty.
As thoroughly discussed by my colleagues, I would refer the recipient for a vascular surgeon for further assessment:
As long as there is no active infection and delayed healing wounds and it is not severe aorta bi iliac Peripheral vascular disease ,So no contraindications to kidney transplantation
We should make sure that the patient has good artery for anastomosis by CT angiogram and to assess for calcification we can do CT without contrast
KDIGO guidelines
The prevalence of PAD is high among ESRD patients which is result from HT, DM, smoking & calcium-phosphorus imbalance.. But PAD is not a contra-indication for renal transplantation, because it was associated with 50% reduction in mortality( after 5 years) in transplanted persons comparing to patients kept on dialysis.
Screening of PAD indicated in:
This patient have both risk factor & evidence of PAD, so need to assess by:
References:
KDIGO Transplantation Guidelines, 2020.
This patient has peripheral vascular disease and ESRD due to diabetes complication.
We should keep in mind that this is a systemic atherosclerotic complication affecting coronary , iliac vessels, cerebral beside peripheral vascular disease. Which means that this patient has a high potential of having the disease in these areas.
Peripheral vascular disease (PVD) is common among end-stage renal disease (ESRD) patients and is a known independent risk factor for increased post-transplant mortality.
MDT with vascular surgeon involed in the managent of this patient is important .
This patient needs thorough assessment for coronary, iliac and peripheral vasculature .
Detailed history taking and clinical exam. is vital to assess the ischemic symptoms affecting these organ systems .
( CVA, TIA,foot ulceration , gangrene, wound infection , renal buit, )
Investigation :
– ankle brachial index , toe brachial index, douplex US , non contrast CT , CT angiography ( also for iliac vessels) , arteriography, ECG, ECHO, stress cardiac tests, coronary angiograpghy .
Treatment
1- Life style modification (diet , exercise , alcohol )
2- Smoking cessation,
3- Control of diabetes , blood pressure .
4- Medication – Aspirin , clopidogrel , cilostazole, pentoxyphline, statins .
5- Surgery ( vascular surgeon opinion)
One study conclude that While PVD imparts known risks in patients being considered for transplant, with careful graft selection these patients can be expected to achieve favorable outcomes.(1)
In regard to PERIPHERAL ARTERIAL DISEASE (PAD) the KDIGO guidelines suggest the following :
– Patients with clinically apparent PAD should undergo imaging and management of their PAD in consultation with a vascular surgeon prior to transplantation .
– Patients with clinically apparent PAD, Should undergo non-contrast CT imaging of the abdomen/pelvis to evaluate arterial calcification .
– patients with non-healing extremity wounds with active infection from transplantation should be excluded from transplantation until the control of infection.
– Patient with aorto iliac procedure should not excluded from transplantation if there is sufficient area for anastomosis.
– Patients with severe aorto-iliac disease or distal vascular disease Should not be excluded from kidney transplantation .
Peripheral vascular disease (PVD) is highly prevalent in patients on the waiting list for kidney transplantation (KT) and after transplantation and is associated with impaired transplant outcomes. Multiple traditional and nontraditional risk factors, as well as uremia- and transplant-related factors, affect 2 processes that can coexist, atherosclerosis and arteriosclerosis, leading to PVD. Some pathogenic mechanisms, such as inflammation-related endothelial dysfunction, mineral metabolism disorders, lipid alterations, or diabetic status, may contribute to the development and progression of PVD. Early detection of PVD before and after KT, better understanding of the mechanisms of vascular damage, and application of suitable therapeutic approaches could all minimize the impact of PVD on transplant outcomes.
we manage this patient
first from the history ask about othe risk factors to be modify such as smoking HTN family history of IHD or peripheral vascular disease.
examination of CVS system and cardioidexsmination
lab full chemistry(lipid profile and bone profile) HA1C l
image include doppler u/s to lowe limb ,CT angio of LL ,ECG and ECHO.
management need vascular referral and MDT approach include cardiologist ,nephrologist and vascular surgeon
This diabetic patient with chronic kidney disease most likely has features of peripheral vascular disease.
The risk of peripheral vascular disease (PVD) is increased in diabetic patients, occurs earlier and is often more severe and diffuse. Endothelial dysfunction, vascular smooth muscle cell dysfunction, inflammation and hyper-coagubility are the key factors in diabetic arteriopathy. The presence of PVD, apart from its increased risk of claudication, ischemic ulcers, gangrene and possible amputation, is also a marker for generalized atherosclerosis and a strong predictor for cardiovascular ischemic events. However, despite the recognition that PVD is associated with increased ischemic event rates and death, particularly in diabetic patients, this specific manifestation of systemic atherosclerosis is largely under diagnosed and under treated.
this patient need multidisciplinary team work cardiologist, vascular surgeon, transplant team assessment.
Doppler ultrasound of both lower limb vessels and CT angiography.
ECG, echocardiography and coronary angiography, lipid profile, assessment of diabetes control.
he need good control of diabetes, hypertension, lipids and cessation of smoking and ideal body weight.
presence of severe aorto-iliac atherosclerosis not amenable to surgery would make transplantation not possible.
How do you manage this case?
Patient will need overall assessment for atherosclerosis including lipid profile, ECG, carotid Doppler and Echocardiography, Lower limb Doppler scan and CT Scan to assess the vessels.
Treating PVD medically and with lifestyle changes is the best way to prevent it from getting worse and protect against complications, by reducing risk factors
1.Quit smoking, regular exercise, such as walking, nutritious, low-fat foods, and avoid foods high in cholesterol, maintain a healthy weight, control high blood pressure and high cholesterol and DM.
1. Medications used to treat PVD and intermittent claudication include
A. Cilostazol (Pletal) : vasodilator
B. Antiplatelet agents include aspirin, aspirin plus dipyridamole, ticlopidine, and clopidogrel. They prevent clots from forming by keeping blood cells and platelets from clumping together. They may be given to help prevent heart attack and stroke.
C. Pentoxifylline (Trental): This drug is believed to improve blood flow by making red blood cells more flexible and making the platelets less sticky
2. surgery is required only for very severe atherosclerosis that’s unresponsive to medications and angioplasty.
Absent distal pulses in diabetic CKD patients are not uncommon. As bilateral good femoral pulses are there, renal transplant can be carried out with complete vascular screening.
as patient is diabetic and has absent distal pulses that is suggestive of PVD. Aortoiliac disease is not absolute contradiction. Nevertheless he needs complete vascular and cardiology work up prior to transplant
Renal transplantation is the best modality for renal replacement thus efforts should be done to do so .
Absolute contraindications to RTx :
-Active infection
-severe cardiac disease
-severe chest disease
-LC
-recent malignancy
-BMI>40
-HO non compliance or drug abuse
So we should make sure our patient isn’t having any of the absolute contraindications.
One of the relative contraindications is the Aorto iliac disease with absent femoral pulse ( not the case here ) , disabling claudications which may need vascular reconstruction ( we should make sure its not the case here ) ,
So according to the given data , we will go for the transplant after proper cardiological consultation ( will undergo MPI , or CPET ) as the recipient although less then 50 years but he is diabetic , and has PVD so exclusion of IHD is a must .
Optimizing blood pressure , blood sugar , lipid profile , body weight as well as implementation of anti-platelets is advised prior to surgery .
patient is diabetic and has intermittent claudication after 20 yardsincrease possibility of peripheral vascular disease and not execluded by presence of femoral pulse .
so i believe need complete vascular evaluation and image of iliac vessel (dopplar and CT angio) better to avoid MR with gadollinum
also cardiac and coronary vessel need to be evaluated also as patient is diabetic with ? peripheral vascular disease
45 years (young) old with a history of DM, either type one or two, is consistent with previously poor controlled DM. from the vascular point of view, this patient is at high risk and needs detailed cardiovascular evaluation (cardiac in addition to vascular). CPET is not helpful and should not be done. but I will proceed with cardiac scintigraphy in addition to evaluation of limb vasculature first by doppler and then (as I think will be needed), a CT angiogram. I will consult with the cardiovascular surgeon for treatment, but we need to confirm the patency of the iliac arteries as this will affect the anastomosis of the transplanted kidney. unless the iliac artery and vein are patent, we can not proceed with transplantation because of the risk of thrombosis and delays graft function with a high risk of failure.
This male patient is 45 years old with diabetic nephroathy he had
calf intermittent claudication after 20 yards with good femoral pulses on both sides, but absent distal pulses picture of PVD
Peripheral vascular disease is common among ESRD patients and is a known independent risk factor for increased post-transplant hospital readmission and mortality.
The survival benefit of transplantation in these patients is not well understood.
a retrospective analysis by E. Min, et al of post-transplant outcomes of PVD patients
7831 recipients with PVD were matched to controls (MC) without PVD showed that Post-transplant patient survival was significantly worse in the PVD cohort compared to MC at 1, 3, and 5 years
PVD recipients with DGF had the worst long-term patient survival .
PVD recipients with DGF only achieved survival benefit if they survived 2-years post-transplant . PVD recipients with IGF achieved survival benefit after 7.6-months post-transplant.
They concluded that PVD imparts known risks in patients being considered for transplant, with careful graft selection these patients can be expected to achieve favorable outcomes.
Some pathogenic mechanisms, such as inflammation-related endothelial dysfunction, mineral metabolism disorders, lipid alterations, or diabetic status, may contribute to the development and progression of PVD
2 processes that can coexist, atherosclerosis and arteriosclerosis, leading to PVD.
▪︎Controling risk factors is corner stone in mangment Such as
-Diabetic state ,HBA1C
-lipid profile
-Ca ,Phosphorus,PTH,
– adequacy of dialysis, volum status.
-blood pressure control
-proper cardiovascular evaluation, ECG ,echocardiography, vascular duplex of aortoiliac vessels, Ankle-brachial index (ABI) ,CTAngiography.
-stop smoking.
-weight control
– investigate other causes of thrombophilia as the patient is 45 presnted with vascular occlusion (protein c and s, antithrombin III, etc).
-antiplatelets and vasodilator to imrove blood flow and reduce further occlusion
▪︎Reference
Early Graft Function Correlates with Survival Benefit in Kidney Transplant Recipients with Peripheral Vascular Disease
E. Min, V. Tatapudi, N. Ali, B. Gelb, N. Dagher.
New York, NY.Meeting: 2018 American Transplant Congress
Background
The increased susceptibility of diabetic transplant recipients to cerebrovascular and peripheral vascular disease mandates particular attention to these issues in the pre-transplant evaluation. Any history of cerebrovascular events, intermittent claudication or findings of carotid or femoral bruits, or poor peripheral pulses should be further assessed during patient evaluation. Further consultation with a vascular surgeon is necessary.
Risk factor for peripheral vascular disease:
How do you manage this case?
Patient will need overall assessment for atherosclerosis including lipid profile, ECG, carotid Doppler and Echocardiography, Lower limb Doppler scan and CT Scan to assess the vessels.
Treating PVD medically and with lifestyle changes is the best way to prevent it from getting worse and protect against complications, by reducing risk factors
1.Quit smoking, regular exercise, such as walking, nutritious, low-fat foods, and avoid foods high in cholesterol, maintain a healthy weight, control high blood pressure and high cholesterol and DM.
1. Medications used to treat PVD and intermittent claudication include
A. Cilostazol (Pletal) : vasodilator
B. Antiplatelet agents include aspirin, aspirin plus dipyridamole, ticlopidine, and clopidogrel. They prevent clots from forming by keeping blood cells and platelets from clumping together. They may be given to help prevent heart attack and stroke.
C. Pentoxifylline (Trental): This drug is believed to improve blood flow by making red blood cells more flexible and making the platelets less sticky
2. surgery is required only for very severe atherosclerosis that’s unresponsive to medications and angioplasty.
*Regarding management this case :
This male patient 45-year-old, CKD stage V due to DM Nephropathy. He has a history of intermittent claudication with intact femoral pulses but ; absence of distal pulsation. so, he has PVD
Patient has many risk factors for PVD being : DM, CKD.
He has peripheral artery disease due to absent peripheral pulsation.
So, patient has risk of cardiovascular disease as hypertension , coronary artery disease and CVS strokes.
There are many symptoms of PVD with different severities : from mild with only pain when walking , claudication up to pain at rest , gangrene which consider severe and indicate rapid intervention.
*For diagnosis of PVD/PAD:
1. Imagining : Doppler ultrasound , Ankle-brachial index (ABI) ,CT Angiography , Magnetic resonance angiography.
*Other investigations for this high risk patient for cardio and cerebrovascular diseases include : ECG, Echo, CPT (cardiopulmonary test), Duplex of neck and iliac vessels.
Treatment is directed towards the following :
1) Avoid and treat all risk factors as; smoking , well balanced diet high in vegetables , fruits, intense dialysis , correction of CKD-MBD ( with target calcium and Po4 ), treat dyslipidemia before reaching dialysis with lipid lower drugs as ; statins, tight control of blood pressure ( beta-blocker to be avoided) and diabetes, add cardio-protective doses of antiplatelets as aspirin 75-150mg per day, improving circulation by some platelet-aggregation inhibitors as cilostazol which has also vasodilator effect improve walking time accepted to be taken for three months then stopped, more over hemorrheologic agent as pentoxifylline can be used 400mg/day.
Finally ; surgical intervention as angioplasty as salvage management.
After that he can proceed for transplantation with high mortality risk post transplantation up to 35% in recipient with history of PAD/PVD.
This gentleman is diabetic with peripheral vascular disease. We need to know if he has other risk factors rather than diabetes that may further increase his risk of PVD such as dyslipidemia, Hypertension, smoking history and vascular diseases elsewhere. His gender also increases the risk of PVD. His cardiovascular risk is also high and he will need as per guideline MPI +/- stress ECHO or coronaro angiogram and cardiology review. Patients with PAD have an increased cardiovascular risk and among them the patients with diabetes and ESRF have an even higher cardiovascular risk.
This gentleman would require a full clinical examination from the vascular point of view (for e.g. carotid bruit that may indicate a vascular disease elsewhere, ischemic ulceration).
I would organize an ABPI as it is a useful test to screen for PVD but we have to bear in mind that in approximately 30% of these patients, ABI is inaccurate and may be normal or falsely elevated. Furthermore this patient may have peripheral vascular disease in other vascular territories and this should be suspected in case of abnormal ABI or TBI increasing his mortality and morbidity risk.
He will require a Doppler of the iliac vessels (Lower limbs vascular and iliac vessels) or non-contrast CT of the pelvic vessels to assess the suitability of the vessels for the anastomosis and in case of large vessel disease an angiography should be organized. If he has a PAD this may increase the risk of renal artery stenosis of the graft and consequently he will be at higher risk of hypertension which may affect his graft function. A severe aortoiliac disease would be a contraindication for renal transplant . He is at risk of critical limb ischemia which may occur as a worsening process of his claudication which indicates an arterial damage already present. Furthermore the immunosuppressive therapy may worsen their vascular disease particularly when the critical limb ischemia occurs with tissue loss or gangrene. The presence of gangrene, ulcers or tissue loss will require an urgent vascular review.
In terms of managements include smoking cessation, blood pressure control (ACE inhibitor or ARB for patient with high cardiovascular risk), Diabetes control, anti-platelets in PVD (aspirin and clopidrogel) and statins. In case of acute limb ischaemia patient requires an urgent surgical review (endovascular revasularisation, angioplasty-stenting)
References:
Presence of peripheral artery disease in renal transplant outcomes – Don’t throw the baby out with the bath water. Mehdi H,Shishehbor, Baran Aksut, Emilio Poggio, …First Published April 8, 2017 Editorial Find in PubMed
Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC Guideline on the management of patients with lower extremity peripheral artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135:e726–e779.
SIXTH EDITION Handbook of Kidney Transplantation
Chadban SJ, Ahn C, Axelrod DA, Foster BJ, Kasiske BL, Kher V, Kumar D, Oberbauer R, Pascual J, Pilmore HL, Rodrigue JR. KDIGO clinical practice guideline on the evaluation and management of candidates for kidney transplantation. Transplantation. 2020 Apr 1;104(4S1):S11-03
This patient has high incidence of peripheral vascular disease as:
age , Males, diabetics,
also this increase if the patient has hypertension, lipid abnormalities,cigarette smoking or a history of vascular disease
Also the risk increase because of CKD-associated conditions such as atheromatosis-related inflammation or endothelial dysfunction
The Evaluation Process
-A detailed medical history and examination
-MDT including the Nephrologists, Endocinologist,Surgeons , dietion,Renal Pharmacist, Renal Psychologists and cardiologist.
– Noninvasive evaluation of the peripheral vasculature, preferably noncontrast CT of the pelvic vasculature.
-Angiography should be considered if noninvasive studies suggest the presence of large-vessel disease
-Control of glucose levels, high blood pressure, serum lipids, obesity, and smoking
-All the risk factors pre/post transplant must be discussed with the patient
as PVD is also very common posttransplantation, particularly among high-risk populations like diabetic and elderly recipients, all of whom have a significantly higher mortality after KT.
-The ACC/AHA guidelines recommend pharmacological management of PVD with mainly antiplatelet drugs (aspirin or clopidrogel) and statins.
-Additionally, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers are recommended to reduce the risk of cardiovascular events in patients with PVD
-Likewise, the ACC/AHA also recommends cilostazol, an oral phosphodiesterase-3 inhibitor that induces smooth muscle relaxation and reduces platelet aggregation, for relieving claudication symptoms
-Furthermore, anticoagulation with heparin is recommended in patients with ALI.
SourceSIXTH EDITION Handbook of Kidney Transplantation
Peripheral Vascular Disease and Kidney Transplant Outcomes: Rethinking an Important Ongoing Complication
Transplantation105(6):1188-1202, June 2021.
18. Weiner DE, Carpenter MA, Levey AS, et al. Kidney function and risk of cardiovascular disease and mortality in kidney transplant recipients: the FAVORIT trial. Am J Transplant. 2012;12:2437–2445.
19. Hernández D, Triñanes J, Salido E, et al. Artery wall assessment helps predict kidney transplant outcome. PLoS One. 2015;10:e0129083.
26. Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC Guideline on the management of patients with lower extremity peripheral artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135:e726–e779.
116. Armstrong EJ, Chen DC, Singh GD, et al. Angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use is associated with reduced major adverse cardiovascular events among patients with critical limb ischemia. Vasc Med. 2015;20:237–244.
117. Robless P, Mikhailidis DP, Stansby GP. Cilostazol for peripheral arterial disease. Cochrane Database Syst Rev. 2008:CD003748.
119. Bonaca MP, Bauersachs RM, Anand SS, et al. Rivaroxaban in peripheral artery disease after revascularization. N Engl J Med. 2020;382:1994–2004.
· How do you manage this case?
This is a 45-year-old male patient with:
1. End-stage renal disease (ESRD), on regular haemodialysis
2. T2DM
3. Suspect peripheral vascular disease (PVD), or peripheral arterial occlusion disease (PAOD)
Ageing, smoking, male gender, hypertension, dyslipidaemia, diabetes, and CKD are important risk factors of PVD. The presence of vascular claudication in this patient coupled with absence of distal pulsations of lower extremities should prompt the consideration of PVD. Ankle-brachial index (ABI) should be obtained, and radiological assessment of vascular patency is needed, preferably via a non-contrast CT scan of abdomen, pelvis and lower extremities. Any radiological evidence of inadequate arterial patency of the aortoiliac vasculature should warrant endovascular therapy prior to the kidney transplantation in addition to the conventional medical therapy. Needless to say, smoking is a must.
Reference:
1. Hernández D, et al. Peripheral Vascular Disease and Kidney Transplant Outcomes: Rethinking an Important Ongoing Complication. Transplantation. 2021 Jun 1;105(6):1188-1202. doi: 10.1097/TP.0000000000003518.
Patient with DM, CKD 5 due to diabetic nephropathy and has intermittent claudication are suggestive of peripheral vascular disease (PVD)
PVD is associated with poor patient and graft survival.
The patient should have investigations to assess vasculature and severity of PVD as lower extremity segmental flow, pressure studies and duplex evaluation
Non-contrast CT imaging of abdomen and pelvis to evaluate arterial calcification of ilio-aortic vessels and help pre-operative planning.
CT angiography is considered if large vessel disease is suspected
Advanced aorto-iliac disease or required intra-abdominal reconstructive arterial surgery is considered a relative contraindication for transplantation and should be assessed individually.
The patient should be referred to vascular surgeon to determine treatment plan either conservative therapy, revascularization or open surgery.
Conservative therapy includes risk factor modification, optimal medical therapy and supervised exercise,
Control of comorbidities as HTN, DM, dyslipidemia and cessation of smoking.
Patients with PVD are likely to have cardiovascular disease as both have the same risk factors, IHD should be evaluated with stress echocardiography, myocardial perfusion studies and may need coronary angiography.
The major cause of mortality in those patients is cardiovascular disease,
Chadban SJ, Ahn C, Axelrod DA, Foster BJ, Kasiske BL, Kher V, Kumar D, Oberbauer R, Pascual J, Pilmore HL, Rodrigue JR. KDIGO clinical practice guideline on the evaluation and management of candidates for kidney transplantation. Transplantation. 2020 Apr 1;104(4S1):S11-03.
Hernández D, Vázquez T, Armas-Padrón AM, Alonso-Titos J, Casas C, Gutiérrez E, Jironda C, Cabello M, López V. Peripheral vascular disease and kidney transplant outcomes: rethinking an important ongoing complication. Transplantation. 2021 Jun 1;105(6):1188-202.
GM Danovitch (Editor). Handbook of Kidney Transplantation. Wolters Kluwar, 2017, 606 pp. ISBN: 9781496326157.
1) Gender: male
2) Age >50
3) DM
4) +ve history (intermittent claudication) and
5) +ve clinical finding absent distal pulses.
*Males, diabetics, patients with hypertension, lipid abnormalities, a history of vascular disease elsewhere, and cigarette smoking are at higher risk for peripheral vascular disease.
· If he had significant aortoiliac disease may require intra-abdominal reconstructive arterial surgery and transplantation may be contraindicated.
In general Peripheral arterial disease (PAD) in the legs or lower extremities is the narrowing or blockage of the vessels that carry blood from the heart to the legs. It is primarily caused by the buildup of fatty plaque in the arteries, which is called atherosclerosis. PAD can happen in any blood vessel, but it is more common in the legs than the arms.
# Symptom & Signs
The classic symptom is pain in the legs (claudication)with physical activity, such as walking, that gets better after rest. However, up to 4 in 10 people have no leg pain, it can happen in the buttock, hip, thigh, or calf.
Physical signs include muscle atrophy ; hair loss; smooth, shiny skin; decreased or absent pulses in the feet; sores or ulcers in the legs or feet that don’t heal; and cold or numb toes.
#The risk of PAD
* Smoking
* High blood pressure
*Atherosclerosis
* Diabetes
* High cholesterol
* Age above 60 years
# To manage this case:
Medical history and clinical examination.
MDT should be involved.
# The investigstion
include:
*Blood ( for Dm , lipid profile, RFT and other inves. related to the disease)
*Ankle brachial index (ABI)
This is a commonly used to diagnose PAD.
* U/S of the legs or feet
The Doppler ultrasound is a special type of ultrasound used to spot blocked or narrowed arteries.
*Angiography
*Cardic investigation (ECG, ECHO ,CXR and CPST…) to exclude any cardic issues
*Investigate the illac vessels to make sure they are adequate for renal transplantation.
#Treatment of PAD in general
the main objective:
*To treat the symptoms, such as leg pain
*To prevent the risk of heart attack , stroke and death m
* To change the lifestyle so improve the symptoms, in early disease.
# Medications
*Control the holesterol level
*Control BP
* Control DM
* Medication to prevent blood clots and thrombolytic therapy
# Surgeries or other procedures
*In some cases, angioplasty or surgery may be necessary to treat PAD that’s causing claudication
*Angioplasty and stent placement
This procedure is done to open clogged arteries. It can diagnose and treat a blocked vessel at the same time.
* Bypass surgery
By createing a path around the blocked artery using either a healthy blood vessel from another part of the body or a synthetic one.
# Complications of PAD
Caused mainly by atherosclerosis include:
* Critical limb ischemia
In this condition, an injury or infection causes tissue to die. Symptoms include open sores on the limbs that don’t heal. Treatment may include amputation of the affected limb.
*Strok and heart attack
Plaque buildup in the arteries can also affect the blood vessels in the heart and brain.
PAD(peripheral artery disease):
also known as Peripheral Vascular Disease, is a very common medical condition in which atherosclerotic plaque makes it difficult for blood to circulate through the arteries. PAD primarily affects the legs, but can also damage arteries in the kidneys, abdomen, feet, ankles, pelvis, hips, buttocks and arms.The prevalence of PAD is more among diabetic patients and it’s associated with poor graft function and survival,as well as increase incidence of CAD.
THE RISK FACTORS FOR PAD?
Risk factors include:
SYMPTOMS OF PAD?
It’s either asymptomatic in early stages of PAD
Or symptomatic PAD,the most common ones are pain, cramping and discomfort in the legs, calves, thighs or buttocks. The pain occurs when walking, climbing stairs or exercising, but usually goes away during rest.
The legs may also feel cold or numb, tired, weak, achy or heavy. There might be a tingling that wakes up at night. In addition, the skin of legs may become discolored. If there is any sores or wounds on feet, PAD will prevent them from being able to heal, so it’s important to check the feet daily for any cuts or swelling.
Diagnosis of PAD :
To reach the diagnosis we need proper history and physical examination
initially checking the pulse in both feet and perform a non-invasive test called ankle-brachial pressure index (ABI).
ABI is used to compare the blood pressure in arms with the blood pressure in the ankles. Based on test results, doppler ultrasound done to evaluate blood flow.
If further tests are required, an MRI or CT angiography may help identify the extent of narrowing in blood vessels due to atherosclerosis.
FBS , post prandial, Hb A1C, lipid profile, CBP,PTH,Ca and P all should be checked.
Severe PAD can lead to foot sores or wounds on feet that are not healing, which raises the risk for permanent tissue damage and leg amputation or foot amputation. PAD is also considered a risk factor for heart attack and stroke.
Other tests should be done:ECG,Echocardiogram, stress test ,CPET
HOW IS PAD TREATED?
This depend on if the patient is asymptomatic or symptomatic. In most patient cases, lifestyle modification and medications are used as the first line of defense against PAD, unless the patient’s health is at risk.
ASYMPTOMATIC PAD
Patients with asymptomatic PAD should receive a comprehensive program ,which includes a structured exercise and lifestyle modification program, to reduce cardiovascular events, such as stroke or heart attack, and improve function. Suggested lifestyle modifications would include eating healthy foods,exercises , lowering blood pressure and cholesterol, good glycemic control,losing weight and stopping smoking. Medications are customized to each patient’s individual risk factors, such as diabetes, high blood pressure or hyperlipidemia.
SYMPTOMATIC PAD
Patients who have experienced symptoms of PAD and have an ABI of less than 0.90 are diagnosed with one of two conditions: Claudication or Critical Limb Ischemia (CLI).
Claudication is present when the patient experiences cramping and pain in the leg from exercising. This is caused by the lack of blood flow from the obstructed arteries. Once the patient stops exercising and is at rest, the pain and discomfort fade – this is known as intermittent claudication.If left untreated, the pain may become present at all times, which can limit the quality of life and ability to be active.
Each patient is given a customized care plan that includes a supervised exercise program as initial therapy to relieve symptoms of claudication and improve their quality of life.
Revascularization is recommended as a treatment option when the patient is experiencing lifestyle-limiting claudication with no improved response to life style program.
Critical limb ischemia occurs when there is severe obstruction of the arteries, which reduces blood flow to the extremities (hands, feet and legs) causing severe pain and development of ulcers or sores on the feet. Unlike intermittent claudication where the pain subsides while you rest, patients with CLI experience constant pain.
Chronic limb ischemia (CLI) is associated with an increased risk of major amputation and the symptoms include:
To avoid amputation, surgical or endovascular revascularization is recommended. The goal of revascularization is to provide blood flow back into the foot which will help decrease ischemic pain and allow healing of any wounds while preserving limb function. This will help minimize the loss of tissue.
If PAD progresses, it could develop into Acute limb ischemia which is seen as a medical emergency. Patients with ALI must be treated rapidly because the longer the symptoms are present, the lower the chance of limb salvage.
Surgical options include either angioplasty, stenting, laser atherectomy and endovascular revascularization and reconstruction which if reached mean contraindication for transplantation
☆How do you manage this case?
▪︎ This patient is diabetic with intermittent claudication and absent distal pulses, this is most likely peripheral arterial disease (PSD). ▪︎PAD can cause graft ischemia and failure so this patient should be investigated and treated accordingly.
▪︎ Investigation:
1.Blood tests: to check for conditions related to PAD such as high cholesterol, high triglycerides and diabetes.
2. Ankle-brachial index (ABI): this is a common test used to diagnose PAD. It compares the blood pressure in the ankle with the blood pressure in the arm. 3.Ultrasound of the legs or feet: Doppler ultrasound to spot blocked or narrowed arteries.
4. Angiography: MRI or CT scans to look for blockages in the arteries.
▪︎ Treatment:
The goals of treatment for peripheral artery disease are:
a.Manage symptoms, such as leg pain. b.Improve artery health to reduce the risk of heart attack and stroke.
The management include:
a. Lifestyle changes.
b. Medication ( statins for high cholesterol, control of blood pressure and blood sugar, Asprin and Plavix for prevention of blood clot, cilostazol for leg pain).
C. In some cases, angioplasty or surgery may be necessary
How do you manage this case?
Intermittent claudication post kidney transplant is suggestive of likely possibility of developing peripheral vascular disease in the patient after transplantation.
common causes of post transplant Peripheral vascular disease are:
atherosclerotic vascular disease,
diabetes,
endothelial dysfunction,
elderly patients, etc.
If such patients present to us post transplantation in the outpatient clinic the first and foremost thing as a part of management office in this case his detailed clinical examination which primarily will include examination of cardiovascular system checking all the pulses auscultation for presence of any bruit.
The risk factors for developing peripheral vascular disease post-kidney transplantation or as follows
The diagnostic algorithm of peripheral vascular disease is as follows:
blob:https://fship.worldkidneyacademy.org/d971040f-4784-45bf-94c5-c39ed772e1c0
Nonpharmacological, pharmacological and surgical approach to the management of established peripheral vascular disease is as follows
Hernández, Domingo MD, PhD1; Vázquez, Teresa MD1; Armas-Padrón, Ana MarÃa MD2; Alonso-Titos, Juana MD1; Casas, Cristina MD1; Gutiérrez, Elena MD1; Jironda, Cristina MD1; Cabello, Mercedes MD, PhD1; López, Verónica MD, PhD1. Peripheral Vascular Disease and Kidney Transplant Outcomes: Rethinking an Important Ongoing Complication. Transplantation: June 2021 – Volume 105 – Issue 6 – p 1188-1202
doi: 10.1097/TP.0000000000003518
diagnostic algorithm of peripheral vascular disease is as follows:
this MALE patient with history of ESRD , DM , complaining of CLAUDICATION and ABSENT DISTAL PULES carry a high risk of PVD and CAD so this patient needs MDT ( vascular , cardiologist nephrologist may be interventional radiologist for proper evaluation
for his PVD risk he needs :
because PVD carry a risk of post transplant morbidity ( DGF , Renal vessels thrombosis ) and mortality ( acute MI )
he needs assessment of cardiovascular risk such ( ECG , Echo , CXR , stress test , CPET )
SIXTH EDITION Handbook of Kidney Transplantation
Very good.
This patient is very likely to have PVD.
Uremia and other traditional and nontraditional risk factors contribute to its higher prevalence in the CKD population.
Atherosclerosis and arteriosclerosis are pathogenic processes that can coexist.
It has been proven that PVD is associated with impaired transplant outcomes.
Altered diabetes, lipid and mineral status should be searched out and properly corrected in this patient
vascular and cardiac consultation should be requested before transplantation.
Thank You, but this is a very short answer. How would you investigate this patient?
You have not answered the question
How do you manage this case?
45 year old diabetic male with CKD 5, intermittent claudication and absent distil pulses- There is high of peripheral vascular disease.
Peripheral vascular disease is associated with significant morbidity in case of transplantation. Even those with asymptomatic peripheral vascular disease can have significant underlying ischemia which may carry significant risk of morbidity and poor prognosis.
This patient needs full workup for peripheral vascular disease and diabetic control .He will life style modification including control of diabetes , hypertension, hypercholesterolemia , stopping of smoking etc
Assessment will include-
Assessment of diabetic control including fasting sugar, post prandial sugar level, HBA1c.
Patient will need overall assessment for atherosclerosis including lipid profile, ECG, carotid Doppler and Echocardiography
Lower limb Doppler scan and CT Scan to assess the vasculature.
This case will require a multimodality approach. His case will need discussion and vascular MDT
Depending on scan finding patient may require angiography with angioplasty and stenting or bypass with graft.
Transplantation will be contraindicated in those with significant aortoilliac disease or those require significant vascular reconstruction or bypass.
Renal transplant will be postponed until vascular issue is sorted out.
Thank You, well done
PVD one of premorbid and preoperative risk Factors for Delayed Graft Function due to Acute Tubular Necrosis and also one of relative contraindications especially in our previous such case.
PVD is important both as a cause of allograft ischemia and lower-extremity amputation. There is a high incidence of peripheral vascular disease in diabetic recipients. Patients who have undergone lower-extremity amputations have a significantly higher mortality rate in the 2 years following transplant. Males, diabetics, patients with hypertension, lipid abnormalities, a history of vascular disease elsewhere, and cigarette smoking are at higher risk for peripheral vascular disease. Patients with diabetes and history of ischemic ulceration in the lower extremity or patients with claudication should, have an evaluation of the peripheral vasculature with ct angio of the pelvis and lower limb vasculature.also must be evaluated by cardiologist .
Patients who have significant aortoiliac disease or have required intra-abdominal reconstructive arterial surgery represent a formidable surgical challenge and transplantation may be contraindicated.
So management of above mentioned patient will be
From my opinion I’m not going for transplantation for such patient with many risk factors for developed major cardiovascular event even after transplantation.
SIXTH EDITION Handbook of Kidney Transplantation
Edited by Gabriel M. Danovitch, MD
Very good
thie scenario should alarm the transplant physician to consider each of:
1- possible PAD, that needs attentive evaluation before the transplant. if the patient is not already on HD, i would consider Duplex of the iliac vessels, if the patient is on HD already i would consider either of CT angio of iliac vessels or conventional iliac angio (cath)
2- possible increased risk of CAD, so attentive preop evaluation of CAD should be undertaken, given the fact that potential PAD is CAD quivalent.
this patient is at high risk for Peripheral vascular disease because of :
based on this , this patient should have good evaluation of peripheral vasculature , knowing that PVD is an important factor for both allograft ischemia & lower extremity amputation .
so , work up should include :
transplantation may be contraindicated here in case of presence of significant aorto iliac disease or requiring intra abdominal reconstructive arterial surgery ( surgical challenge )
also , should be evaluated for cardiovascular and cerebrovascular disease, including ECG, ECHO and stress testing in the presence of this risk factors : diabetes and presence of PAD
Very good.
How do you manage this case?
This scenario indicates presence of peripheral vascular disease as complications of long duration uncontrolled diabetic mellitus.
Patients need good history of last visit of diabetic clinic and if she’s regular fallow up the clinic and last HbA1c and last visit of ophthalmology clinic to role out retinopathy
Examination of lower limb and dopplur ultrasound because may need to stent to blocked arteries.
ECG and Echo to role out CAD.
Control blood sugar less than 7%
Control blood pressure
Control hyperlipidemia by statin
Anticoagulant
Calcium channel blocker’s
control hyperparathyrodism.
Consider pancreatic kidney transplant
Cilostazol, an oral phosphodiesterase type III inhibitor used as vasodilator to control intermittent claudication.
Finally revascularization of lower limb
consider to cessation of smoking if he is smoker
Thankyou very good
Management of this diabetic patient would start by:
Detailed history taking regarding smoking history, other muscle cramps, abdominal pain
History of calf muscle claudication relation to exercise, HDx, rest, sleep, positioning.
Medication history: the use of trental, statins, aspirin.
Symptoms suggestive of cardiac ischemia as dyspnea or chest pain should be ruled out.
Arterial and venous mapping is suggested and consulting vascular surgery is mandatory to decide either medical treatment is satisfactory or the necessity of other intervention as balloon interventions or arterial bypassing is urgent in this case.
This patient carries the risk of limb ischemia later on post transplantation if untreated, as other diseases (aorto-iliac or Le Riche syndrome)
He may need anticoagulation according to the vascular team opinion.
Autoimmune antibodies, cry globulins, calcium, phosphorous and PTH levels are important too.
Screening for other peripheral vascular disease is a must.
Tight glycemic control is crucial in this case.
Renal transplantation would be postponed after management of his condition.
Treating pateints with PVD reqires addressing each risk factor that lead to the development of pvd permamnat abstinence from cigarette smoking is the most important factor related to outcomes in pateint with intermittent claudication .
How do you manage this case?
The pt is long standing diabetic with diabetic nephropathy resulting in ESRD on HD also giving history of calf intermittent claudication with clinically absent distal peripheral pulsation so pt mostly has PVD as :
Long standing DM with nephropathy
Dialysis dependent with imbalance in ca and phosphorus levels
To be diagnosed by :
douplex us , Ankle -brachial index , CTA , MRA
Also this pt must be assessed by cardiologist as he has high risk of cardio vascular disease by ECG , Echo , stress test
This pt must be managed as multidisciplinary approach by cardio , vascular surgeon , nephrologist
Management:
-blood sugar and blood pressure control
-decrease weight
-diet control
-stop smoking
-regular exercise
-proper dialysis
-adequate control of ca and phosphorus and PTH
-Antiplatlet
-revascularization if severe stenosis
Very good
The goals of tratment are control blood sugure level , high blood pressure ,dyslipidemia and change lifestyl to prevent progress DKD .