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Severe peripheral arterial diseases in hemodialysis patient: A case report
Jiali Li1, Mingming Yan2, Jiao Qin1
1Department of Nephrology, University of South China affiliated Changsha Central Hospital.
Insights
Peripheral arterial diseases (PADs) are more common in hemodialysis patients, increasing cardiovascular mortality risk. Early diagnosis and treatment by nephrologists and cardiovascular physicians are crucial for better outcomes.
Area of Science:
- Cardiovascular Medicine
- Nephrology
- Vascular Surgery
Background:
- Peripheral arterial diseases (PADs) are systemic arterial disorders affecting lower extremity, iliac, and carotid arteries.
- PADs are significantly more prevalent in patients with chronic kidney disease (CKD) compared to the general population.
- The co-occurrence of mesenteric artery disease and lower extremity artery disease (LEAD) is uncommon.
Observation:
- Hemodialysis patients with PADs face a dramatically elevated risk of cardiovascular mortality.
- Early diagnosis of PADs in CKD patients presents a significant challenge for nephrologists, negatively impacting prognosis.
- A case study highlighted a 48-year-old male on hemodialysis with type 2 diabetes mellitus presenting with acute lower extremity pain and later abdominal pain.
Findings:
- Computed tomography angiography revealed severe stenosis in the femoral artery, while diagnostic angiography confirmed superior mesenteric artery occlusion and severe stenosis in the distal femoral, peroneal, and posterior tibial arteries.
- The patient was diagnosed with PADs, encompassing both LEAD and mesenteric artery disease.
- Percutaneous transluminal angioplasty (PTA) combined with antiplatelet therapy and beraprost improved symptoms, alongside medications to manage mineral metabolism.
Implications:
- The unique biochemical and endocrine abnormalities in dialysis patients contribute to a higher incidence of PADs.
- High uremic status and PAD burden in hemodialysis patients markedly increase short-term cardiovascular disease mortality risk.
- There is a critical need for enhanced collaboration between nephrologists and cardiovascular physicians for early identification and timely intervention in these high-risk patients.
Rationale:
Peripheral arterial diseases (PADs) is defined as a systemic arterial disorders involving the lower extremity arteries, iliac, and carotid, which is developed more common in patients with chronic kidney disease (CKD) than individual with normal renal function. Concurrence of mesenteric artery disease and lower extremity artery disease (LEAD) is rare. The presence of PADs in patients receiving hemodialysis leads to a dramatic increase in risk of cardiovascular mortality. However, the early diagnosis of PADs in patient with CKD remains a challenge to nephrologists, which adds an adverse effect on prognosis.
Patient Concerns:
A 48-year-old man received regular hemodialysis due to end-stage renal failure caused by type 2 diabetes mellitus (T2DM) for 7 years, who was admitted into hospital for acute, severe rest pain of the right lower extremity at the first time. The computed tomography angiography showed severe, diffuse stenosis of the distal third of femoral artery. After discharged, he was readmitted into hospital for abdominal pain and the recurred right lower limb pain. A diagnostic angiography confirmed the initial occlusion of superior mesenteric artery, severe obstruction of the distal segment of femoral artery and diffuse, irregular stenosis of arteria peronea and arteria tibialis posterior.
Diagnosis:
The patient was diagnosed as PADs including LEAD and mesenteric artery disease.
Interventions:
The percutaneous transulminal angioplasty (PTA) combined with antiplatelet therapy and beraprost were performed. Moreover, the cinacalcet and lanthanum carbonate were prescribed to control calcium-phosphorus- parathyroid hormone metabolism.
Outcomes:
The patient was free of abdominal pain and partly relieved from the ache of lower limb after PTA. However, he finally succumbed to acute myocardial infarction.
Lessons:
The incidence of PADs is higher in dialysis patients due to a unique set of biochemical and endocrine abnormalities. As there is a high uremic status and PADs burden in patients with hemodialysis, the short term risk of cardiovascular disesase mortality markedly increases. There is a need for nephrologists and cardiovascular physicians to identify these patients and then provide early and proper treatment.
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