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Assessment of Vascular Function in Patients With Chronic Kidney Disease
Published on: June 16, 2014
Guideline-Directed Medical Therapy in Patients with Chronic Kidney Disease Undergoing Peripheral Vascular
Qurat-Ul-Ain Jelani1, Fiorella Llanos-Chea1, Pragati Bogra2
1Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA.
Insights
Patients with critical limb ischemia (CLI) and chronic kidney disease (CKD) receive guideline-directed medical therapy (GDMT) less often. Significant site variation exists in GDMT delivery for CLI patients, highlighting a need for improved care.
Area of Science:
- Vascular Surgery
- Nephrology
- Cardiology
Background:
- Guideline-directed medical therapy (GDMT) is crucial for improving outcomes in critical limb ischemia (CLI).
- Patients with comorbid chronic kidney disease (CKD) represent a high-risk group for poor outcomes in CLI.
- Understanding GDMT prescription patterns and variations is essential for optimizing care in CLI patients.
Purpose of the Study:
- To assess GDMT prescription rates in patients with CLI undergoing peripheral vascular interventions (PVIs).
- To examine variations in GDMT delivery across different clinical sites.
- To compare GDMT rates between CLI patients with and without comorbid CKD.
Main Methods:
- Analysis of data from the Vascular Quality Initiative (VQI) database (October 2016-April 2019).
- Inclusion of 28,652 patients with CLI undergoing PVI.
- Definition of CKD as GFR <60 mL/min/1.73 m2; GDMT included antiplatelet therapy, statins, and ACE inhibitors/ARBs for hypertension.
Main Results:
- 47.5% of included patients had CKD.
- Patients with CKD had significantly lower GDMT prescription rates before (31.7% vs. 38.9%) and after (36.5% vs. 48.8%) PVI compared to those without CKD (p < 0.0001).
- Significant site variability in GDMT delivery was observed for both CKD and non-CKD groups (adjusted MORs: 1.31-1.41).
Conclusions:
- CLI patients with CKD are less likely to receive guideline-directed medical therapy.
- Substantial variability exists in the implementation of GDMT across healthcare sites for CLI patients.
- Improvements in the medical management of CLI, especially for high-risk CKD patients, are urgently needed.
Introduction:
Guideline-directed medical therapy (GDMT) is imperative to improve cardiovascular and limb outcomes for patients with critical limb ischemia (CLI), especially amongst those at highest risk for poor outcomes, including those with comorbid chronic kidney disease (CKD). Our objective was to examine GDMT prescription rates and their variation across individual sites for patients with CLI undergoing peripheral vascular interventions (PVIs), by their comorbid CKD status.
Methods:
Patients with CLI who underwent PVI (October 2016-April 2019) were included from the Vascular Quality Initiative (VQI) database. CKD was defined as GFR <60 mL/min/1.73 m2. GDMT included the composite use of antiplatelet therapy and a statin, as well as an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker if hypertension was present. The use of GDMT before and after the index procedure was summarized in those with and without CKD. Adjusted median odds ratios (MORs) for site variability were calculated.
Results:
The study included 28,652 patients, with a mean age of 69.4 ± 11.7 years, and 40.8% were females. A total of 47.5% had CKD. Patients with CKD versus those without CKD had lower prescription rates both before (31.7% vs. 38.9%) and after (36.5% vs. 48.8%) PVI (p < 0.0001). Significant site variability was observed in the delivery of GDMT in both the non-CKD and CKD groups before and after PVI (adjusted MORs: 1.31-1.41).
Discussion/Conclusion:
In patients with CLI undergoing PVI, patients with comorbid CKD were less likely to receive GDMT. Significant variability of GDMT was observed across sites. These findings indicate that significant improvements must be made in the medical management of patients with CLI, particularly in patients at high risk for poor clinical outcomes.
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