The Effect of Chronic and End-Stage Renal Disease on Long-Term Outcomes after Infrainguinal Bypass

Patients undergoing infrainguinal bypass for chronic limb threatening ischemia (CLTI) with renal dysfunction are at an increased risk for perioperative and long-term morbidity and mortality. Our goal was to examine perioperative and 3-year outcomes after lower extremity bypass for CLTI stratified by kidney function.

A retrospective, single-center analysis of lower extremity bypass for CLTI was performed between 2008 and 2019. Kidney function was categorized as normal (estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m²), chronic kidney disease (CKD) (eGFR 15-59 mL/min/1.73 m²), and end-stage renal disease (ESRD) (eGFR <15 mL/min/1.73 m²). Kaplan-Meier and multivariable analysis were performed.

There were 221 infrainguinal bypasses performed for CLTI. Patients were classified by renal function as normal (59.7%), CKD (24.4%), and ESRD (15.8%). Average age was 66 years and 65% were male. Overall, 77% had tissue loss with 9%, 45%, 24%, and 22% being Wound, Ischemia, and foot Infection stages 1-4, respectively. The majority (58%) of bypass targets was infrapopliteal and 58% used ipsilateral greater saphenous vein. The 90-day mortality and readmission rates were 2.7% and 49.8%, respectively. ESRD, compared to CKD and normal renal function, respectively, had the highest 90-day mortality (11.4% vs. 1.9% vs. 0.8%, P = 0.002) and 90-day readmission (69% vs. 55% vs. 43%, P = 0.017). On multivariable analysis, ESRD, but not CKD, was associated with higher 90-day mortality (odds ratio (OR) 16.9, 95% confidence interval (CI) 1.83-156.6, P = 0.013) and 90-day readmission (OR 3.02, 95% CI 1.2-7.58, P = 0.019). Kaplan-Meier 3-year analysis showed no difference between groups for primary patency or major amputation; however, ESRD, compared to CKD and normal renal function, respectively, had worse primary-assisted patency (60% vs. 76% vs. 84%, P = 0.03) and survival (72% vs. 96% vs. 94%, P = 0.001). On multivariable analysis, ESRD and CKD were not associated with 3-year primary patency loss/death, but ESRD was associated with higher primary-assisted patency loss (hazard ratio (HR) 2.61, 95% CI 1.23-5.53, P = 0.012). ESRD and CKD were not associated with 3-year major amputation/death. ESRD was associated with higher 3-year mortality (HR 4.95, 95% CI 1.52-16.2, P = 0.008) while CKD was not.

ESRD, but not CKD, was associated with higher perioperative and long-term mortality after lower extremity bypass for CLTI. Although ESRD was associated with lower long-term primary-assisted patency, there were no differences in loss of primary patency or major amputation.