Research in context
Evidence before this study
Lower-extremity peripheral artery disease is an important complication for patients on haemodialysis, and its incidence is much higher than that for coronary heart disease and stroke in this clinical population. No formal systematic review was undertaken; KM searched PubMed for papers published to June 30, 2016, and co-authors provided feedback on relevant articles. For low-severity stages of chronic kidney disease, several previous studies have investigated the risk for peripheral artery disease, but most of them were cross-sectional or investigated either (but not both) of the two kidney measures used to define and stage chronic kidney disease: estimated glomerular filtration rate (eGFR) or albuminuria. This limited evidence might have contributed to 2016 guidelines on peripheral artery disease from the American Heart Association and the American College of Cardiology not including chronic kidney disease among the risk factors for peripheral artery disease.
Added value of this study
In this individual-level data meta-analysis, with 18 261 incident peripheral artery disease cases from 0·8 million participants from 21 cohorts, we examined the prospective and independent associations of eGFR and albuminuria with future risk of peripheral artery disease. Our results showed that both albuminuria and reduced eGFR were independently associated with future risk of peripheral artery disease. Even mild-to-moderate chronic kidney disease (when either of eGFR 30–59 mL/min per 1·73 m2 or urine albumin-to-creatinine ratio 30–299 mg/g is present) conferred 1·5–4-times higher risk of peripheral artery disease beyond traditional risk factors. Accordingly, both kidney measures improved the prediction of peripheral artery disease risk beyond traditional risk factors, with more evident improvements with albuminuria than with eGFR. Albuminuria was particularly strongly associated with the risk of leg amputation and substantially improved its risk prediction.
Implications of all the available evidence
Our results suggest that individuals with chronic kidney disease, even at mild-to-moderate stages, might warrant clinical attention to leg signs and symptoms of peripheral artery disease. Annual foot care is currently recommended in patients with diabetes, but adherence to this recommendation is low. Thus, as the first step to improve this low adherence, people with both diabetes and chronic kidney disease (particularly when albuminuria is present) might be a reasonable target for strong encouragement of regular foot care. Assessment of kidney function and albuminuria is already recommended in patients with diabetes or hypertension. As such, in these clinical populations, the chronic kidney disease measures should be readily available to classify the risk of peripheral artery disease.