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Additional prognostic value of toe-brachial index beyond ankle-brachial index in hemodialysis patients.

ABSTRACT: BACKGROUND:Ankle-brachial index (ABI), the first-line diagnostic test for peripheral artery disease, can be falsely elevated when ankle arteries are incompressible, showing a J-shaped association with mortality. In this situation, toe-brachial index (TBI) is the recommended test. However, whether TBI provides additional prognostic information beyond ABI in patients on hemodialysis is unknown. METHODS:In this retrospective cohort study of 247 Japanese prevalent hemodialysis patients (mean age 66.8 [SD 11.6] years), we evaluated mortality (116 deaths over a median follow-up of 5.2?years) related to quartiles of ABI and TBI, as well as three categories of low ABI (?0.9), normal/high ABI (>?0.9)?+?low TBI (?0.6), and normal/high ABI?+?normal TBI (>?0.6) using multivariable Cox models. RESULTS:ABI showed a J-shaped association with mortality (adjusted hazard ratio 2.72 [95% CI, 1.52-4.88] in the lowest quartile and 1.59 [95% CI, 0.87-2.90] in the highest quartile vs. the second highest). Lower TBI showed a potentially dose-response association with mortality (e.g., adjusted hazard ratios 2.63 [95% CI, 1.36-5.12] and 2.89 [95% CI, 1.49-5.61] in the lowest two quartiles vs. the highest). When three categories by both ABI and TBI were analyzed, those with low ABI (?0.9) experienced the highest risk followed by normal/high ABI (>?0.9)?+?low TBI (?0.6). Among patients with normal/high ABI (>?0.9), the increased mortality risk in individuals with low TBI (?0.6) compared to those with normal TBI (>?0.6) were significant (adjusted hazard ratio 1.84 [95% CI, 1.12-3.02]). CONCLUSIONS:Lower TBI was independently associated with mortality in patients on hemodialysis and has the potential to classify mortality risk in patients with normal/high ABI. Our results support the importance of evaluating TBI in addition to ABI in this clinical population.

SUBMITTER: Hishida M

PROVIDER: S-EPMC7439547 | biostudies-literature | 2020 Aug

REPOSITORIES: biostudies-literature

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Additional prognostic value of toe-brachial index beyond ankle-brachial index in hemodialysis patients.

Hishida Manabu M Imaizumi Takahiro T Menez Steven S Okazaki Masaki M Akiyama Shin'ichi S Kasuga Hirotake H Ishigami Junichi J Maruyama Shoichi S Matsushita Kunihiro K

BMC nephrology 20200820 1

<h4>Background</h4>Ankle-brachial index (ABI), the first-line diagnostic test for peripheral artery disease, can be falsely elevated when ankle arteries are incompressible, showing a J-shaped association with mortality. In this situation, toe-brachial index (TBI) is the recommended test. However, whether TBI provides additional prognostic information beyond ABI in patients on hemodialysis is unknown.<h4>Methods</h4>In this retrospective cohort study of 247 Japanese prevalent hemodialysis patient ...[more]

PMID: 32819299

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Project description:BackgroundNon-invasive clinic-based tools for assessing PAD are not without limitations. Therefore, costly tests like Doppler study, CT angiography and MR angiography are often required to make a diagnosis. Ankle brachial index (ABI), commonly used for assessment of PAD, has high false positivity rates in sclerosed, calcified arteries which render them non-compressible. Toe brachial index (TBI) can be an alternative, as digital arteries are relatively unaffected by these changes.AimTo compare the reliability of ABI and TBI in diagnosing PAD in type 2 diabetes using CT angiography (CTA) as the reference.Methods175 adults with T2D were selected. ABI &TBI were measured with an automated vascular Doppler XT 6 ports bilaterally for all subjects. For any subject, the limb with lower ABI and TBI was included for analysis. ABI < 0.9 & TBI < 0.6 were taken as evidence of PAD. CTA showing > 50% narrowing was taken as evidence of PAD.Results24% of our study subjects had CTA confirmed PAD. ABI has low sensitivity of 35.29% (95% CI 0.21-0.52) compared to TBI being 82.35% (95% CI 0.66-0.92). The specificity however was similar. ABI < 0.9 was able to detect CTA confirmed PAD, but ABI > 0.9, including the so-called normal ABI (0.9-1.3) was unable to detect PAD. ROC showed ABI at 1.005 has sensitivity 64.71% (95% CI 0.48- 0.79) and specificity 61.7% (95% CI 0.53-0.69) and TBI at 0.6 has sensitivity 82.35% (95% CI 0.66-0.92) & specificity 92% (95% CI 0.87-0.96). Utilizing Cohen's Kappa, the reliability of ABI with respect to CTA showed fair agreement (K = 0.225, p = 0.001), whereas the reliability of TBI with respect to CTA showed substantial agreement (K = 0.759, p < 0.0001).ConclusionABI < 0.9 detects PAD reliably, but presence of PAD in patients with ABI > 9.0 including the normal of ABI (0.9-1.3) can be confirmed with TBI, which correlated strongly with CTA. TBI is also non-inferior for PAD detection, when ABI < 0.9. TBI and not ABI can be utilized for initial assessment of PAD in subjects with T2D.

Dataset Information

Additional prognostic value of toe-brachial index beyond ankle-brachial index in hemodialysis patients.

Publications

Additional prognostic value of toe-brachial index beyond ankle-brachial index in hemodialysis patients.

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