Dialysis modality and risk of major adverse limb events: a nationwide cohort study
A Guedon, G G Guillaume Goudot, C C Cecile Couchoud, S R Stephane Roueff, H L Helene LazarethAbstract
Introduction
Patients initiating dialysis are at very high cardiovascular risk, yet the burden and determinants of major adverse limb events (MALE) remain poorly characterised at a nationwide level1,2. Understanding limb outcomes in this population is essential to improve risk stratification and prevention strategies.
Purpose
To estimate the incidence of MALE among patients initiating dialysis in France, identify associated risk factors, and assess the impact of dialysis modality on limb outcomes.
Methods
We conducted a nationwide cohort study using the French Renal Epidemiology and Information Network (REIN) registry linked to the French National Health Data System (SNDS). All adults initiating maintenance dialysis between 2009 and 2021 were included and followed until death or 31 December 2021. MALE was defined as a composite of major amputation, endovascular revascularisation, or surgical revascularisation. Cumulative incidences were estimated using Kaplan–Meier methods. Multivariable Cox models were used to identify factors associated with MALE. The association between dialysis modality (peritoneal dialysis vs haemodialysis) and outcomes was assessed using inverse probability of treatment weighting.
Results
Among 108,620 patients (median age 71 years; 64.4% men), 15,513 experienced a MALE during follow-up. The cumulative incidence of MALE was 6.2% (95% CI 6.1–6.4) at 1 year, 10.3% (95% CI 10.1–10.5) at 2 years, 20.2% (95% CI 19.9–20.5) at 5 years, and 32.4% (95% CI 31.7–33.1) at 10 years. Incidence was consistently higher in men than in women (10-year: 37.4% [95% CI 36.4–38.4] vs 24.4% [95% CI 23.4–25.5]). Major amputation occurred in 10.0% (9.5–10.5) at 10 years. Independent predictors of MALE included male sex (HR 1.37, 95% CI 1.32–1.42), smoking (HR 1.32, 95% CI 1.27–1.38), hypertension (HR 2.34, 95% CI 2.09–2.61), dyslipidaemia (HR 1.38, 95% CI 1.32–1.43), prior cardiovascular disease (HR 1.56, 95% CI 1.49–1.62), and pre-existing peripheral artery disease (HR 2.49, 95% CI 2.38–2.59). After propensity-score weighting, peritoneal dialysis was associated with a lower risk of MALE compared with haemodialysis (HR 0.75, 95% CI 0.70–0.81), as well as lower risks of endovascular revascularisation (HR 0.76, 95% CI 0.69–0.82), surgical revascularisation (HR 0.86, 95% CI 0.75–0.99), and major amputation (HR 0.69, 95% CI 0.58–0.81).
Conclusion
MALE are frequent and severe complications among patients initiating dialysis, affecting nearly one-third of patients within 10 years. Traditional cardiovascular risk factors and prior peripheral artery disease strongly predict limb outcomes. Peritoneal dialysis is associated with a lower risk of MALE compared with haemodialysis. These findings highlight the need for systematic vascular risk assessment and targeted prevention strategies in this high-risk population.Figure 1For image description, please refer to the figure legend and surrounding text.Figure 2For image description, please refer to the figure legend and surrounding text.