Ischemic Disease of the Upper Extremity in the End-Stage Renal Disease Patient

ABSTRACT

Upper-extremity ischemia in end-stage renal disease has been attributed to steal syndrome from an ipsilateral arteriovenous fistula. However, the validity of this assumption, as well as the characteristics, risk factors, and mortality in these patients has not been fully described.

Patients with end-stage renal disease and ischemia of the hand (n=20) are described and compared to a randomly-selected group of patients with end-stage renal disease (n=150) with regard to atherosclerotic risk factors, length of time on dialysis, location and function of arteriovenous fistula, and mortality.

Of patients with upper extremity ischemia, 16 (80%) required amputation, sympathectomy, or debridement of one to four digits, with pathology revealing calcific occlusion and tortuosity in all. Although 9 (45%) patients developed ischemia ipsilateral to an arteriovenous fistula, 11 (55%) developed ischemia in the contralateral limb. Time from arteriovenous fistula creation to upper extremity ischemia averaged 60.5 months. Thirteen (65%) patients died of their disease an average 16.4 months after diagnosis whereas another 3 (15%) required frequent hospitalizations. When compared to patients with end-stage renal disease without ischemia, study patients were more likely to be diabetic (70% versus 46.7%, P=.035), have peripheral vascular disease (80% versus 26%, P<.001) and coronary artery disease (65% versus 41.3%, P=.033), and tended to initiate dialysis at a younger age (53 years versus 58 years, P=.07). Surprisingly, no difference was noted in hyperlipidemia (10% versus 19%, P=.28) and study patients were less likely to be hypertensive (60% versus 83.3%, P=.005). Although no difference was noted in survival at 1, 3, and 5 years after initiation of dialysis, a significantly higher overall mortality was reported in the ischemia group (65% versus 34%, P=.003).

Upper extremity ischemia in patients with end-stage renal disease has characteristic pathologic features, often requiring definitive surgical management. Ischemia does not appear to be related to steal syndrome, which would occur soon after creation of an arteriovenous fistula in the ipsilateral limb. Upper extremity ischemia carries a high mortality rate and is associated with diabetes, peripheral vascular disease and coronary artery disease, and may be associated with young age at initiation of dialysis. However, it does not appear related to length of time on dialysis, hypertension, or hyperlipidemia. Further studies are needed to more fully characterize the etiology of this disease process to impact prognosis.