This Article Abstract Full Text (PDF) All Versions of this Article: 109/3/320    most recent 01.CIR.0000114519.75433.DDv1 Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by O’Hare, A. M. Articles by Hsu, C.-y. Search for Related Content PubMed PubMed Citation Articles by O’Hare, A. M. Articles by Hsu, C.-y. Pubmed/NCBI databases Medline Plus Health Information Kidney Failure Peripheral Vascular Diseases Related Collections Risk Factors Chronic ischemic heart disease Epidemiology

(Circulation. 2004;109:320-323.)
© 2004 American Heart Association, Inc.

Brief Rapid Communications

High Prevalence of Peripheral Arterial Disease in Persons With Renal Insufficiency

Results From the National Health and Nutrition Examination Survey 1999–2000

Ann M. O’Hare, MD, MA; David V. Glidden, PhD; Caroline S. Fox, MD, MPH; Chi-yuan Hsu, MD, MSc

From the Division of Nephrology, VAMC San Francisco and University of California (A.M.O.), San Francisco, Calif; Department of Epidemiology and Biostatistics (D.V.G.), University of California, San Francisco, Calif; Framingham Heart Study (C.S.F.), National Heart, Lung, and Blood Institute, Framingham, Mass; and Division of Nephrology, University of California (C.H.), San Francisco, Calif.

Correspondence to Ann M. O’Hare, Staff Physician, VA Medical Center San Francisco, Box 111J Nephrology, 4150 Clement St, San Francisco, CA 94121. E-mail Ann.O'Hare{at}med.va.gov

Received November 3, 2003; revision received December 3, 2003; accepted December 4, 2003.

	Abstract

Top Abstract Introduction Methods Results Discussion References

 
Background— Although renal insufficiency is a recognized risk factor for coronary artery disease, little is known about the epidemiology of lower-extremity peripheral arterial disease (PAD) in persons with renal insufficiency.

Methods and Results— We examined the cross-sectional association of PAD, defined as an ankle-brachial index (ABI) <0.9, and renal insufficiency, defined as an estimated creatinine clearance (CRCL) <60 mL · min^-1 · 1.73 m^-2, among 2229 eligible participants in the National Health and Nutrition Examination Survey (NHANES) 1999 to 2000. An estimated 1.2±0.3 million persons 40 years old with CRCL <60 mL · min^-1 · 1.73 m^-2 (24%) have PAD defined as an ABI <0.9 (versus 3.7% of persons with CRCL 60 mL · min^-1 · 1.73 m^-2). The association of ABI <0.9 with renal insufficiency was independent of potential confounders such as age, diabetes, hypertension, coronary artery disease, stroke history, and hypercholesterolemia (OR 2.5, 95% CI 1.2 to 5.1, P=0.011, referent category ABI 1.0 to 1.3).

Conclusions— Clinicians should be aware of the remarkably high prevalence of PAD among patients with renal insufficiency. In the clinical setting, accurate identification of patients with renal insufficiency combined with routine ABI measurement in this group would greatly enhance efforts to detect subclinical PAD.

Key Words: peripheral vascular disease • kidney • creatinine

	Introduction

Top Abstract Introduction Methods Results Discussion References

 
It is increasingly accepted that mild to moderate chronic renal insufficiency is a risk factor for cardiovascular disease.^1–5 However, most studies of cardiovascular disease in patients with chronic renal insufficiency have not examined lower-extremity peripheral arterial disease (PAD), and disease prevalence has only been described in a few select groups of patients with renal insufficiency.^6–8 Because PAD is highly prevalent among dialysis patients,⁹ as evidenced by the exceedingly high amputation rates in this group,¹⁰ we hypothesize that there is also a high prevalence of PAD among the much larger number of persons with chronic renal insufficiency. We used ankle-brachial index (ABI) measurements from the National Health and Nutrition Examination Survey (NHANES) 1999 to 2000 to test this hypothesis.

	Methods

Top Abstract Introduction Methods Results Discussion References

 
Data Sources
Since the early 1960s, the National Center for Health Statistics has conducted a series of cross-sectional national surveys of the noninstitutionalized civilian population. In each survey, the population was sampled with a complex, stratified, multistage probability cluster sampling design to provide data that are representative of the overall United States population. Beginning in 1999, NHANES became a continuous survey, and NHANES 1999 to 2000 refers to the first 2 years of data for the now ongoing NHANES. As for the prior NHANES, NHANES 1999 to 2000 involved collection of interview, examination, and laboratory data. However, unlike prior surveys, the present survey included a detailed lower-extremity examination that involved ABI measurement, a noninvasive measure of lower-extremity atherosclerosis. It is thus possible to use NHANES 1999 to 2000 data to estimate the prevalence and correlates of PAD as indicated by a low ABI. More detailed information on survey design and procedures is available at http://www.cdc.gov/nchs/about/major/ nhanes/NHANESIII_Reference_ Manuals.htm.

ABI Measurements
Briefly, study participants 40 years old were invited to undergo lower-extremity examination. Persons with bilateral amputations or weighing more than 400 pounds were excluded. Supine systolic pressure was measured in 1 arm (brachial artery) and both ankles (posterior tibial arteries). The ABI was calculated by dividing the mean systolic blood pressure in the arm by the mean systolic blood pressure in the respective ankle. For the purposes of this analysis, the lowest ABI obtained for either leg was taken as the ABI measurement for that patient. Details of the ABI measurement procedure in NHANES 1999 to 2000 are available at http://www.cdc.gov/nchs/data/nhanes/frequency/lexabdoc.pdf.

Estimation of Creatinine Clearance
We used the Cockroft-Gault formula standardized to body surface area¹¹ to estimate creatinine clearance (CRCL).¹² For the purposes of this analysis, subjects were considered to have renal insufficiency if their estimated CRCL was <60 mL · min^-1 · 1.73 m^-2. All analyses compare this group with the reference group of persons with estimated CRCL 60 mL · min^-1 · 1.73 m^-2.

Covariates
Self-reported race was defined as non-Hispanic black versus all other. Determination of comorbid conditions (diabetes, insulin use, diabetic retinopathy, hypertension, coronary artery disease, stroke history, and smoking history) was based on patient interview responses. In addition, body mass index (BMI), the average of 4 measurements of systolic and diastolic blood pressure, glycosylated hemoglobin, and total cholesterol measurements were included in multivariable analysis.

Statistical Analysis
Sampling weights are provided with NHANES 1999 to 2000 data. These take into account the unequal probabilities of selection that result from the sample design, from nonresponse, and from planned oversampling of certain subgroups. Standard errors were calculated by the recommended jackknife method (http://www.cdc.gov/nchs/data/nhanes/guidelines1.pdf) with SAS-callable SUDAAN version 8 software (Research Triangle Park). Differences in continuous variables between renal function categories were compared with a t test, and differences in categorical variables were measured with a ² test. We developed a categorical variable for ABI that adhered to conventional ABI cutoff points (ie, ABI <0.9, 0.9 to 0.99, 1.0 to 1.3, and >1.3). PAD is defined as an ABI <0.9, and values between 1.0 and 1.3 are considered normal.¹³ An ABI of 1.0 to 1.3 served as the referent category for all logistic regression analyses. We measured the association of the categorical ABI variable with renal insufficiency using univariate logistic regression analysis for which the outcome was estimated CRCL <60 versus 60 mL · min^-1 · 1.73 m^-2. We then developed multivariate logistic regression models to adjust sequentially for confounders including demographic (age, gender, and race) and clinical characteristics (diabetes, insulin use, retinopathy, coronary artery disease, stroke history, cholesterol, glycosylated hemoglobin, smoking history, BMI, hypertension history, and blood pressure measurements).

	Results

Top Abstract Introduction Methods Results Discussion References

 
ABI was recorded for at least 1 leg in 2381 (83%) of the 2875 lower-extremity examination participants. Serum creatinine was measured in 2233 of these participants. Four participants were excluded because they were missing weight data, and we were therefore unable to estimate CRCL. The study sample thus consisted of 2229 persons with ABI and CRCL data. Among these, 211 had an estimated CRCL <60 mL · min^-1 · 1.73 m^-2 (a projected 5.8±0.7% of the noninstitutionalized civilian population more than 40 years old, or 5.0±0.6 million persons). Table 1 describes the characteristics of the study sample extrapolated to the US population. A substantially higher percentage of persons with renal insufficiency were in the low ABI categories (<0.9 and 0.9 to 0.99) compared with those with CRCL 60 mL · min^-1 · 1.73 m^-2. However, those with renal insufficiency were on average older; had a higher prevalence of diabetes, coronary artery disease, stroke, and hypertension; had higher mean glycosylated hemoglobin and systolic pressure; and had lower BMI and diastolic blood pressure. There were no statistically significant differences between persons with and without renal insufficiency in either total cholesterol measurements or smoking history. Among persons with renal insufficiency, the prevalence of ABI <0.9 was high both among those with (29±9%) and without (21±5%) self-reported coronary artery disease. On the basis of this analysis, the population prevalence of PAD (as defined by an ABI <0.9) among persons 40 years old with an estimated CRCL <60 mL · min^-1 · 1.73 m^-2 is estimated to be 1.2±0.3 million.

View this table: [in this window] [in a new window]   TABLE 1. Population Characteristics by Level of Renal Function From NHANES 1999–2000

Table 2 shows the results of both univariate and multivariate logistic regression analyses. Univariate logistic regression analysis shows that compared with their counterparts with CRCL 60 mL · min^-1 · 1.73 m^-2, persons with renal insufficiency were more than 9-fold more likely to have an ABI <0.9 (versus an ABI of 1 to 1.3). We developed 2 multivariable models to adjust sequentially for demographic characteristics and comorbid conditions that might confound the association between renal insufficiency and ABI. After adjustment for age, gender, and race, renal insufficiency remained strongly associated with an ABI <0.9 (OR 3.0, 95% CI 1.7 to 5.3, P<0.001). This association persisted after further adjustment for comorbid conditions including diabetes, coronary artery disease, and history of stroke; measures of diabetes severity (glycosylated hemoglobin, self-reported retinopathy, and insulin use); history of diagnosed hypertension; and measured blood pressure, total cholesterol, BMI, and smoking history (ABI <0.9; OR 2.5, 95% CI 1.2 to 5.1, P=0.011, referent category ABI 1.0 to 1.3).

View this table: [in this window] [in a new window]   TABLE 2. Logistic Regression Analyses for Association of ABI With Renal Insufficiency (Defined as Estimated CRCL <60 mL · min-1 · 1.73 m-2) Among NHANES 1999–2000 Participants

	Discussion

Top Abstract Introduction Methods Results Discussion References

 
The present study demonstrates a remarkably high prevalence of PAD (defined as an ABI <0.9) among a representative sample of the US population 40 years old with renal insufficiency. On the basis of these data, an estimated 1.2±0.3 million persons (24%) 40 years old with a CRCL <60 mL · min^-1 · 1.73 m^-2 have PAD. Even after adjustment for important confounders such as age, diabetes, diabetes severity, and coronary artery and cerebrovascular disease, persons with renal insufficiency are still more than twice as likely to have an ABI <0.9 as persons with a CRCL 60 mL · min^-1 · 1.73 m^-2.

The high unadjusted association of renal insufficiency with low ABI reflects, to a large extent, the older age of the renal insufficiency group. A high prevalence in this group of other established cardiovascular risk factors such as diabetes and hypertension, in addition to a high prevalence of existing coronary artery and cerebrovascular disease, also contributes to the high unadjusted association of renal insufficiency with low ABI. Several traditional cardiovascular risk factors, such as cholesterol and smoking, are no more prevalent among persons with renal insufficiency than among those with normal renal function and thus do not appear to explain the cross-sectional association seen here between ABI and renal insufficiency.

There are several possible explanations for the high adjusted association of renal insufficiency with low ABI. One possibility is that renal insufficiency may be a marker for more generalized atherosclerosis. In support of this, the presence of baseline cardiovascular disease is independently associated with progression to end-stage renal disease among patients with chronic kidney disease.¹⁴ Alternatively, there may be a causal association between renal insufficiency and progression of lower-extremity atherosclerosis. Potential pathophysiological mechanisms by which decreased CRCL itself might predispose to PAD include altered calcium-phosphorus, homocysteine, and lipoprotein(a) metabolism and alterations in inflammatory and coagulation pathways.⁹

Accurate diagnosis of PAD is important. Low ABI is associated with an increased risk of stroke, myocardial infarction, and cardiovascular death, and PAD is known to affect lower-extremity function and quality of life.¹⁵ Several specific interventions, such as exercise training¹⁶ and statin therapy,¹⁷ are effective in reducing the functional limitation associated with PAD. Unfortunately, in part owing to the lack of specific PAD symptomatology, clinician awareness of PAD in the primary care setting is notoriously low,^15,18 which translates into missed opportunities to prescribe specific therapy for PAD and to implement general cardiovascular risk reduction measures for this high-risk group.¹⁸

Relative to methods for detecting other forms of cardiovascular disease (eg, cardiac stress testing), ABI measurement is a simple, noninvasive procedure that can be performed easily in the outpatient setting.¹⁵ Routine ABI measurement could be used to identify patients with subclinical PAD who might benefit from educational and therapeutic interventions for PAD. Early identification of PAD before progression to advanced ischemia may be particularly important in patients with renal insufficiency, given data showing that patients with renal insufficiency who undergo lower-extremity bypass are more likely than those with normal renal function to present with gangrene and ischemic ulceration at the time of surgery and to experience postoperative death and cardiovascular complications.¹⁹

In addition, because of the well-documented association of low ABI with cardiovascular mortality, ABI measurement could also help to target patients at highest risk for cardiovascular death as candidates for secondary prevention efforts. The present results show that self-reported history of coronary artery disease is an insensitive predictor of low ABI in patients with renal insufficiency. Thus, measurement of ABI in patients with renal insufficiency could contribute valuable information on cardiac risk beyond what is supplied by the medical history alone.

NHANES provides nationally representative data and overcomes many problems of sampling bias, but the present findings must be interpreted in the context of the study design. Specifically, it is unclear from these cross-sectional data whether renal insufficiency is a true causal "risk factor" for the development of PAD. Although renal insufficiency does appear to be associated with the future development of claudication,²⁰ further studies are needed to measure the association of baseline renal insufficiency with progression of PAD and future PAD events. A second concern is that the present analysis may underestimate the prevalence of PAD in persons with renal insufficiency because of the high prevalence of vascular calcification in this group, leading to falsely elevated ABIs. In this situation, a toe brachial index may be a more accurate screening test for PAD. We are unable to overcome this limitation because toe pressures were not measured in NHANES 1999 to 2000.

Conclusions
PAD is remarkably common in persons with renal insufficiency, and there is an independent cross-sectional association between PAD and renal insufficiency. In the primary care setting, the combination of accurate diagnosis of renal insufficiency (either via measurement or estimation of CRCL or via estimation of glomerular filtration rate) and routine ABI measurement in this group would facilitate more efficient identification of patients with subclinical PAD, a group most likely to benefit from PAD-specific educational interventions and therapy and also from more general cardiovascular risk-reduction efforts.

	Acknowledgments

 
Dr O’Hare is supported by a Health Services Research Career Development Award from the Department of Veterans Affairs. Dr Hsu is funded by the National Institutes of Health (DK 61520).

	References

Top Abstract Introduction Methods Results Discussion References

 

1. Garg AX, Clark WF, Haynes RB, et al. Moderate renal insufficiency and the risk of cardiovascular mortality: results from the NHANES I. Kidney Int. 2002; 61: 1486–1494.[CrossRef][Medline] [Order article via Infotrieve]
   
2. Manjunath G, Tighiouart H, Coresh J, et al. Level of kidney function as a risk factor for cardiovascular outcomes in the elderly. Kidney Int. 2003; 63: 1121–1129.[CrossRef][Medline] [Order article via Infotrieve]
   
3. Muntner P, He J, Hamm L, et al. Renal insufficiency and subsequent death resulting from cardiovascular disease in the United States. J Am Soc Nephrol. 2002; 13: 745–753.[Abstract/Free Full Text]
   
4. Shlipak MG, Simon JA, Grady D, et al. Renal insufficiency and cardiovascular events in postmenopausal women with coronary heart disease. J Am Coll Cardiol. 2001; 38: 705–711.[Abstract/Free Full Text]
   
5. Shlipak MG, Fried LF, Crump C, et al. Cardiovascular disease risk status in elderly persons with renal insufficiency. Kidney Int. 2002; 62: 997–1004.[CrossRef][Medline] [Order article via Infotrieve]
   
6. Lamar W, V, Casper M, Greenlund K, et al. Prevalence of lower extremity arterial disease defined by the ankle-brachial index among American Indians: the Inter-Tribal Heart Project. Ethn Dis. 2002; 12: S1–S7.[Medline] [Order article via Infotrieve]
   
7. Leskinen Y, Salenius JP, Lehtimaki T, et al. The prevalence of peripheral arterial disease and medial arterial calcification in patients with chronic renal failure: requirements for diagnostics. Am J Kidney Dis. 2002; 40: 472–479.[CrossRef][Medline] [Order article via Infotrieve]
   
8. Newman AB, Siscovick DS, Manolio TA, et al. Ankle-arm index as a marker of atherosclerosis in the Cardiovascular Health Study: Cardiovascular Heart Study (CHS) Collaborative Research Group. Circulation. 1993; 88: 837–845.[Abstract/Free Full Text]
   
9. O’Hare A, Johansen K. Lower-extremity peripheral arterial disease among patients with end-stage renal disease. J Am Soc Nephrol. 2001; 12: 2838–2847.[Abstract/Free Full Text]
   
10. Eggers PW, Gohdes D, Pugh J. Nontraumatic lower extremity amputations in the Medicare end-stage renal disease population. Kidney Int. 1999; 56: 1524–1533.[CrossRef][Medline] [Order article via Infotrieve]
    
11. Dubois D, Dubois EF. A formula to estimate the approximate surface area if height and weight be known. Arch Intern Med. 1916; 17: 863–871.
    
12. Hsu CY, Chertow GM, Curhan GC. Methodological issues in studying the epidemiology of mild to moderate chronic renal insufficiency. Kidney Int. 2002; 61: 1567–1576.[CrossRef][Medline] [Order article via Infotrieve]
    
13. Sacks D, Bakal CW, Beatty PT, et al. Position statement on the use of the ankle-brachial index in the evaluation of patients with peripheral vascular disease: a consensus statement developed by the standards division of the Society of Cardiovascular & Interventional Radiology. J Vasc Interv Radiol. 2002; 13: 353.[Medline] [Order article via Infotrieve]
    
14. Levin A, Djurdjev O, Barrett B, et al. Cardiovascular disease in patients with chronic kidney disease: getting to the heart of the matter. Am J Kidney Dis. 2001; 38: 1398–1407.[Medline] [Order article via Infotrieve]
    
15. Belch JJ, Topol EJ, Agnelli G, et al. Critical issues in peripheral arterial disease detection and management: a call to action. Arch Intern Med. 2003; 163: 884–892.[Free Full Text]
    
16. Stewart KJ, Hiatt WR, Regensteiner JG, et al. Exercise training for claudication. N Engl J Med. 2002; 347: 1941–1951.[Free Full Text]
    
17. McDermott MM, Guralnik JM, Greenland P, et al. Statin use and leg functioning in patients with and without lower-extremity peripheral arterial disease. Circulation. 2003; 107: 757–761.[Abstract/Free Full Text]
    
18. Hirsch AT, Criqui MH, Treat-Jacobson D, et al. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA. 2001; 286: 1317–1324.[Abstract/Free Full Text]
    
19. O’Hare AM, Feinglass J, Sidawy AN, et al. Impact of renal insufficiency on short-term morbidity and mortality after lower extremity revascularization: data from the Department of Veterans Affairs’ National Surgical Quality Improvement Program. J Am Soc Nephrol. 2003; 14: 1287–1295.[Abstract/Free Full Text]
    
20. Fried LF, Shlipak MG, Crump C, et al. Renal insufficiency as a predictor of cardiovascular outcomes and mortality in elderly individuals. J Am Coll Cardiol. 2003; 41: 1364–1372.[Abstract/Free Full Text]
    

This article has been cited by other articles:

				Y. Kumada, T. Aoyama, H. Ishii, M. Tanaka, Y. Kawamura, H. Takahashi, T. Toriyama, T. Aoyama, Y. Yuzawa, S. Maruyama, et al. Long-term outcome of percutaneous transluminal angioplasty in chronic haemodialysis patients with peripheral arterial disease Nephrol. Dial. Transplant., July 2, 2008; (2008) gfn378v1. [Abstract] [Full Text] [PDF]

				Y. P. Liew, J. R. Bartholomew, S. Demirjian, J. Michaels, and M. J. Schreiber Jr. Combined Effect of Chronic Kidney Disease and Peripheral Arterial Disease on All-Cause Mortality in a High-Risk Population Clin. J. Am. Soc. Nephrol., July 1, 2008; 3(4): 1084 - 1089. [Abstract] [Full Text] [PDF]

				D. J. Margolis, O. Hofstad, and H. I. Feldman Association Between Renal Failure and Foot Ulcer or Lower-Extremity Amputation in Patients With Diabetes Diabetes Care, July 1, 2008; 31(7): 1331 - 1336. [Abstract] [Full Text] [PDF]

				W. Rosamond, K. Flegal, K. Furie, A. Go, K. Greenlund, N. Haase, S. M. Hailpern, M. Ho, V. Howard, B. Kissela, et al. Heart Disease and Stroke Statistics--2008 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee Circulation, January 29, 2008; 117(4): e25 - e146. [Full Text] [PDF]

				T. S. Perlstein, R. L. Pande, J. A. Beckman, and M. A. Creager Serum Total Bilirubin Level and Prevalent Lower-Extremity Peripheral Arterial Disease: National Health and Nutrition Examination Survey (NHANES) 1999 to 2004 Arterioscler. Thromb. Vasc. Biol., January 1, 2008; 28(1): 166 - 172. [Abstract] [Full Text] [PDF]

				A. R. Chade, J. D. Krier, O. Galili, A. Lerman, and L. O. Lerman Role of Renal Cortical Neovascularization in Experimental Hypercholesterolemia Hypertension, October 1, 2007; 50(4): 729 - 736. [Abstract] [Full Text] [PDF]

				S. S. DeLoach and E. R. Mohler III Peripheral Arterial Disease: A Guide for Nephrologists Clin. J. Am. Soc. Nephrol., July 1, 2007; 2(4): 839 - 846. [Abstract] [Full Text] [PDF]

				R. C. Ozsoy, W. A. van der Steeg, J. J. P. Kastelein, L. Arisz, and M. G. Koopman Dyslipidaemia as predictor of progressive renal failure and the impact of treatment with atorvastatin Nephrol. Dial. Transplant., June 1, 2007; 22(6): 1578 - 1586. [Abstract] [Full Text] [PDF]

				H. H.H. Feringa, S. E. Karagiannis, M. Chonchol, R. Vidakovic, P. G. Noordzij, A. Elhendy, R. T. van Domburg, G. Welten, O. Schouten, J. J. Bax, et al. Lower Progression Rate of End-Stage Renal Disease in Patients with Peripheral Arterial Disease Using Statins or Angiotensin-Converting Enzyme Inhibitors J. Am. Soc. Nephrol., June 1, 2007; 18(6): 1872 - 1879. [Abstract] [Full Text] [PDF]

				H. Bang, S. Vupputuri, D. A. Shoham, P. J. Klemmer, R. J. Falk, M. Mazumdar, D. Gipson, R. E. Colindres, and A. V. Kshirsagar SCreening for Occult REnal Disease (SCORED): A Simple Prediction Model for Chronic Kidney Disease Arch Intern Med, February 26, 2007; 167(4): 374 - 381. [Abstract] [Full Text] [PDF]

				W. Rosamond, K. Flegal, G. Friday, K. Furie, A. Go, K. Greenlund, N. Haase, M. Ho, V. Howard, B. Kissela, et al. Heart Disease and Stroke Statistics--2007 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee Circulation, February 6, 2007; 115(5): e69 - e171. [Full Text] [PDF]

				A. Guerrero, R. Montes, J. Munoz-Terol, A. Gil-Peralta, J. Toro, M. Naranjo, P. Gonzalez-Perez, C. Martin-Herrera, and A. Ruiz-Fernandez Peripheral arterial disease in patients with stages IV and V chronic renal failure Nephrol. Dial. Transplant., December 1, 2006; 21(12): 3525 - 3531. [Abstract] [Full Text] [PDF]

				K.-W. Mui, M. Sleeswijk, H. van den Hout, J. van Baal, G. Navis, and A.-J. Woittiez Incidental Renal Artery Stenosis Is an Independent Predictor of Mortality in Patients with Peripheral Vascular Disease J. Am. Soc. Nephrol., July 1, 2006; 17(7): 2069 - 2074. [Abstract] [Full Text] [PDF]

				R. de Silva, N. P. Nikitin, K. K.A. Witte, A. S. Rigby, K. Goode, S. Bhandari, A. L. Clark, and J. G.F. Cleland Incidence of renal dysfunction over 6 months in patients with chronic heart failure due to left ventricular systolic dysfunction: contributing factors and relationship to prognosis Eur. Heart J., March 1, 2006; 27(5): 569 - 581. [Abstract] [Full Text] [PDF]

				A. M. O'Hare, D. Bertenthal, A. N. Sidawy, M. G. Shlipak, S. Sen, and M.-M. Chren Renal Insufficiency and Use of Revascularization among a National Cohort of Men with Advanced Lower Extremity Peripheral Arterial Disease Clin. J. Am. Soc. Nephrol., March 1, 2006; 1(2): 297 - 304. [Abstract] [Full Text] [PDF]

				T. Thom, N. Haase, W. Rosamond, V. J. Howard, J. Rumsfeld, T. Manolio, Z.-J. Zheng, K. Flegal, C. O'Donnell, S. Kittner, et al. Heart Disease and Stroke Statistics--2006 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee Circulation, February 14, 2006; 113(6): e85 - e151. [Full Text] [PDF]

				G. J. Hankey, P. E. Norman, and J. W. Eikelboom Medical Treatment of Peripheral Arterial Disease JAMA, February 1, 2006; 295(5): 547 - 553. [Abstract] [Full Text] [PDF]

				A. M. O'Hare, A. B. Newman, R. Katz, L. F. Fried, C. O. Stehman-Breen, S. L. Seliger, D. S. Siscovick, and M. G. Shlipak Cystatin C and Incident Peripheral Arterial Disease Events in the Elderly: Results From the Cardiovascular Health Study Arch Intern Med, December 12, 2005; 165(22): 2666 - 2670. [Abstract] [Full Text] [PDF]

				A. M. O'Hare, R. A. Rodriguez, and P. Bacchetti Low Ankle-Brachial Index Associated With Rise in Creatinine Level Over Time: Results From the Atherosclerosis Risk in Communities Study Arch Intern Med, July 11, 2005; 165(13): 1481 - 1485. [Abstract] [Full Text] [PDF]

				A. R. Chade, A. Lerman, and L. O. Lerman Kidney in Early Atherosclerosis Hypertension, June 1, 2005; 45(6): 1042 - 1049. [Abstract] [Full Text] [PDF]

				A. M. O'Hare, D. Bertenthal, M. G. Shlipak, S. Sen, and M.-M. Chren Impact of Renal Insufficiency on Mortality in Advanced Lower Extremity Peripheral Arterial Disease J. Am. Soc. Nephrol., February 1, 2005; 16(2): 514 - 519. [Abstract] [Full Text] [PDF]

				Z. A. Massy, O. Ivanovski, T. Nguyen-Khoa, J. Angulo, D. Szumilak, N. Mothu, O. Phan, M. Daudon, B. Lacour, T. B. Drueke, et al. Uremia Accelerates both Atherosclerosis and Arterial Calcification in Apolipoprotein E Knockout Mice J. Am. Soc. Nephrol., January 1, 2005; 16(1): 109 - 116. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) All Versions of this Article: 109/3/320    most recent 01.CIR.0000114519.75433.DDv1 Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by O’Hare, A. M. Articles by Hsu, C.-y. Search for Related Content PubMed PubMed Citation Articles by O’Hare, A. M. Articles by Hsu, C.-y. Pubmed/NCBI databases Medline Plus Health Information Kidney Failure Peripheral Vascular Diseases Related Collections Risk Factors Chronic ischemic heart disease Epidemiology