| Abstract: | Background and objectives: Atheroembolic renal disease (AERD) can require dialytic support. Because anticoagulation may trigger atheroembolization, peritoneal dialysis may be preferred to hemodialysis. However, the effect of dialysis modality on renal and patient outcomes in AERD is unknown.Design, settings, participants, & measurements: A subcohort of 111 subjects who developed acute/subacute renal failure requiring dialysis was identified from a larger longitudinal study of AERD. The main exposure of interest was dialysis modality (peritoneal versus extracorporeal therapies). Logistic regression was used to study the probability of renal function recovery. Times from dialysis initiation to death were studied using Cox''s regression.Results: Eighty-six patients received hemodialysis and 25 received peritoneal dialysis. The probability of renal function recovery was similar by dialysis modality (25% among hemodialysis patients and 24% among peritoneal dialysis patients; P = 0.873). During follow-up, 58 patients died, 14 among peritoneal patients and 44 among hemodialysis patients (P = 0.705). In multivariable analysis, gastrointestinal tract involvement and use of statins maintained an independent effect on the risk of patient death.Conclusions: This study does not support the notion that one dialysis modality is superior to the other. However, the observational nature of the data precludes any firm conclusions.Atheroembolic renal disease (AERD) is due to the occlusion of small renal arteries and glomerular capillaries by cholesterol crystals derived from atherosclerotic aortic plaques (1). The severity of renal dysfunction depends on the amount and frequency of embolic showers and inflammatory reactions. Although chronic “spontaneous” AERD may represent an underdiagnosed, slowly progressive cause of ESRD mimicking nephrosclerosis, in patients developing acute or subacute renal failure AERD is usually “iatrogenic” and dialysis may be required in 25% to 60% of the patients. In one third of these patients renal function may recover. Recovery may be related to reversal of inflammation, resolution of acute tubular necrosis in ischemic areas, hypertrophy in surviving nephrons, and reduction in intensity of embolic showers (2–6).Invasive aortic manipulation, including angiography and vascular surgery, is the leading cause of AERD. However, the disease may be rarely precipitated by anticoagulation; by preventing the formation of a protective thrombus overlying the ulcerated plaques; or even disrupting the fibrin cap of atherosclerotic plaques and exposing their soft, cholesterol-laden core to the arterial circulation (1–3,7–12). The requirement for systemic anticoagulation makes extracorporeal dialysis treatments less attractive for patients with AERD who need dialysis. Although systemic anticoagulation can be avoided or at least minimized initially, this can be more difficult in the long run. On the other hand, peritoneal dialysis may not be available in all facilities to treat acute kidney injury and can be contraindicated in patients with AERD for gut ischemia or protein losses.Current data on benefits and harms of extracorporeal and peritoneal dialysis therapies are scant and come from small cohorts or case series (2,3,13–16). Although evidence from clinical trials of interventions is ideally necessary to inform practice, for rare disorders cohort studies may provide relevant information. In this study, we sought to determine whether peritoneal dialysis is superior to extracorporeal therapies in terms of renal and patient outcomes of acute/subacute AERD using data from a large longitudinal study (12). |
