From the Guidelines
Starting daily aspirin (ASA) for peripheral artery disease (PAD) in a dialysis patient with diabetic kidney failure is recommended, with careful consideration of bleeding risk, as it may help reduce cardiovascular events and improve PAD outcomes, as suggested by the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline 1. When considering ASA for PAD in dialysis patients, it's crucial to weigh the benefits against the risks, particularly the increased risk of bleeding. The patient should undergo a thorough bleeding risk assessment, including evaluation of recent gastrointestinal bleeding history, platelet count, and concurrent use of other anticoagulants or antiplatelet medications. Some key points to consider when starting ASA in these patients include:
- Low-dose aspirin (81 mg daily) is often recommended, as it may provide adequate antiplatelet effects while minimizing bleeding risk.
- Adding a proton pump inhibitor, such as omeprazole 20 mg daily, for gastrointestinal protection may be beneficial when starting aspirin.
- The timing of aspirin administration should avoid the dialysis session and any heparin administration to reduce the risk of bleeding complications.
- Regular monitoring for bleeding complications is essential, particularly checking for occult gastrointestinal bleeding. The benefit of aspirin in PAD patients on dialysis comes from its antiplatelet effects that may help prevent arterial thrombosis and reduce cardiovascular events, which are especially common in this high-risk population with both diabetes and end-stage renal disease, as noted in earlier guidelines 1. However, the most recent and highest-quality evidence from the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline 1 supports the use of ASA in PAD patients, including those on dialysis, to prevent major adverse cardiovascular events and major adverse limb events.
From the Research
Peripheral Artery Disease and Dialysis
- Peripheral artery disease (PAD) is a common condition in patients with chronic kidney disease (CKD) and those on dialysis, with a higher prevalence in hemodialysis patients compared to peritoneal dialysis patients 2.
- The presence of PAD in patients receiving hemodialysis leads to a dramatic increase in risk of cardiovascular mortality 3.
- Diabetes mellitus is a significant risk factor for PAD, and patients with diabetes on dialysis are at higher risk of developing PAD 2, 4.
Treatment of Peripheral Artery Disease in Dialysis Patients
- Percutaneous transluminal angioplasty (PTA) is a feasible and effective treatment option for dialysis patients with severe PAD, with a high success rate and good limb salvage rates 5.
- Antiplatelet therapy, such as aspirin, may be beneficial in patients with PAD, but its use in dialysis patients requires careful consideration of the risk of bleeding 3, 6.
- The management of PAD in dialysis patients should involve a multidisciplinary approach, including nephrologists, cardiologists, and vascular specialists, to provide early and proper treatment 3, 6.
Use of Aspirin in Dialysis Patients with Peripheral Artery Disease
- There is no direct evidence to suggest that aspirin should not be used in dialysis patients with PAD, but its use should be individualized based on the patient's risk of bleeding and cardiovascular events 3, 6.
- The decision to start daily aspirin in a dialysis patient with PAD should be made after careful consideration of the potential benefits and risks, and in consultation with the patient's healthcare team 3, 6.