Factors influencing pathological ankle-brachial index values along the chronic kidney disease spectrum: the NEFRONA study

Nephrol Dial Transplant. 2017 Mar 1;32(3):513-520. doi: 10.1093/ndt/gfw039.


Background: The ankle-brachial index (ABI) is widely used to diagnose subclinical peripheral artery disease (PAD) in the general population, but data assessing its prevalence and related factors in different chronic kidney disease (CKD) stages are scarce. The aim of this study is to evaluate the prevalence and associated factors of pathological ABI values in CKD patients.

Methods: NEFRONA is a multicentre prospective project that included 2445 CKD patients from 81 centres and 559 non-CKD subjects from 9 primary care centres across Spain. A trained team collected clinical and laboratory data, performed vascular ultrasounds and measured the ABI.

Results: PAD prevalence was higher in CKD than in controls (28.0 versus 12.3%, P < 0.001). Prevalence increased in more advanced CKD stages, due to more patients with an ABI ≥1.4, rather than ≤0.9. Diabetes was the only factor predicting both pathological values in all CKD stages. Age, female sex, carotid plaques, higher carotid intima-media thickness, higher high-sensitivity C-reactive protein (hsCRP) and triglycerides, and lower 25-hydroxi-vitamin D were independently associated with an ABI ≤0.9. Higher phosphate and hsCRP, lower low-density lipoprotein (LDL)-cholesterol and dialysis were associated with an ABI ≥1.4. A stratified analysis showed different associated factors in each CKD stage, with phosphate being especially important in earlier CKD, and LDL-cholesterol being an independent predictor only in Sage 5D CKD.

Conclusions: Asymptomatic PAD is very prevalent in all CKD stages, but factors related to a low or high pathological ABI differ, revealing different pathogenic pathways. Diabetes, dyslipidaemia, inflammation and mineral-bone disorders play a role in the appearance of PAD in CKD.

Keywords: ankle-brachial index; atheromatosis; cardiovascular risk; chronic kidney disease; peripheral artery disease.

MeSH terms

  • Aged
  • Ankle Brachial Index*
  • C-Reactive Protein / metabolism
  • Carotid Intima-Media Thickness
  • Cholesterol, LDL / blood
  • Cohort Studies
  • Diabetes Mellitus / epidemiology*
  • Female
  • Humans
  • Kidney Failure, Chronic / epidemiology
  • Kidney Failure, Chronic / therapy
  • Male
  • Middle Aged
  • Peripheral Arterial Disease / epidemiology*
  • Peripheral Arterial Disease / physiopathology
  • Prevalence
  • Prospective Studies
  • Renal Dialysis
  • Renal Insufficiency, Chronic / epidemiology*
  • Risk Factors
  • Severity of Illness Index
  • Spain / epidemiology
  • Triglycerides / blood
  • Vitamin D / analogs & derivatives
  • Vitamin D / blood


  • Cholesterol, LDL
  • Triglycerides
  • Vitamin D
  • C-Reactive Protein
  • 25-hydroxyvitamin D