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The Association Between Socioeconomic Factors and Incident Peripheral Artery Disease in the Chronic Renal Insufficiency Cohort (CRIC)

  • Jordan B Stoecker
    Correspondence
    Correspondence to: Jordan Stoecker, MD, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, 3400 Spruce St, 4 Maloney, USA
    Affiliations
    Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
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  • Jordana B Cohen
    Affiliations
    Renal, Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA

    Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
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  • Nathan Belkin
    Affiliations
    Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
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  • Jing C Chen
    Affiliations
    Department of Medicine, Tulane University School of Medicine, New Orleans, LA

    Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA
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  • Raymond R Townsend
    Affiliations
    Renal, Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA

    Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
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  • Dawei Xie
    Affiliations
    Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
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  • Harold I Feldman
    Affiliations
    Renal, Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA

    Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
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  • Grace J Wang
    Affiliations
    Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
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  • Affiliations
    Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
  • Author Footnotes
    # Lawrence J. Appel, Alan S. Go, James P. Lash, Robert G. Nelson, Mahboob Rahman, Panduranga S. Rao, Vallabh O Shah, Mark L. Unruh
Published:October 14, 2021DOI:https://doi.org/10.1016/j.avsg.2021.07.057

      Highlights

      • We found that lower annual household income, female gender, and Black race were independently associated with development of PAD even with strict multivariable adjustment in this prospectively followed CKD cohort
      • Level of educational attainment was not independently associated with incident PAD, but educational level was a possible surrogate for annual income if missing
      • Given the high incidence of PAD in this cohort, with 19% developing PAD over a median of 10 years, the role of periodic PAD screening by ABI in high-risk subpopulations should be considered

      Abstract

      Background

      The association between socioeconomic factors and development of peripheral artery disease (PAD) has not been as well characterized compared to other cardiovascular diseases. We sought to define how annual income, sex, race, and education level are associated with newly diagnosed PAD in a well-characterized, diverse set of adults with CKD.

      Methods

      The Chronic Renal Insufficiency Cohort Study (CRIC) is a multicenter, prospective cohort study designed to examine risk factors for progression of CKD and cardiovascular disease. Demographic and clinical data including ankle brachial index (ABI) and interventions were collected at baseline, as well as yearly during follow-up visits. Annual income was categorized as: <$25,000, $25,000–50,000, $50,000–100,000, or above $100,000. We excluded those with pre-existing PAD, defined as enrollment ABI of <0.9 or >1.4, or missing income data. Cox proportional hazards regression was used to estimate the risk for incident PAD during CRIC enrollment, defined as a drop in ABI to <0.90 or a confirmed PAD intervention, including revascularization or amputation.

      Results

      A total of 3,313 patients met inclusion criteria, the mean age was 58.7 years, 56% were male, and 42% were Black. Over a median follow-up of 10.1 years, 639 participants (19%) were newly diagnosed with PAD. After adjusting for cardiovascular risk factors, all lower levels of annual household income were associated with increased incidence of PAD (income <$25,000 HR 1.7, 95% CI 1.1–2.4, P = 0.008; income $25,000–50,000 HR 1.5, 95% CI 1.1–2.3, P = 0.009; income $50,000–100,000 HR 1.6, 95% CI 1.2–2.4, P = 0.004), relative to a baseline annual income of >$100,000 (overall P-value = 0.02). In the multivariable model, there was no association between education level and PAD incidence (P = 0.80). Black race (HR 1.2, 95% CI 1.0–1.5, P = 0.023) and female sex (HR 1.7, 95% CI 1.4–2.0, P < 0.001) were independently associated with PAD incidence. Multiple imputation analysis provided similar results.

      Conclusions

      In the CRIC, a multi-center cohort of prospectively followed CKD patients undergoing yearly CVD surveillance, lower annual household income, female sex, and Black race were significantly associated with the PAD incidence. In contrast, level of education was not independently associated with incident PAD.
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