Prevalence of Peripheral Artery Disease by Ankle-Brachial and Toe-Brachial Indices and Factors Associated with Toe-Brachial Index–Defined Disease in Maintenance Hemodialysis Patients

BackgroundPeripheral artery disease (PAD) is common in maintenance hemodialysis patients, and ankle-brachial index (ABI) may underestimate disease because arterial calcification can yield falsely normal or elevated values. Toe-brachial index (TBI) may better detect distal ischemia. This study compared PAD detection by ABI and TBI and identified factors associated with TBI-defined PAD.MethodsIn this multicenter cross-sectional study, 211 maintenance hemodialysis patients underwent ABI and TBI assessment. PAD was defined separately as ABI <0.90 and TBI <0.70 using guideline-supported thresholds. Intermittent claudication, chronic wounds and burning toe pain were recorded. Detection rates were compared using McNemar's test, and associated factors were evaluated using multivariable Poisson regression with robust variance.ResultsPAD prevalence was 13.3% by ABI and 76.3% by TBI. TBI identified more patients with PAD than ABI (p < 0.001), with 133 patients (63.0%) showing normal ABI but abnormal TBI. Among these, 9.2% had at least one clinical ischemic feature. Diabetes mellitus, older age, and longer renal replacement therapy duration were independently associated with TBI-defined PAD.ConclusionTBI identified substantially more PAD than ABI and may provide complementary information when ABI alone could miss clinically relevant ischemia. Diabetes mellitus, older age, and longer RRT duration were independent correlates of TBI-defined PAD.