Why PAD Goes Undetected in Advanced CKD, With Pranav Garimella, MBBS, MPH

Peripheral artery disease (PAD) is common in patients with advanced chronic kidney disease (CKD), but it is often underdiagnosed and undertreated. Calcified vessels in these patients can also produce misleading results on a common screening test.

Pranav Garimella, MBBS, MPH, a nephrologist, director of acute dialysis services at UC San Diego Health, and chief medical officer of the American Kidney Fund, discussed PAD in advanced kidney disease during a session at the American Society of Nephrology (ASN) Kidney Week 2026 in Denver, Colorado. He said nearly 45% of patients have PAD by the time they reach kidney failure. He noted this estimate comes from claims data and likely undercounts the true number.

“My most important takeaway is that peripheral artery disease is very common in patients with kidney disease,” Garimella said in an interview with HCPLive. “It’s often underdiagnosed, and even when it is diagnosed, it’s diagnosed late, and sometimes we hesitate to intervene.”

He said studies show medications, structured exercise, and revascularization improve outcomes. He said accurate diagnosis and early intervention are key to preserving limbs.

Why Vascular Calcification Can Mask PAD on Ankle Brachial Index Testing

CKD and PAD share risk factors, including diabetes, vascular disease, and metabolic abnormalities. In patients with diabetes and kidney failure, calcified vessels may not compress during testing. Garimella said this may produce falsely normal ankle brachial index (ABI) results and cause clinicians to miss PAD.

Symptoms can also be misleading. Patients with neuropathy or arthritis may not report typical calf pain when walking.

Concerns about iodinated contrast in advanced CKD have also delayed imaging. Garimella said this is part of a pattern called renalism, in which patients with kidney disease are left out of trials or not offered aggressive testing and treatment early.

Choosing PAD Treatment for Claudication vs Limb Threatening Ischemia

Garimella said he first considers what he is treating and what matters to the patient. For claudication, he starts with risk factor management, including smoking cessation and control of diabetes and lipids. He then recommends structured exercise, which he said improves walking distance and quality of life almost as much as endovascular revascularization.

For limb threatening symptoms, such as ulcers, rest pain, night pain, or early gangrene, Garimella said revascularization should be pursued more aggressively. He said comorbidities help determine whether open surgery or endovascular stenting is the better option.

Nephrologists’ Role in Amputation Prevention on Dialysis

“Given that we’re seeing these patients more often than anyone else, I think it’s important for us to leverage the trust and relationships we have with these patients to advocate for them receiving aggressive care and not putting it off just because they’re on dialysis,” Garimella said.

He said nephrology teams can use thrice weekly dialysis visits to check patients’ feet, ask about symptoms, and refer when needed. He also said nephrologists should tell vascular surgeons when calcification may make a normal ABI unreliable.

Some dialysis units have podiatrists perform foot exams monthly or every other month. Complication and amputation rates increase as kidney function declines, but Garimella said trial evidence shows patients on dialysis still benefit from revascularization.

Toe Pressures, AI Waveform Analysis, and CKD Inclusion in PAD Trials

For diagnosis, Garimella recommended segmental pressures and toe brachial pressures, because toe vessels are less likely to calcify. He also said ABI waveforms are often recorded but not fully interpreted. He noted colleagues are using machine learning to analyze them.

A systematic review Garimella coauthored found 104 of 237 randomized PAD trials (44%) excluded patients with CKD. Exclusion criteria varied, and only 11% of trials reported baseline kidney function.² Garimella said including these patients in trials may reduce the need to apply results from the general population to them.

He also noted new treatment options. In the phase 3b STRIDE trial of 792 participants with type 2 diabetes and symptomatic PAD, once weekly semaglutide (Ozempic) improved maximum walking distance by 13% vs placebo at 52 weeks. The trial did not specifically enroll patients with CKD.¹

Garimella advised clinicians to look for PAD, ask about symptoms, and refer patients for further testing.

Editors’ Note: Disclosures for Pranav Garimella, MBBS, MPH, include Otsuka and the PKD Foundation.

References

1. Bonaca MP, Catarig AM, Houlind K, et al. Semaglutide and walking capacity in people with symptomatic peripheral artery disease and type 2 diabetes (STRIDE): a phase 3b, double-blind, randomised, placebo-controlled trial. Lancet. 2025;405(10489):1580-1593. doi:10.1016/S0140-6736(25)00509-4
2. Wen Y, Potok OA, Wei X, et al. Exclusion of persons with kidney disease in trials of peripheral artery disease: a systematic review of randomized trials. Clin J Am Soc Nephrol. 2020;15(1):117-119. doi:10.2215/CJN.10330819