When is pedal pulse absent

Use these tips to find a patient's pedal pulses:. Assess the patient's radial pulse rate and rhythm so you know what you are seeking. Check for either the dorsalis pedis pulse on the top of the foot or the posterior tibial pulse located behind the medial malleolus — the ankle bone. For dorsalis pedis, first, visualize because you might see the skin pulsating above the artery.

If you are unable to see anything, hold two or more fingers lightly against the skin. Move up from the toes towards the leg until you locate the pulse. For posterior tibial — on the medial side of the ankle — use two or more fingers. I find more pressure is needed to find this pulse. If you are unable to find the pedal pulse on one leg, switch to the patient's other leg.

Knowing the location of one pulse might help you find the other. Once you have found a pedal pulse, consider using a ballpoint or felt pen to make a light mark at the pulse location to make reassessment easier.

What else works well for finding a pedal pulse? Why might a pedal pulse be absent or diminished? Several studies have suggested that patients with diabetes and CKD have higher levels of ET-1, reflecting coincidental endothelial and renal dysfunction that can lead to vascular remodeling and ultimately, ischemic nephropathy and PAD [ 36—43 ].

In a rodent study, kidney ET-1 was found to mediate the development of renal damage, while a separate study found that urinary ET-1 was a marker of severity of renal damage [ 44 , 45 ]. It is possible that baseline urinary ET-1 may reflect underlying inflammation and vascular endothelial dysfunction that leads to the development of both vascular disease and eGFR decline. These findings add to a growing body of data that identify pedal pulses as a novel predictor for renal function decline among DKD patients.

There are several limitations to our study. Our results may be restricted by the relatively small sample size of 91 patients. Furthermore, renal biopsies were not performed in the patient cohort. As a result, the diagnosis of DKD was subject to interpretation of historical and laboratory data. The diagnosis of ADPPs, an indicator of vascular disease, by standardized history and physical examination does contain some subjective elements.

Patients with known severe peripheral vascular disease were not excluded from the study. Furthermore, we did not analyze the renal function decline to look for episodes of AKI. Future directions for this project include exploring the pathophysiologic mechanisms, such as inflammatory markers and oxidative stress, underlying the complex interplay between DKD and vascular health. Furthermore, we would like to identify if urinary biomarkers can be utilized to identify patients at greatest risk for vascular disease and renal function decline.

In summary, our findings highlight and support the use of ADPP to potentially identify patients at risk for development of further renal functional decline. In addition, our study supports the notion that urinary biomarkers, particularly ET-1, may reflect the underlying mechanism by which ADPP may lead to further renal decline.

Targeted screening resulting in timely diagnosis of vascular disease and ultimately, potential modification of risk factors may help those patients with DKD who are at heightened risk for further renal function decline. National Center for Biotechnology Information , U.

Journal List Ren Fail v. Ren Fail. Published online Jul Author information Article notes Copyright and License information Disclaimer. This article has been cited by other articles in PMC. Abstract Background: Peripheral artery disease PAD is a complication of type 2 diabetes that leads to critical limb ischemia and amputation. Keywords: Peripheral arterial disease, type 2 diabetes, CKD, renal failure. Introduction Vascular disease reflects a combination of pathophysiologic processes that culminate in altered structure and function of vessels, leading to arterial insufficiency.

Methods Study sample and design Ninety-one participants with type 2 diabetes were recruited from a consecutive sample of patients in outpatient clinics in endocrinology and nephrology at University Hospitals Cleveland Medical Center.

Open in a separate window. Figure 1. Vascular disease assessment Standardized history and physical examination were used to assess peripheral pulses [ 7 , 8 , 19 ]. Results Participant selection and baseline characteristics Among the 91 patients, the median age was 58 range 30—83 , median eGFR was Table 1. Patient characteristics, total and stratified by pedal pulses. Table 2. Table 3. Urinary biomarkers, total and stratified by PAD.

Table 4. Conclusions In summary, our findings highlight and support the use of ADPP to potentially identify patients at risk for development of further renal functional decline.

Disclosure statement No potential conflict of interest was reported by the authors. References 1. Peripheral artery disease and chronic kidney disease: clinical synergy to improve outcomes. Adv Chronic Kidney Dis. Subclinical peripheral arterial disease in patients with chronic kidney disease: prevalence and related risk factors. Kidney Int Suppl. Association between renal failure and foot ulcer or lower-extremity amputation in patients with diabetes.

Younger patients with claudication may be referred early to exclude entrapment syndromes. Sign in. Register Now. Stay signed in. This site is intended for UK healthcare professionals. Championing and informing general practice professionals. Arterial ulcer is a symptom of PVD, also indicated by the poor condition of the patient's veins. Related Drug Categories Circulatory disorders Circulatory disorders.

Have you registered with us yet? Register now to enjoy more articles and free email bulletins Register Already registered? Physical examination findings in patients with PVD vary.

They may include absent or diminished pulses, abnormal skin color, poor hair growth, and cool skin. The most reliable physical findings are diminished or absent pedal pulses, presence of femoral artery bruit, abnormal skin color, and cool skin Table 3 10 , but their absence does not preclude PVD. Physical examination and chronic lower-extremity ischemia: a critical review.

Arch Intern Med ; The presence of an ABI less than 0. The ABI will not exclude proximal aneurysms or arterial disease distal to the ankle. Laboratory studies to be ordered at the time of diagnosis include complete blood count with platelet count, fasting glucose or A1C, fasting lipid profile, serum creatinine, and urinalysis for glucosuria and proteinuria. Additional studies such as duplex ultrasonography, magnetic resonance arteriography, and angiography are indicated for determining lesion localization and are best used when invasive or surgical intervention is a possibility.

PVD can be managed by monitoring degree of pain, pain-free walking distance, and other areas in which PVD affects patients' lives. Changes in functional status may prompt the physician to repeat ABI testing, order further testing, or refer the patient to a vascular subspecialist.

Patients with claudication may progress to acute or critical limb ischemia, although the risk is less than 1 percent per year. Critical limb ischemia is the progression of symptoms to the point that rest and night pains are present.

These symptoms mark ongoing ischemia and necessitate intervention. History of CHF; severe low output state leads to lack of pulse and to classic findings of pain, pallor, paresthesia, and paralysis similar to acute limb ischemia; angiography does not show occlusion. Presents as a large, swollen, and painful leg, which appears blue because of incipient venous infarction; pallor is not present; results from extensive thrombotic occlusion of the iliofemoral veins; pulses may be absent.

Information from reference 5. Permanent abstinence from cigarette smoking is the most important factor related to outcomes in patients with intermittent claudication.

Drug therapy for patients with PVD includes several options. In a recent meta-analysis, 17 antiplatelet therapy was evaluated for risk reduction in serious vascular events including stroke, nonfatal myocardial infarction, or death from a vascular cause. Aspirin was most commonly studied in this analysis, with dosages of 75 to mg per day being as effective as higher dosages. Most current approaches recommend aspirin first and then clopidogrel for patients who are intolerant of aspirin or who continue to have events while taking aspirin.

Cilostazol Pletal is a vasodilator with antiplatelet properties. It has been shown to increase walking distance by 35 to percent in several randomized, blinded trials, 19 — 21 but it has never been compared with exercise in a trial. Pentoxifylline Trental is a rheologic modulator that also has antiplatelet effects. It is approved by the U. Food and Drug Administration for the treatment of intermittent claudication. However, critical reviews 20 , 21 have found limited evidence of effectiveness, which the authors believed was insufficient to recommend routine use in treating PVD.

Addressing any comorbidity that affects the course of PVD is essential to its treatment. Hypercholesterolemia clearly is related to atherosclerotic disease.

One systematic review 22 and a recent clinical trial 23 have shown lipid lowering to be beneficial for patients with PVD; however, a variety of outcomes were used and the generalizability of these findings remains an issue until clear patient-oriented trials are conducted. Considering the number of patients with conditions that merit lipid-lowering therapy, patients with PVD and hypercholesterolemia should be treated with appropriate dietary modification and lipid-lowering agents, if needed.

When hypertension and type 2 diabetes are present with PVD, one trial 24 has shown that aggressive blood pressure reduction reduces cardiovascular events, although only 53 patients were followed for four years and this is a subgroup analysis.

If these results can be replicated, most patients with PVD would benefit from ramipril or any ACE inhibitor shown to have this effect, provided the physician monitors serum creatinine levels for deterioration when occult renal artery stenosis is present. Anticoagulants i. Beyond medical therapy for intermittent claudication, patients who progress to critical or acute limb ischemia face several treatment options. These include endovascular stenting, intra-arterial thrombolytic drugs urokinase [Abbokinase] , angioplasty, angioplasty combined with brachytherapy i.

To date, there are no firm evidence-based criteria for deciding which patients will benefit from a given procedure. Factors to be considered in such situations are location of lesion, patient-related risks, surgery-related risks, type of clot, and contra-indications to thrombolysis. Several studies have demonstrated that patients with PVD have higher mortality rates than those in the control groups. One study 30 showed an all cause mortality rate of 3. This study included 1, patients men and women from Scotland who were followed prospectively for five years and highlights the risk found in patients with PVD.

Unfortunately, there are no data to demonstrate that early identification of patients with PVD is beneficial in terms of mortality or morbidity reduction. Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. Address correspondence to Daniel L.

Sontheimer, M. Jefferson Ave. Reprints are not available from the author. Update on some epidemiologic features of intermittent claudication: the Framingham Study. J Am Geriatr Soc. Peripheral arterial disease detection, awareness, and treatment in primary care. Intermittent claudication.