Commentary on “Hepatitis C virus infection increases risk of peripheral arterial disease in end-stage renal disease patients receiving maintenance hemodialysis therapy”

Abstract

We read with great interest the article titled, “Hepatitis C virus infection increases risk of peripheral arterial disease in end-stage renal disease patients receiving maintenance hemodialysis therapy” by Wang et al.¹ The study investigates the association between hepatitis C virus (HCV) infection and peripheral arterial disease (PAD) in patients undergoing hemodialysis, utilizing brachial-ankle pulse wave velocity (baPWV) as an assessment tool. The authors found that HCV infection significantly increases baPWV levels and that higher viral loads and genotype 1 are notably associated with an elevated risk of PAD. We commend the authors for highlighting this critical intersection between infectious disease and vascular complications. However, we would like to address several methodological concerns that may impact the study's findings.

First, the study's statistical power is directly related to its sample size.² A relatively small sample may limit the robustness of the findings and increase the margin of error. Prior research emphasizes the need for adequate sample sizes to ensure reliable results in studies involving hemodialysis patients. Increasing the sample size could enhance the precision and generalizability of the results.

Second, the selection of laboratory parameters appears limited. Including additional biomarkers such as glomerular filtration rate (GFR), blood urea nitrogen (BUN), creatinine (Cr), and glycated hemoglobin (HbA1c) could provide a more comprehensive assessment of the patients' renal function and metabolic status. Moreover, inflammatory markers like C-reactive protein (CRP) and interleukin-6 (IL-6) have been shown to predict cardiovascular events and could offer valuable insights into the risk of adverse outcomes in this patient population.

Third, the study does not account for other medications that patients may have been taking, such as insulin or pentoxifylline, which could potentially influence vascular outcomes. Insulin therapy, for instance, has been associated with an increased risk of PAD in diabetic patients.³ Pentoxifylline, on the other hand, has vasodilatory effects that could impact baPWV measurements. Accounting for these medications would help isolate the effect of HCV infection on PAD risk.

Fourth, the study did not explore alcohol consumption as a potential predictor of PAD, despite evidence suggesting its association with PAD risk. Including lifestyle factors like alcohol intake and smoking status could provide a more nuanced understanding of the risk profile. Additionally, underlying comorbidities such as cancer, psychological disorders, and autoimmune diseases were not thoroughly addressed, even though they can significantly affect vascular health.

Fifth, key demographic factors like education level, urban versus rural residency, and age categories were not examined. Socioeconomic status and geographical factors can influence access to healthcare and adherence to treatment, thereby impacting disease outcomes. Including these variables could help identify at-risk populations and tailor intervention strategies accordingly.

Lastly, the study lacks details on the duration of diabetes among participants and whether they had received vaccinations, such as the influenza vaccine, which has been associated with reduced PAD incidence in chronic kidney disease patients.⁴ The duration of diabetes is a crucial factor, as longer disease duration increases the risk of vascular complications.

In conclusion, while the study offers valuable insights into the link between HCV infection and PAD risk in patients undergoing maintenance hemodialysis, addressing these methodological concerns could enhance its impact. We encourage the authors to consider these points in future research to deepen our understanding of this critical area.

Mostafa Javanian: Conceptualization; methodology. Mohammad Barary: Writing—original draft; writing—review and editing. Fatemeh Rasolpoor: Investigation; writing—original draft; Soheil Ebrahimpour: Investigation; supervision; writing—original draft. All authors have read and approved the final version of the manuscript. Mohammad Barary, Fatemeh Rasolpoor, and Soheil Ebrahimpour had full access to all data in this study and take complete responsibility for the integrity of the data and the accuracy of the data analysis.

The authors declare no conflicts of interest.