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The association between renal failure and foot ulcer or lower extremity amputation in those patients with diabetes.
Margolis DJ, Hofstad O, Feldman HI. Diabetes Care. 2008 Apr 4 [Epub ahead of print]
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Objective: The objective of this study was to evaluate in those with diabetes the association between foot ulcer (DFU) and lower extremity amputation (LEA) and chronic kidney disease (CKD).
Design: A retrospective cohort study of individuals enrolled between 2002 and 2006. Setting: Individuals cared for in general practice who were between 35 years of age and older with a history of diabetes mellitus. Datasources: Physicians who participate in The Health Information Network of the United Kingdom. Main outcome and measurements: The presence of DFU or LEA and estimated glomerular filtration rate (eGFR).
Results: 90,617 individuals were fully evaluated with a median time of observation of 2.4 years. 378 individuals had LEA and 2619 had DFU. CKD (eGFR<60 ml/min/1.73m(2)) was noted in 23,350 (26%) of our cohort. For the development of DFU as compared to our reference group (group 1 (eGFR >/= 60 ml/min/1.73m(2))) the hazard ratios were for group 2 (eGFR >/=30 and <60 ml/min/1.73m(2)) of 1.85 (1.71, 2.01) and for group 3 (eGFR <30 ml/min/1.73m(2)) of 3.92 (3.23, 4.75) (all p-values <0.001). For LEA the hazard ratios for group 2 was 2.08 (1.68, 2.58) and for group 3 was 7.71 (5.29, 11.26) (all p-values <0.001). Limitations: This was an observational study.
Conclusions: There is a strong association between stage of CKD and DFU or LEA, which is likely not just related to presence of peripheral arterial disease. Individuals with even moderate CKD (eGFR <60 ml/min/1.73m(2)) are at increased risk for DFU and LEA.
Re: Renal failure and foot ulcer or lower extremity amputation in those patients with diabetes
Diabetic foot syndrome and renal function in type 1 and 2 diabetes mellitus show close association.
Wolf G, Müller N, Busch M, Eidner G, Kloos C, Hunger-Battefeld W, Müller UA. Nephrol Dial Transplant. 2009 Jan 7. [Epub ahead of print]
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BACKGROUND: Diabetic nephropathy and diabetic foot syndrome (DFS) are two major complications of diabetes. Surprisingly, little is known of a potential relationship between renal function and the development of DFS in patients with preterminal renal insufficiency. A retrospective cohort study at a single tertiary university centre caring for a large collective of patients with type 1 and 2 diabetes was performed.
Patients and methods. All patients with type 1 or 2 diabetes from 1989 to 2007 on the electronic patient sheet who had standardized food examination, albuminuria and serum creatinine were analysed. A total number of 899 patients with type 1 and 4007 individuals with type 2 diabetes were studied. Estimated glomerular filtration rate (eGFR) was calculated according to the modified equation 7 MDRD formula. Patients were grouped into the chronic kidney disease (CKD) stages according to the eGFR and presence of albuminuria. DFS was classified according to Wagner as well as Armstrong stages.
RESULTS: Forty-six patients (5.1%) of 899 patients with type 1 diabetes have active or a history of DFS. Patients with type 1 diabetes and DSF had significantly higher serum creatinine levels, lower eGFR, higher systolic blood pressure and higher HbA1c levels compared to those without DFS. There was a significant negative correlation between eGFR and the presence of DFS in patients with type 1 diabetes (r = -0.155, P < 0.01). In type 1 diabetes patients, there was a significant negative correlation (Spearman test) between eGFR and Wagner stages (r = -0.218, P = 0.01) as well as Armstrong stages (r = -0.255, P = 0.01). Multiple logistic regression analysis revealed a significant association between the presence of DFS and eGFR (odds ratio 0.696 per 10 ml/min increase, 95% confidence interval 0.627-0.773, P < 0.001). A total of 532 type 2 patients from 4007 patients had DFS (13.7%). Compared with type 2 patients without DFS, those with DFS were significantly older (P < 0.005), exhibited a higher HbA1c, had a longer duration of diabetes (P < 0.005), higher serum creatinine levels (P < 0.005) and a lower eGFR (P < 0.005). There was a significant negative correlation between the Wagner stages and eGFR (r = -0.104, P < 0.01) as well as Armstrong stages and eGFR (r = -0.125, P < 0.01) in all patients with type 2 diabetes (Spearman test). Multiple logistic regression analysis revealed a significant association between the presence of DFS and eGFR (odds ratio 0.873 per 10 ml/min increase, 95% confidence interval 0.842-0.904, P < 0.001). There were also significant associations between DFS and duration of diabetes as well as diastolic blood pressure. In addition, the Jonckheere-Terpstra test confirmed the decrease of eGFR with increasing Wagner and Armstrong stages in patients with type 2 diabetes. Smoking was not associated with a higher prevalence of DFS in type 1 and 2 diabetic patients.
CONCLUSION: There was a strong association between the degree of renal function impairment and DFS in this observational study. Data show that diabetics with DFS undergo a higher incidence of amputation; thus, it should be recommended that diabetic patients with renal insufficiency should be regularly screened for the presence of DFS.
Re: Renal failure and foot ulcer or lower extremity amputation in those patients with diabetes
Associations between oxidized LDL to LDL ratio, HDL and vascular calcification in the feet of hemodialysis patients.
An WS, Kim SE, Kim KH, Bae HR, Rha SH. J Korean Med Sci. 2009 Jan;24 Suppl:S115-20.
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Cardiovascular mortality is associated with vascular calcification (VC) in hemodialysis (HD) patients. The present study was designed to find factors related with medial artery calcification on the plain radiography of feet by comparing C-reactive protein (CRP), plasminogen activator inhibitor type 1 (PAI-1) and lipid profile including oxidized low density lipoprotein (ox-LDL) and to elucidate associations among these factors in HD patients. Forty-eight HD patients were recruited for this study. VC in the feet was detected in 18 patients (37.5%) among total patients and 12 patients (85.7%) among diabetic patients. Diabetes, cardiovascular disease (CVD), pulse pressure, ox-LDL/LDL were higher and high density lipoprotein (HDL) was lower in patients with VC than in patients without VC. Negative associations were found between HDL and CRP, PAI-1. PAI-1 had positive association with ox-LDL/LDL. History of CVD was the only determinant of vascular calcification on the plain radiography of feet. Ox-LDL/LDL, HDL, CRP, and PAI-1 were closely related with one another in HD patients. History of CVD is the most important factor associated with the presence of VC and low HDL and relatively high oxidized LDL/LDL ratio may affect VC formation on the plain radiography in the feet of HD patients.
Objectives: To determine the microbiological profile of diabetes related foot infections (DRFI) and the impact of wound duration, inpatient treatment and chronic kidney disease (CKD). Research Design & Methods: Post-debridement microbiological samples were collected from individuals presenting with DRFI from 1/1/05-31/12/07. Results: 653 specimens were collected from 379 individuals, with 36% identifying only one isolate. Of the total isolates, 77% were Gram-positive bacteria (staphylococci 43%, streptococci 13%). Methicillin-resistant Staphylococcus aureus (MRSA) was isolated from 23% [risk factors: prolonged wound duration (OR 2.31), inpatient management (OR 2.19), CKD (OR 1.49)]. Gram-negative infections were more prevalent with inpatient management (p=0.002) and prolonged wound duration (p<0.001). Pseudomonal isolates were more common in chronic wounds (p<0.001). Conclusions: DRFI are predominantly due to Gram-positive aerobes but are usually polymicrobial and complexity increases with inpatient care and ulcer duration. In the presence of prolonged duration, inpatient management or CKD empiric MRSA antibiotic cover should be considered.
Re: Renal failure and foot ulcer or lower extremity amputation in those patients with diabetes
High levels of foot ulceration and amputation risk in a multiracial cohort of diabetic patients on dialysis therapy.
Ndip A, Lavery LA, Lafontaine J, Rutter MK, Vardhan A, Vileikyte L, Boulton AJ. Diabetes Care. 2010 Jan 12. [Epub ahead of print]
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Objective: To evaluate the prevalence of lower limb complications (LLCs) in a multi-racial cohort of patients with diabetes receiving dialysis.
Research design and methods: A cross-sectional study of LLCs in dialysis-treated patients with diabetes in the UK and USA.
Results: We studied 466 patients (UK 139; USA 327). The prevalence of LLCs was high (foot ulcers 12%, neuropathy 79%, peripheral arterial disease (PAD) 57%, history of foot ulceration 34% and prior amputation 18%), with no significant ethnic variation, except that foot ulcers were more common in Whites than in patients of African-descent (p=0.013). Ninety-five percent of patients were at-risk of LLCs. Prior amputation was related to foot ulcer history, PAD and hemodialysis modality in multivariable analysis. Prevalent ulceration showed independent associations with foot ulcer history and PAD, but not with ethnicity.
Conclusions: All patients with diabetes receiving dialysis are at high risk of LLCs independent of ethnic background.
INTRODUCTION. A diabetic foot lesion remains a major cause of morbidity in diabetic patients with chronic kidney disease. We studied the relation between kidney function and the risk of amputation in patients with diabetic foot.
MATERIALS AND METHODS. We reviewed retrospectively the charts of 244 patients admitted to Imam Khomeini Hospital of Sari, Iran, for diabetic foot from 1996 to 2005. Their clinical characteristics and kidney function indicators, including urine protein excretion and serum creatinine were analyzed and compared between amputees and nonamputees.
RESULTS. There were 244 patients with diabetic foot who were admitted to our center during the studied period. The duration of being affected by DM was between 3 months and 34 years (mean, 11.80 +/- 6.81 years). Sixty-six patients (27.0%) underwent amputation. The amputees were older than the nonamputees (61.1 +/- 11.5 years versus 55.6 +/- 12.5 years, P < .001). There were 20 patients (30.3%) in the amputee group and 44 (24.7%) in the nonamputee group who had proteinuria (P = .38). The mean creatinine level was significantly higher in the amputees compared to the nonamputees (1.78 +/- 1.36 mg/dL versus 1.28 +/- 1.23 mg/dL, P = .03).
CONCLUSIONS. Lower extremity amputations in our patients with diabetic foot were strongly associated with elevated serum creatinine levels. The presence of this complication necessitates intensifying actions in order to prevent amputations.
Re: Renal failure and foot ulcer or lower extremity amputation in those patients with diabetes
Implementation of a diabetic foot management best practice guideline (BPG) in hemodialysis units.
Prentice D, Ritchie L, Crandall J, Harwood L, McAuslan D, Lawrence-Murphy JA, Ridley J, Tigert J, Wilson B. CANNT J. 2009 Oct-Dec;19(4):20-4.
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The aim ofthis study was to examine the impact of introducing the Registered Nurses' Association of Ontario Best Practice Guideline (BPG), Assessment and management of foot ulcers for people with diabetes (2005), on foot ulcer incidence, recurrence, and amputation rate in adult diabetic clients who are undergoing chronic hemodialysis treatments. Fifty-seven individuals from three hemodialysis units participated in the study. Data were collected at three points in time over a 15-month period. A significant reduction in the number of wounds was noted (p < 0.05) from time one to time three, and the grade of wounds (p < 0.01). However, five new amputations were reported Although implementation of the BPG showed a positive patient outcome, further research needs to be conducted with a larger sample size.
Objective: To evaluate the frequency of foot prevention strategies among high risk patients with diabetes.
Research design and methods: Electronic medical records were used to identify 150 patients on dialysis and 150 patients with previous foot ulceration or amputation with 30 months follow-up to determine the frequency patients received education, podiatry care, and therapeutic shoes and insoles as prevention services.
Results: Few patients had formal education (1.3%), therapeutic shoes/insoles (7%), or preventative podiatric care (30%). The cumulative ulcer incidence was the same in both groups (210 per thousand person-years). In contrast, the cumulative amputation incidence was higher in the dialysis group compared to the ulcer group (58.7 vs. 13.1 per thousand person-years, p<0.001). Patients on dialysis were younger and more likely to be of non-Hispanic white descent (p=0.006) than patients with a previous history of ulcer or amputation.
Conclusions: Prevention services are infrequently provided to high risk patients.
Re: Renal failure and foot ulcer or lower extremity amputation in those patients with diabetes
The effect of creatinine clearance on the short-term outcome of neuropathic diabetic foot ulcers.
Akinci B, Yesil S, Bayraktar F, Kucukyavas Y, Yener S, Comlekci A, Eraslan S. Prim Care Diabetes. 2010 May 13. [Epub ahead of print]
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Reduced creatinine clearance is related to an increased risk for diabetic foot ulcer development. Wound healing has been reported to be worse in diabetic patients with impaired kidney functions than general diabetic population. This study aimed to investigate the effect of creatinine clearance on the short-term outcome of neuropathic diabetic foot ulcers. Data from 147 neuropathic diabetic foot ulcer episodes were included in this observational study. Patients were admitted to Dokuz Eylul University Hospital between January 2003 and June 2008. Patients were excluded if they had limb ischemia. Diabetic nephropathy was investigated by 24h urinary albumin excretion and serum creatinine levels. Creatinine clearance was calculated according to Cockcroft-Gault formula. Foot ulcers were followed up for 6 months to determine the outcome. Our short-term follow-up revealed that neuropathic diabetic ulcers healed worse in patients with decreased creatinine clearance than in those who had normal creatinine clearance. Amputation rates were also found to be higher. Our results suggest that creatinine clearance is an important factor affecting wound healing in patients with neuropathic diabetic foot ulcers
Re: Renal failure and foot ulcer or lower extremity amputation in those patients with diabetes
Dialysis treatment is an independent risk factor for foot ulceration in patients with diabetes and stage 4 or 5 chronic kidney disease.
Ndip A, Rutter MK, Vileikyte L, Vardhan A, Asari A, Jameel M, Tahir HA, Lavery LA, Boulton AJ. Diabetes Care. 2010 May 18. [Epub ahead of print]
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Objective: To determine whether dialysis treatment is an independent risk factor for foot ulceration in patients with diabetes and renal impairment.
Research design and methods: We performed a cross-sectional study of consecutive patients with diabetes and stage 4 or 5 chronic kidney disease (CKD) attending clinics in Manchester (UK). Patients were classified as either receiving dialysis therapy (dialysis) or not (no-dialysis). Foot assessment included diabetic peripheral neuropathy (DPN), peripheral arterial disease (PAD), prior foot ulceration and amputation, and foot self-care. Risk factors for prevalent foot ulceration were assessed by logistic regression.
Results: We studied 326 patients with diabetes and CKD (mean age 64 years; 61% male; 78% Type 2 diabetes; 11% prevalent foot ulceration). Compared to non-dialysed patients, dialysis patients had higher prevalence of DPN (79% vs65 %), PAD (64% vs 43%), prior amputations (15% vs 6.4%), prior foot ulceration (32% vs 20%), and prevalent foot ulceration (21% vs 5%, all p<0.05). In univariate analyses, foot ulceration was related to wearing bespoke footwear, (OR (95% CI): 5.6 (2.5 to 13)) dialysis treatment (5.1 (2.3 to 11)), prior foot ulceration (4.8 (2.3 to 9.8), PAD (2.8 (1.3 to 6.0), and years of diabetes (1.0 (1.0 to 1.1), all p<0.01). In multivariate logistic regression, only dialysis treatment (4.2 (1.7 to 10), p=0.002) and prior foot ulceration (3.1 (1.3 to 7.1), p=0.008) were associated with prevalent foot ulceration.
Conclusion: Dialysis treatment was independently associated with foot ulceration. Guidelines should highlight dialysis as an important risk factor for foot ulceration requiring intensive foot care.
Among the spectrum of risk for diabetic foot disease conferred by chronic kidney disease (CKD), end-stage renal disease (ESRD) has emerged as a novel independent risk factor. Apart from the classical triad of neuropathy, infection, and peripheral arterial disease that operate in these individuals, the risk is further compounded by inadequate foot self-care by patients and by dialysis centers not providing onsite foot care, as medical priorities are diverted to the dialysis itself. Consequently, the burden of diabetic foot disease has increased in the CKD and ESRD population as exemplified by high ulceration, amputation, and foot-related mortality rates. Current guidelines on foot care in diabetes should recognize advanced CKD and ESRD/dialysis as a separate risk factor for foot disease to alert professionals and highlight the opportunity for prevention. Recent studies have demonstrated improved foot outcomes when chiropody programs are instituted within dialysis units.
Re: Renal failure and foot ulcer or lower extremity amputation in those patients with diabetes
Diabetic Foot Prevention: A neglected opportunity in high-risk patients
Lawrence A. Lavery, Nathan A. Hunt, Javier LaFontaine, Cory L. Baxter, Agbor Ndip and Andrew J.M. Boulton Diabetes Care July 2010 vol. 33 no. 7 1460-1462
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OBJECTIVE To evaluate the frequency of foot prevention strategies among high-risk patients with diabetes.
RESEARCH DESIGN AND METHODS Electronic medical records were used to identify 150 patients on dialysis and 150 patients with previous foot ulceration or amputation with 30 months follow-up to determine the frequency with which patients received education, podiatry care, and therapeutic shoes and insoles as prevention services.
RESULTS Few patients had formal education (1.3%), therapeutic shoes/insoles (7%), or preventative podiatric care (30%). The ulcer incidence density was the same in both groups (210 per 1,000 person-years). In contrast, the amputation incidence density was higher in the dialysis group compared with the ulcer group (58.7 vs. 13.1 per 1,000 person-years, P < 0.001). Patients on dialysis were younger and more likely to be of non-Hispanic white descent (P = 0.006) than patients with a previous history of ulcer or amputation.
CONCLUSIONS Prevention services are infrequently provided to high-risk patients.
Re: Renal failure and foot ulcer or lower extremity amputation in those patients with diabetes
Dialysis Treatment Is an Independent Risk Factor for Foot Ulceration in Patients With Diabetes and Stage 4 or 5 Chronic Kidney Disease
Agbor Ndip, Martin K. Rutter, Loretta Vileikyte, Anand Vardhan, Ashwinbhai Asari, Mehreen Jameel, Hassan A. Tahir, Lawrence A. Lavery, and Andrew J.M. Boulton Diabetes Care August 2010 vol. 33
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OBJECTIVE To determine whether dialysis treatment is an independent risk factor for foot ulceration in patients with diabetes and renal impairment.
RESEARCH DESIGN AND METHODS We performed a cross-sectional study of consecutive patients with diabetes and stage 4 or 5 chronic kidney disease (CKD) attending clinics in Manchester (U.K.). Patients were classified as either receiving dialysis therapy (dialysis) or not (no dialysis). Foot assessment included diabetic peripheral neuropathy (DPN), peripheral arterial disease (PAD), prior foot ulceration and amputation, and foot self-care. Risk factors for prevalent foot ulceration were assessed by logistic regression.
RESULTS We studied 326 patients with diabetes and CKD (mean age 64 years; 61% male; 78% type 2 diabetes; 11% prevalent foot ulceration). Compared with no dialysis patients, dialysis patients had a higher prevalence of DPN (79 vs. 65%), PAD (64 vs. 43%), prior amputations (15 vs. 6.4%), prior foot ulceration (32 vs. 20%), and prevalent foot ulceration (21 vs. 5%, all P < 0.05). In univariate analyses, foot ulceration was related to wearing bespoke footwear (odds ratio 5.6 [95% CI 2.5–13]) dialysis treatment (5.1 [2.3–11]), prior foot ulceration (4.8 [2.3–9.8], PAD (2.8 [1.3–6.0], and years of diabetes (1.0 [1.0–1.1], all P < 0.01). In multivariate logistic regression, only dialysis treatment (4.2 [1.7–10], P = 0.002) and prior foot ulceration (3.1 [1.3–7.1], P = 0.008) were associated with prevalent foot ulceration.
CONCLUSIONS Dialysis treatment was independently associated with foot ulceration. Guidelines should highlight dialysis as an important risk factor for foot ulceration requiring intensive foot care.
Re: Renal failure and foot ulcer or lower extremity amputation in those patients with diabetes
Plasma albumin levels correlate with decreased microcirculation and the development of skin defects in hemodialyzed patients.
Mistrík E, Dusilová-Sulková S, Bláha V, Sobotka L. Nutrition. 2010 Sep;26(9):880-885.
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OBJECTIVES: Difficulty healing wounds and skin defects is a frequent problem in patients on chronic hemodialysis (HD) because of malnutrition, inflammation, and atherosclerosis (MIA) syndrome. The aim of the present study was to estimate the influence of peripheral blood flow changes during HD on the development of foot defects and its relationship to plasma albumin levels.
METHODS: Peripheral skin blood flow was measured using a laser Doppler line scanner in 10 different areas of the dorsal part of the instep and the toes of each foot before and during HD with ultrafiltration (897 +/- 465 mL/procedure) in 31 HD patients (10 female, 21 male; age 36-79 y, body mass index = 28 +/- 5.0). No skin defects or apparent acute disease or infection were detected in any patient at the time of laser Doppler line scanner measurement. The feet of the patients were clinically re-examined carefully over the next 18 mo.
RESULTS: We found a significant and constant decrease of skin blood flow during the HD procedure (P < 0.001). Skin blood flow was significantly correlated with serum albumin level both before HD (r = 0.36, P = 0.05) and during HD (r = 0.47, P = 0.007). Skin defects developed in 11 patients, with significantly lower skin blood flow during the 18-mo follow-up period. A significantly larger number of patients who had normal perfusion remained defect-free in comparison to patients with critical perfusion (93% versus 38%, P = 0.002, Kaplan-Meier analysis).
CONCLUSION: Skin blood flow may be impaired in HD patients. The apparent malnutrition and inflammation in HD patients are likely responsible for the decreased skin blood flow and the development of the difficulty to heal skin defects and wounds.
Re: Renal failure and foot ulcer or lower extremity amputation in those patients with diabetes
The impact of chronic kidney disease on survival after amputation in persons with diabetes.
Lavery LA, Hunt NA, Ndip A, Lavery DC, Van Houtum W, Boulton AJ. Diabetes Care. 2010 Aug 25. [Epub ahead of print]
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Objective: To identify factors that influence survival after diabetes related amputations.
Research design and methods: We abstracted medical records of 1043 hospitalized subjects with diabetes and a lower extremity amputation from January 1 to December 31, 1993 in six metropolitan statistical areas in South Texas. We identified mortality in the 10 year period after amputation from death certificate data. Diabetes was verified using World Health Organization criteria. Amputations were identified by ICD-9-CM codes 84.11-84.18 and categorized as foot, below-knee (BKA), and above-knee amputations(AKA) and verified by reviewing medical records. We evaluated three levels of renal function: chronic kidney disease (CKD), hemodialysis, and no renal disease. We defined CKD based on a glomerular filtration rate < 60 mL/min and hemodialysis from CPT codes (90921, 90925, 90935, 90937). We used chi square for trend and cox regression analysis to evaluate risk factors for survival after amputation.
Results: Patients with CKD and dialysis had more BKAs and AKAs than patients with no renal disease (p<0.01). Survival was significantly higher in patients with no renal impairment (p<0.01). The Cox regression indicated a 290% increase in hazard for death for dialysis treatment (HR 3.9 CI 3.07-5.0) and a 46% increase for CKD (HR 1.46 CI 1.21 - 1.77). Subjects with an AKA had a 167% increase in hazard (HR 2.67, CI 2.14-3.34), and BKA had a 67% increase in hazard for death.
Conclusion: Survival after amputation is lower in diabetic patients with CKD, dialysis, and high level amputations.
Re: Renal failure and foot ulcer or lower extremity amputation in those patients with diabetes
The role of chronic kidney disease as a predictor of outcome after revascularisation of the ulcerated diabetic foot.
Venermo M, Biancari F, Arvela E, Korhonen M, Söderström M, Halmesmäki K, Albäck A, Lepäntalo M. Diabetologia. 2011 Aug 16.
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AIMS/HYPOTHESIS:
The aim of the study was to stratify the risk of diabetic patients with leg ulcer or gangrene undergoing infrainguinal revascularisation for critical limb ischaemia.
METHODS:
The study cohort included 732 revascularisation procedures performed in 597 diabetic patients with ulcer or gangrene. Logistic regression and CART analysis were used for identification of predictors of 1-year outcome.
RESULTS:
Logistic regression showed that chronic kidney disease (CKD) class (OR 1.38, 95% CI 1.16, 1.65) was an independent predictor of 1-year leg salvage (area under the receiver operating characteristic [ROC] curve 0.60, 95% CI 0.54, 0.65). The terminal nodes of the CART for 1-year leg salvage were CKD classes 4-5, the level (infrapopliteal vs femoropopliteal revascularisation), type of revascularisation (bypass surgery vs percutaneous transluminal angioplasty) and gangrene (area under the ROC curve 0.62, 95% CI 0.57, 0.68). Logistic regression showed that pulmonary disease (OR 1.76, 95% CI 1.11, 2.78), CKD class (OR 1.43, 95% CI 1.24, 1.65), foot gangrene (OR 1.76, 95% CI 1.21, 2.60) and patient age (OR 1.02, 95% CI 1.01, 1.04) were independent predictors of 1-year amputation-free survival (area under the ROC curve 0.65, 95% CI 0.60, 0.69). The terminal nodes of the CART for 1-year amputation-free survival were CKD classes 3-5, patient's age of ≥75 years and foot gangrene (area under the ROC curve 0.64, 95% CI 0.60, 0.68).
CONCLUSIONS/INTERPRETATION:
CKD is a formidable risk factor for poor intermediate outcome after infrainguinal revascularisation in diabetic patients with foot ulcer or gangrene. CART analysis indicates that foot gangrene is also a significant risk factor for adverse outcome.
Background: End stage renal disease (ESRD) has been associated with foot ulceration and lower extremity amputation (LEA). However, the underlying risk factors for foot ulceration have received limited attention in this population. The aim of this study was to investigate the prevalence and type of risk factors for foot ulceration present in patients with ESRD on haemodialysis without the coexistence of diabetes mellitus (DM).
Methods: One hundred and ninety participants with ESRD and/or DM were recruited over a six week period. Participants were allocated into one of three groups: (i) ESRD without DM, (ii) DM without ESRD and (iii) coexisting ESRD and DM. Participants were screened for the risk factors for foot ulceration. Statistical comparisons were made between the three groups for both the prevalence and type of risk factors using a Fisher's Exact Test.
Results: Risk factors for foot ulceration were found to be highly prevalent in the ESRD population. Participants with both ESRD and DM exhibited statistically significant differences in risk factor presentation for peripheral neuropathy (p = 0.033), vascular insufficiency (p = 0.001) and footwear (p = 0.037) in comparison to participants with DM alone.
Conclusion: There are high prevalence rates of risk factors for foot ulceration in the ESRD population on haemodialysis and are comparable to those with DM. Individuals with coexisting ESRD and DM have an even greater risk for foot ulceration and LEA. This highlights the importance that regular foot screening, preventative education and treatment are necessary for patients with ESRD to potentially reduce the risk of foot ulcerations and LEAs.
Re: Renal failure and foot ulcer or lower extremity amputation in those patients with diabetes
Peripheral arterial disease in diabetic patients with renal insufficiency: a review.
Lepäntalo M, Fiengo L, Biancari F. Diabetes Metab Res Rev. 2012 Feb
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Peripheral arterial disease is common among diabetic patients with renal insufficiency, and most of the diabetic patients with end-stage renal disease (ESRD) have peripheral arterial disease. Ischaemia is probably overrepresented as an etiological factor for a diabetic foot ulcer in this group of patients compared with other diabetic patients. ESRD is a strong risk factor for both ulceration and amputation in diabetic patients. It increases the risk of nonhealing of ulcers and major amputation with an OR of 2.5-3. Renal disease is a more important predictor of poor outcome after revascularizations than commonly expected. Preoperative vascular imaging is also affected by a number of limitations, mostly related to side effects of contrast agents poorly eliminated because of kidney dysfunction. Patients with renal failure have high perioperative morbidity and mortality. Persistent ischaemia, extensive infection, forefoot and heel gangrene, poor run-off, poor cardiac function, and the length of dialysis-dependent renal failure all affect the outcome adversely. Despite dismal overall outcome, recent data indicate that by proper selection, favourable results can be obtained even in ESRD patients, with the majority of studies reporting 1-year limb salvage rates of 65-75% after revascularization among survivors. High 1-year mortality of 38% reported in a recent review has to be taken into consideration, though. The preferential use of endovascular-first approach is attractive in this vulnerable multimorbid group of patients, but the evidence for endovascular treatment is very scarce. The need for complete revascularization of the foot may be even more important than in other patients with ischaemic ulcerated diabetic foot because there are a number of factors counteracting healing in these patients. Typically, half of the patients are reported to lose their legs despite open bypass. To control tissue damage and improve chances of ulcer healing, one should understand that early referral to vascular consultation is necessary.
Re: Renal failure and foot ulcer or lower extremity amputation in those patients with diabetes
From the 2012 ADA Mtg: A Retrospective Analysis of Risk of Acute Kidney Injury among People with Diabetic Foot Disease Undergoing Surgical Interventions
JUNAID IQBAL, ELAINE HIGGINS, ANDREW FISHER, JANE ASTLE, IRFAN AKHTAR, KHALID MAKDHOOMI, DEVAKA J. FERNANDO
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Acute Kidney injury (AKI) is a significant cause of in patient morbidity and mortality. Renal impairment is often associated with foot ulceration. Patients with diabetic foot disease are exposed to nephrotoxic antibiotics, radiological investigations involving potentially nephrotoxic contrast media and surgical interventions. Hence they are at higher risk of developing AKI. We reviewed the medical records of 45 consecutive people (Mean age 68.1 SD 10.2 years, 30 males) with diabetes (HBa1c 8.1 SD 1.5%) admitted with diabetic foot problems to a district general hospital retrospectively during a six month period. The frequency of Chronic Kidney Disease (CKD) and progression to AKI if any, during their in patient stay was determined. 23 (51%) satisfied criteria for CKD on admission. 12 (26.7%) developed AKI during in patient stay. 10 (43.5%) of those with CKD developed AKI (Likelihood ratio 7.2, p= 0.007) compared to 2 (9.1%) in whom AKI developed de novo. 5 (41.7%) of those receiving contrast media, developed AKI compared to 7 (21.2%) of those who did not (Likelihood ratio 69.2, p = 0.001) while 11 (18.3%) of those undergoing surgery developed AKI compared to 8 (25%) of those who did not (Likelihood ratio 67.4, p=0.001). Those who did not receive surgery had a higher frequency of co morbidities and were hence deemed unsuitable for surgical treatment. Patients admitted with diabetic foot problems are at high risk of deteriorating renal function requiring inputs from specialist nephrologists. Service provision for this patient group should include early assessment of risk of AKI, access to renal care and acute renal support services
From the 2012 ADA Mtg: High Mortality Rates from Foot Complications in Diabetic Patients on Dialysis
AGBOR NDIP, ANAND VARDHAN, KAREN BREISLIN, ANDREW J. BOULTON
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Diabetes is the commonest cause of end-stage renal disease (ESRD), requiring renal replacement therapy. Lower extremity complications in diabetes can result in significant morbidity and mortality further compounding the poor survival of the dialysis population.
A prospective observational study involving diabetic patients with ESRD on dialysis was undertaken to evaluate the impact of foot ulcers and amputations on mortality. We studied 192 diabetic patients receiving dialysis at the Manchester Royal Infirmary, UK. These included 17 (8.9%) African-Caribbeans, 38 (19.8%) Indo-Asians and 137 (71.4%) White Europeans aged (mean ± SD) 59 ± 14 years, with a male/female ratio of 121/71. Comprehensive foot assessment was performed at baseline including evaluating for neuropathy, peripheral arterial disease, foot deformities, and foot ulcers/amputation. Patients were followed up for a two-year period. Overall mortality at the end of two years was high (102/192, 53.1%). Patients who had a foot ulcer at baseline (35/59, 59.3%) had a higher mortality after 2 years of follow-up, compared with patients without (55/133, 41.4%, p = 0.028). Similarly, patients who had had an amputation at baseline had higher mortality at 2 years (26/35, 74.3%) compared to patients without amputation (64/157, 40.8%, p < 0.0001).
These data highlight the excess mortality in dialysis-treated diabetic patients resulting from foot ulcers and amputations, therefore underpinning the importance of integrating foot care and amputation prevention within the dialysis population.
Re: Renal failure and foot ulcer or lower extremity amputation in those patients with diabetes
The impact of creatinine clearance on the outcome of diabetic foot ulcers in north Indian tertiary care hospital.
Zubair M, Malik A, Ahmad J. Diabetes Metab Syndr. 2011 Jul;5(3):120-5
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AIM:
Wound healing has been reported to be poor in diabetic patients with impaired kidney functions that usually accompanies retinopathy and neuropathy. The insensitive foot is vulnerable to repeated trauma and development of ulcer precedes 70-80% of non-traumatic lower extremity amputation. The present study was aimed to study the impact of creatinine clearance (CCre) on the outcome of diabetic foot ulcers (DFU).
MATERIALS AND METHODS:
Data from 162 DFU patients admitted to Rajiv Gandhi Centre for Diabetes and Endocrinology of J.N. Medical College, Aligarh Muslim University, Aligarh, India, between December 2009 and March 2011 were analyzed. Detailed history and patient's profile, grade of DFU, co-morbidities and complications, laboratory data, microbiological profile and final outcome were collected. CCre was calculated according to MDRD formula.
RESULTS:
The study revealed that, DFU healing was worst in patients with decreased CCre than in those who had normal CCre. Other factors associated with poor outcome were, higher grade of ulcer, infection type (subcutaneous and osteomyelitis) and biofilm infection. Amputation rates were also found to be higher in those with poor renal functions.
CONCLUSIONS:
The results suggest that CCre is an important factor affecting wound healing in patients with DFUs. The automatic reporting of eGFR each time a serum creatinine concentration is requested will increase the awareness of significant kidney dysfunction in clinical practice especially in DFU patients and appropriate measures will improve the outcome.
Re: Renal failure and foot ulcer or lower extremity amputation in those patients with diabetes
Renal failure: implications of chronic kidney disease in the management of the diabetic foot. Lewis S, Raj D, Guzman NJ. Semin Vasc Surg. 2012 Jun;25(2):82-8.
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Foot complications are common in patients with diabetes, however, chronic kidney disease has emerged as an independent risk factor for development of foot lesions in the diabetic population. Apart from peripheral arterial disease, infection, and neuropathy, which are classic factors contributing to development of foot lesions, skin disorders specific to renal failure, impaired wound healing from uremia, and psychosocial issues offer further compounded risk. Consequently, there are high ulceration and amputation rates that are associated with increased morbidity and mortality. In recent studies, foot-care programs with a multidisciplinary approach within dialysis units have demonstrated improved outcomes.
Re: Renal failure and foot ulcer or lower extremity amputation in those patients with diabetes
ALLIED HEALTH SERVICES TO NEPHROLOGY: AN AUDIT OF CURRENT WORKFORCE AND MEETING FUTURE CHALLENGES.
Campbell KL, Murray EM. J Ren Care. 2013 Jan 8:1-10.
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AIM:
The aim of this study is to evaluate the breadth and depth of the allied health workforce providing renal services in Queensland, Australia.
METHODS:
Workforce statistics were reported for allied health renal services (excluding transplant) across all 14 publically funded regions across Queensland, Australia. Dietetics, pharmacy, podiatry, psychology and social work were compared with workforce benchmarks capturing full-time equivalent (FTE) to dialysis patient numbers (1 FTE:diaysis patients).
RESULTS:
Wide variation was evident within and between professions. All services provided dietetics, with nine services meeting the benchmark, with an average (median) of 1:127 (range 1:36-1:207). Ten services provided pharmacy (1:245 [1:36-1:845]), twelve provided social work (1:191 [1:71-1:845]) and seven provided psychology services (1:396 [1:155-1:1690]). Only one-third of units funded podiatry services (1:1077 [1:143-1:4300]), none of which met benchmark.
CONCLUSION:
There is a clear disparity in allied health workforce across in this region, with the vast majority below benchmark recommendations. In light of increasing demand for this area, it is timely to identify strategies for innovative workforce design to manage growth in allied health service needs into the future.
Re: Renal failure and foot ulcer or lower extremity amputation in those patients with diabetes
The value of Doppler waveform analysis in predicting major lower extremity amputation among dialysis patients treated for diabetic foot ulcers.
Tsai CY, Chu SY, Wen YW, Hsu LA, Chen CC, Peng SH, Huang CH, Sun JH, Huang YY. Diabetes Res Clin Pract. 2013 Mar 26.
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AIMS:
This study examined the predictors for lower extremity amputation (LEA) in patients with diabetic foot ulcers according to kidney function and, in the case of dialysis patients, specifically evaluated the vasculature with the ankle-brachial index (ABI) and Doppler waveforms.
METHODS:
Among 658 diabetic patients admitted to the Diabetic Foot Care Center, 286 had an estimated glomerular filtration rate (eGFR)≥60ml/min per 1.73m2, 275 had an eGFR<60, and 97 patients were under maintenance dialysis. All clinical variables were analyzed. A specialist retrospectively reviewed Doppler images of 78 of the patients in dialysis to evaluate peripheral arterial disease.
RESULTS:
Forty-two percent of patients with eGFR<60 presented with ABI≤0.90. For ABI values>1.40, the proportion of dialysis patients (31.3%) was greater than the proportion of patients with eGFR<60 (5.3%). Wagner wound classifications, reduced serum albumin levels, and low ABI values were the predictors for major LEA among patients in the non-dialysis groups. Nevertheless, these indicators were not predictive of the risk of amputation in diabetic patients on dialysis. The presence of poor monophasic waveforms in the dorsalis pedis artery or posterior tibial artery served as an independent predictor (odds ratio: 7.61; P=0.008) for major LEA among dialysis patients. The sensitivity and specificity were 88.0% and 59.6%, respectively.
CONCLUSIONS:
Poor monophasic Doppler waveforms of below-the-knee arteries, commonly found among dialysis patients in treatment for diabetic foot ulcers, can serve as an independent predictor for major LEA.
Diabetes is commonly complicated by the development of chronic kidney disease (CKD). Equally prevalent is the development of diabetic foot disease and it is now recognised that there is a higher risk of the development of foot disease and major amputation in those patients with CKD. This is particularly marked in those patients with end-stage kidney disease receiving renal replacement therapy for which there are many possible mechanisms, including the effect of dialysis on tissue hypoxia. What has been recognised recently is that the risk of the development of foot disease appears to start prior to the onset of renal replacement therapy. Whilst this may be due to the fact that the emphasis of care shifts towards the requirements of the patients' renal disease, here we discuss the possibility that the presence of a foot ulcer itself may contribute to the development or progression of CKD through repeated episodes of sepsis or chronic inflammation, or both.
Diabetes is commonly complicated by the development of chronic kidney disease (CKD). Equally prevalent is the development of diabetic foot disease and it is now recognised that there is a higher risk of the development of foot disease and major amputation in those patients with CKD. This is particularly marked in those patients with end-stage kidney disease receiving renal replacement therapy for which there are many possible mechanisms, including the effect of dialysis on tissue hypoxia. What has been recognised recently is that the risk of the development of foot disease appears to start prior to the onset of renal replacement therapy. Whilst this may be due to the fact that the emphasis of care shifts towards the requirements of the patients' renal disease, here we discuss the possibility that the presence of a foot ulcer itself may contribute to the development or progression of CKD through repeated episodes of sepsis or chronic inflammation, or both.
Renal failure and foot ulcer or lower extremity amputation in those patients with diabetes
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