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BACKGROUND: The aim of this study was to seek a temporal association between the start of renal replacement therapy (RRT) and the first recorded foot ulcer in diabetes.
METHODS: Details of all patients with diabetes who had received RRT were extracted from the renal database and were cross-checked with the database held in the specialist foot clinic. The date of onset of first registered foot ulcer was taken and compared with the date of onset of RRT. The self-controlled case-series method was used to establish any significant temporal association between the start of RRT and first recorded foot ulcer in diabetes.
RESULTS: Of 466 patients with diabetes dialysed at our hospital since 1976, 94 (20.2%) were recorded as having at least one foot ulcer, with 15 of these undergoing major amputation. Incidence ratios (IRs) were calculated for 90 patients in whom complete data were available. A close temporal association was observed between the start of RRT and the first recorded foot ulceration: IR (95% CI) in the first and between the second and fifth years of dialysis were 3.35 (95% CI: 1.59-7.04), and 4.56 (2.19-9.50), respectively, relative to the time before dialysis. The IR for major amputation was 31.98 (2.09-490.3) in the first year and 34.01 (1.74-666.2) in the second to fifth years.
CONCLUSION: These results reveal a close relationship between the onset of RRT in diabetes and the onset of foot ulceration, and confirm the high incidence of amputation in those on dialysis. Urgent steps should be taken to coordinate all aspects of diabetes foot care before and after the start of RRT.
Background: Although chronic kidney disease (CKD) has been associated with foot ulceration, the pathological pathway involved remains unclear. This pilot study was designed to investigate the risk factors for foot ulceration in individuals with CKD who do not have diabetes. The aims of this study were to establish the risk status for foot ulceration in individuals with CKD and to identify the particular foot ulcer risk factors most prevalent in this group.
Methods: One hundred outpatients were recruited from a metropolitan hospital and allocated into one of four groups: (i) control: neither diabetes nor CKD, (ii) diabetes alone, (iii) coexisting CKD and diabetes and (iv) CKD alone. All participants were assessed for past/current foot ulcers, peripheral neuropathy, vascular insufficiency, structural deformity and skin pathology. Comparisons were made between the groups regarding the prevalence of these factors.
Results: Participants with CKD who did not have diabetes displayed no significant differences in risk factor presentation from those with diabetes alone. Of the participants with CKD and no diabetes, 36% had peripheral neuropathy, 20% had vascular insufficiency and 24% had the copresentation of peripheral neuropathy and structural deformity. Overall, participants with both CKD and diabetes had the highest presentation of past/current foot ulcers, peripheral neuropathy and vascular insufficiency, all significantly more frequent in this group than in controls (P < 0.05). Eight of the total 10 participants found to have a past/current foot ulcer were in end-stage kidney failure.
Conclusion: Individuals with CKD frequently display risk factors for foot ulceration. Risk factors are more prevalent in individuals who also have diabetes and foot ulcers become more frequent with progression to end-stage kidney failure. Risk assessment and patient awareness strategies should therefore be extended to include all patients with CKD so as to reduce future foot ulcer development.
Comparison of bacterial isolates cultured from hemodialysis patients and other patients with diabetic foot and their antimicrobial resistance.
Cetin M, Ocak S, Kuvandik G, Aslan B.
Department of Microbiology and Clinical Microbiology, Mustafa Kemal University, Hatay, Turkey. Ren Fail. 2007;29(8):973-8.
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The aim of this study was to compare microbial findings and their resistance to antibiotics between hemodialysis patients and patients without end-stage renal failure with diabetic foot infections. An 18-month-long descriptive study analyzed bacterial isolates obtained from 32 hemodialysis (HD) patients with diabetic foot infection in an Antakya hemodialysis center and 65 patients with diabetic foot infection admitted to the Education and Research Hospital of Mustafa Kemal University, Turkey. No significant difference in the mean number of pathogens per patient was found between the dialysis patients and other patients (2.3 vs. 2.1, respectively) (p > 0.05). While the occurrence of gram-positive bacteria in the HD patients was found to be 59.0%, this rate in the other patients was 53.1% (p > 0.05). While most frequent bacterial species isolated in the HD patients were S. aureus (22.9%), followed by coagulase-negative Staphylococcus spp. (CNS) (19.7%), the microorganisms in the other patients were found as CNS (20.7%), followed S. aureus (18.0%). The data recommend that antibiotic therapy in HD patients with diabetic foot infection should be more closely guided by culture findings and antimicrobial susceptibility results.
Freeman, K. May, N. Frescos, P. R. Wraight (2008) Frequency of risk factors for foot ulceration in individuals with chronic kidney disease Internal Medicine Journal 38 (5) , 314–320
Background: Although chronic kidney disease (CKD) has been associated with foot ulceration, the pathological pathway involved remains unclear. This pilot study was designed to investigate the risk factors for foot ulceration in individuals with CKD who do not have diabetes. The aims of this study were to establish the risk status for foot ulceration in individuals with CKD and to identify the particular foot ulcer risk factors most prevalent in this group.
Methods: One hundred outpatients were recruited from a metropolitan hospital and allocated into one of four groups: (i) control: neither diabetes nor CKD, (ii) diabetes alone, (iii) coexisting CKD and diabetes and (iv) CKD alone. All participants were assessed for past/current foot ulcers, peripheral neuropathy, vascular insufficiency, structural deformity and skin pathology. Comparisons were made between the groups regarding the prevalence of these factors.
Results: Participants with CKD who did not have diabetes displayed no significant differences in risk factor presentation from those with diabetes alone. Of the participants with CKD and no diabetes, 36% had peripheral neuropathy, 20% had vascular insufficiency and 24% had the copresentation of peripheral neuropathy and structural deformity. Overall, participants with both CKD and diabetes had the highest presentation of past/current foot ulcers, peripheral neuropathy and vascular insufficiency, all significantly more frequent in this group than in controls (P < 0.05). Eight of the total 10 participants found to have a past/current foot ulcer were in end-stage kidney failure.
Conclusion: Individuals with CKD frequently display risk factors for foot ulceration. Risk factors are more prevalent in individuals who also have diabetes and foot ulcers become more frequent with progression to end-stage kidney failure. Risk assessment and patient awareness strategies should therefore be extended to include all patients with CKD so as to reduce future foot ulcer development.
Vascular complications of the lower extremities in diabetic patients on peritoneal dialysis.
Pliakogiannis T, Bailey S, Cherukuri S, Taskapan H, Ahmad M, Oliver T, Bargman JM, Oreopoulos DG. Clin Nephrol. 2008 May;Volume 69(May):361-367.
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Background: Diabetic patients with end-stage renal disease (ESRD) are at high risk for developing foot complications and few have studied this complication in the diabetic patients treated with peritoneal dialysis (PD). The purpose of this study was to examine peripheral vascular disease (PVD) in diabetic patients with ESRD, who are being treated with PD, and to identify those factors that may contribute to its development.
Patients: We reviewed retrospectively the charts of 71 diabetic patients who started PD between January 1999 and January 2006, inclusive, and recorded their demographic data, their treatment regimens, their complications and the results of biochemical investigation(s) at the beginning and throughout their follow-up period. All patients were under the care of a chiropodist who examined them at regular intervals and more often when needed. We divided the patients into two groups with respect to the presence of complications in the lower extremities, such as ulcers, open wounds, osteomyelitis, necrotizing or gangrenous lesions, and amputations, intermittent claudication and/or the presence on an imaging examination of changes in the leg vessels consistent with vascular disease.
Results: 33 of the 71 patients had some type of a foot lesion. There were 8 amputations in the course of 176 patient-years (2 double amputations), or 1 amputation per 30 PD patient-years. Those patients with foot complications were treated more frequently with CCPD (p < 0.05), more often had peripheral neuropathy (p < 0.002), as well as coronary artery disease (p < 0.044). They had lower serum albumin (p < 0.005), significantly higher serum phosphorus (p < 0.047) and they received higher doses of erythropoietin (p < 0.042). There was no statistically significant difference between the groups regarding sex, age at initiation of PD, type of diabetes, use of insulin, levels of HbA1c, body mass index (BMI), presence of retinopathy, cerebral vascular disease, hyperlipidemia, smoking, rate of transplantation, rate of drop-out from PD, time-averaged Kt/V, creatinine clearance, serum calcium, Ca A P and intact PTH. In a multiple logistics regression model, only peripheral neuropathy and hypoalbuminemia were independently associated with the development of lower-extremity complications (p < 0.0066 and p < 0.026, respectively). One-, two- and three-year cumulative survival of the whole group was 91.5%, 78.8% and 69%, respectively. Patients with foot lesions had a lower survival than those without. Interestingly though, those patients, who had had an amputation, survived as long as those patients, who did not have foot complications at all.
Conclusion: In conclusion, compared to reports in the literature, our diabetic patients on PD had a lower rate of foot complications and amputation probably because of early intervention by our chiropodist. This fact stresses the need for constant and expert monitoring of the condition of the diabetic patientâs feet, especially in those with low serum albumin and peripheral neuropathy.
OBJECTIVES: To determine the influence of haemodialysis on the poor healing of ischaemic ulcers in end-stage renal failure patients regardless of successful revascularization.
MATERIALS AND METHODS: We investigated the microscopic findings of subcutaneous small vessels in the amputated limbs of 78 patients (27 diabetic/haemodialysis, 26 diabetic/non-haemodialysis and 25 non-diabetic/non-haemodialysis patients) who underwent foot/toe or limb amputation because of ischaemic foot ulcers in the period between 1998 and 2006. All the haemodialysis patients were diabetic. Multivariate logistic analysis was conducted to identify important clinical factors related to the histological findings.
RESULTS: Marked medial thickening was observed in both small veins and arteries in diabetic patients compared with non-diabetic patients. In diabetics, there was significant medial thickening of small veins, which was greater in haemodialysis patients than in non-haemodialysis patients (Dunnett test, P<0.05). Multivariate analysis indicated that haemodialysis treatment (odds ratio 14.12, P<0.01), ABI value (odds ratio 5.41, P<0.01) and poor stump wound healing (odds ratio 6.19, P=0.03) were important factors related to medial thickening of small veins.
CONCLUSIONS: Our data suggest that medial thickening of small veins, or phlebosclerosis, might affect the healing of ischaemic ulcers in end-stage renal failure, although the strong influence of diabetes cannot be ignored.
Health-related quality of life and all-cause mortality in patients with diabetes on dialysis.
Osthus TB, von der Lippe N, Ribu L, Rustøen T, Leivestad T, Dammen T, Os I. BMC Nephrol. 2012 Aug 3;13(1):78.
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BACKGROUND:
This study tests the hypotheses that health-related quality of life (HRQOL) in prevalent dialysis patients with diabetes is lower than in dialysis patients without diabetes, and is at least as poor as diabetic patients with another severe complication, i.e.. foot ulcers. This study also explores the mortality risk associated with diabetes in dialysis patients.
METHODS:
HRQOL was assessed using the Short Form-36 Health Survey (SF-36), in a cross-sectional study of 301 prevalent dialysis patients (26% with diabetes), and compared with diabetic patients not on dialysis (n = 221), diabetic patients with foot ulcers (n = 127), and a sample of the general population (n = 5903). Mortality risk was assessed using a Kaplan-Meier plot and Cox proportional hazards analysis.
RESULTS:
Self-assessed vitality, general and mental health, and physical function were significantly lower in dialysis patients with diabetes than in those without. Vitality (p = 0.011) and general health (p <0.001) was impaired in diabetic patients receiving dialysis compared to diabetic patients with foot ulcers, but other subscales did not differ. Diabetes was a significant predictor for mortality in dialysis patients, with a hazard ratio (HR) of 1.6 (95% CI 1.0-2.5) after adjustment for age, dialysis vintage and coronary artery disease. Mental aspects of HRQOL were an independent predictor of mortality in diabetic patients receiving dialysis after adjusting for age and dialysis vintage (HR 2.2, 95% CI 1.0-5.0).
CONCLUSIONS:
Physical aspects of HRQOL were perceived very low in dialysis patients with diabetes, and lower than in other dialysis patients and diabetic patients without dialysis. Mental aspects predicted mortality in dialysis patients with diabetes. Increased awareness and measures to assist physical function impairment may be particularly important in diabetes patients on dialysis.
Background
Lower extremity complications are a major cause of morbidity and mortality in patients with end-stage renal disease (ESRD) and diabetes mellitus. Patient education programs may decrease the risk of diabetic foot complications.
Methods
A preventive program was instituted, consisting of regular assessments by a foot care nurse with expertise in foot care and wound management and patient education about foot care practices and footwear selection. Medical records were reviewed and patients were examined. A comparison was made with data about patients from a previous study done from this institution prior to development of the foot care program.
Results
Diabetic subjects more frequently had weakness of the left tibialis anterior, left tibialis posterior, and left peroneal muscles than non-diabetic subjects. A smaller percentage of diabetic subjects had sensory neuropathy compared with the previous study from 5 years earlier, but a greater percentage of diabetic subjects had absent pedal pulses in the current study. The frequency of inadequate or poor quality footwear was less in the current study compared with the previous study.
Conclusions
The current data suggest that a foot care program consisting of nursing assessments and patient education may be associated with a decrease in frequency of neuropathy and improved footwear adequacy in diabetic patients with ESRD.
It is well documented that diabetic foot ulceration contributes to increased morbidity and mortality associated with renal replacement therapy. Much less is known about the risk of foot ulceration and lower limb amputation in the non diabetic dialysis population. The aim of this study was to determine if the prevalence of risks factors for lower limb amputation in a stable haemodialysis population was greater in the diabetic cohort compared with the non diabetic cohort. The study design is a prospective observational cohort study. Sixty patients attending a satellite haemodialysis unit in Cardiff were invited to have a comprehensive foot assessment as part of a Podiatry service review. The medical notes and hospital information system were used to identify the diabetic cohort. Patients were classified according to diabetic status (diabetic versus non diabetic). The Renal Foot Screening Tool was developed to prospectively identify risk factors associated with foot ulceration. The assessment included peripheral neuropathy (PN), peripheral arterial disease (PAD) and foot pathology (FP). Fifty-seven patients gave informed verbal consent prior to inclusion. Risk factors for foot ulceration were recorded at baseline in the diabetic (n = 24) and non diabetic (n = 33) groups and mortality data was revisited after a 3-year period. FP was identified in 79% of patients. Eighteen per cent of the non diabetic patients had PN. PAD was identified in 45% of diabetic and 30% of non diabetic patients. Forty-nine per cent of the total cohort had ≥2 of the 3 independent risk factors for foot ulceration (16/24 diabetic versus 12/33 non diabetic). The presence of PAD and PN was predictive of mortality independent age. The limitations of this study are its small sample size and patients were from a single satellite dialysis unit. There was a high prevalence of risk factors for foot ulceration in this population, which were not confined to the diabetic cohort. These findings suggest that non diabetic patients on haemodialysis therapy are also at risk of developing foot ulceration. Further work on strategies to monitor and prevent FP in this high-risk cohort is needed to minimize morbidity and mortality associated with foot ulceration.
Diabetes remains the single most common cause of both end-stage renal disease and non-traumatic amputation of the lower limb. There is a close association between renal disease, peripheral symmetrical neuropathy, peripheral vascular disease, foot ulcers, amputation and survival in patients with diabetes. The risk of foot ulcers or major limb amputation appears to accelerate soon after the start of renal replacement therapy. All professionals involved in the care of patients with diabetes and renal disease should be aware of the extent to which the patients' feet are at risk. Diabetic foot disease on the renal unit
Diabetic foot wounds in haemodialysis patients: 2-year outcome after percutaneous transluminal angioplasty and minor amputation.
Matsuzaki K, Miyamoto A, Hakamata N, Fukuda M, Yamauchi Y, Akita T, Kuhara R, Tezuka S. Int Wound J. 2012 Oct 24.
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Critical limb ischaemia (CLI) is known to be associated with high mortality. In some patients, surgery cannot be performed due to high risk of perioperative death and complications. In other cases, there is only pain at rest but no wound. Therefore, it is difficult to accurately predict the prognosis of individual patients. We examined the prognosis of CLI cases in which therapeutic footwear was made for ambulation after wounds healed. The subjects were 31 haemodialysis patients with diabetic foot wounds, which were treated with percutaneous transluminal angioplasty and minor amputation. The subjects were 22 men and 9 women. Female patients were significantly older than male patients (P = 0·046). Two-year postoperative outcomes were survival in 19 patients and death in 12 patients. Eight of twelve deceased patients had a history of coronary intervention. There were 8 deaths among 13 patients with such history, indicating a marginally significant increase in the mortality rate (P = 0·060). Re-amputation was performed in 6 of 19 patients who survived. Two years postoperatively, 41·9% of patients overall survived without re-amputation. It is important to increase the number of cases for further study to improve the well-being of CLI patients and to examine medical economics.
There is a prevalence of lower extremity amputations in patients with diabetes mellitus who are receiving hemodialysis; the frequency occurs because diabetes affects sensation, circulation, and the healing process, which predisposes patients with diabetes to skin damage and increases the risk for infections and foot ulcers. In a lifetime, about 15% of patients with diabetes will develop foot ulcers requiring an amputation. Previous research demonstrates that proper foot care and adequate footwear with frequent inspections of the feet will prevent foot ulcers. This article proposes the use of a comprehensive foot care model.
Foot ulceration and onset of renal dialysis
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