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Does the Proximity of an Amputation, Length of Time Between Foot Ulcer Development and Amputation, or Glycemic Control at the Time of Amputation Affect the Mortality Rate of People with Diabetes who Undergo an Amputation?
Jones RN, Marshall WP. Adv Skin Wound Care. 2008 Mar;21(3):118-23
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OBJECTIVES:: The main purpose of the authors' research was to compare the 3- and 5-year mortality rates of diabetic patients who have undergone a lower-extremity amputation, evaluating the proximity of the amputation in 3 groups (toe and foot amputation, BKA, and AKA), the timing of the amputation (within or after 2 years of the onset of the foot ulcer), and the effect of glycemic control at the time of amputation, regardless of the level of amputation.
METHODS AND DESIGN:: The subjects were 80 male inpatients at Illiana Veterans Health Care System who had diabetes, diabetic neuropathy, peripheral vascular disease, and a diabetic foot ulcer that resulted in an amputation. Of the 80 patients, 29 had a toe amputation, 30 had a BKA, and 21 had an AKA. The mean age in all 3 groups was 68.5 years +/- 7.2 years. The authors used the hemoglobin A1C (Hgb A1C) level to assess glycemic control.
MAIN OUTCOME MEASURES:: Several chi tests were used to compare the 3- and 5-year mortality rates among the amputation groups. An Hgb A1C level of 8% or less defined good glycemic control; an Hgb A1C level of more than 8% defined poor glycemic control. A chi test was used to compare glycemic control, the level of amputation, and the mortality rate. A chi test was also used to evaluate the length of time between ulcer formation and amputation, the level of amputation, and the mortality. All statistics were done using SPSS 10.0 student version.
CONCLUSIONS:: The research revealed a statistically significant difference in mortality among the 3 groups at 3 and 5 years. No statistically significant difference in mortality in patients with good glycemic control and patients with bad glycemic control was found. At 3 years, a statistically significant difference in mortality existed between patients who had an amputation within 2 years of ulcer formation and those who had an amputation after 2 years. At 5 years, no statistically significant difference existed between these 2 groups.
High Rates of Comorbid Conditions in Patients With Type 2 Diabetes and Foot Ulcers
John Doupis, MD, PhD; Penelope Grigoropoulou, MD; Christina Voulgari, MD; Andreas Stylianou, MD; Anna Georga, MD; Petros Thomakos, MD; Konstantinos Xiromeritis, MD; Xrysi Koliaki, MD; Nicholas Katsilambros, MD; Nicholas Tentolouris, MD Wounds - Volume 20 - Issue 5 - May 2008
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Background/Aim. Foot ulceration is one of the most important diabetic complications that results in major medical, social, and economic consequences for patients, their families, and society as a whole. Previous studies have shown increased mortality in patients with diabetes with foot ulcers; however, the reason for the high mortality in this group of patients is not known. The aim of this cross-sectional study was to investigate prevalence rates of comorbid conditions in patients with diabetes and foot ulcers.
Methods. A total of 742 patients with type 2 diabetes (234 with foot ulcers and 508 without ulcers), consecutively attending the outpatient diabetes and diabetic foot clinics of the authors’ hospital were reviewed. Clinical examination was performed to classify ulcers as neuropathic or neuroischemic, microvascular and macrovascular complications, as well as laboratory tests that were reviewed from medical records.
Results. Patients with diabetes with and without foot ulcers did not differ significantly in terms of age, sex, smoking habits, glycemic control, and prevalence rates of hypertension, dyslipidemia, and cerebrovascular disease. Known duration of diabetes was longer (P < 0.001), while the values of body mass index (P = 0.03) and creatinine clearance (P = 0.003) were lower in the patients with foot ulcers than in those without ulcers. In addition, prevalence rates of coronary artery disease (P = 0.005), lower extremity arterial disease (P < 0.001), retinopathy (P < 0.001), and nephropathy (P = 0.04), were higher in the patients with foot ulcers compared to those without ulcers. Additionally, duration of diabetes was longer and the prevalence rates of microvascular and macrovascular complications as well as hypertension, dyslipidemia, and smoking were much higher in the patients with neuroischemic ulcers in comparison to those with neuropathic ulcers.
Conclusion. The high mortality rates in patients with diabetes and foot ulcers may be due to the high prevalence rates of comorbid conditions, especially coronary artery disease and nephropathy.
Five-year mortality rates after new-onset diabetic ulceration have been reported between 43% and 55% and up to 74% for patients with lower-extremity amputation. These rates are higher than those for several types of cancer including prostate, breast, colon, and Hodgkin’s disease. These alarmingly high 5-year mortality rates should be addressed more aggressively by patients and providers alike. Cardiovascular diseases represent the major causal factor, and early preventive interventions to improve life expectancy in this most vulnerable patient cohort are essential. New-onset diabetic foot ulcers should be considered a marker for significantly increased mortality and should be aggressively managed locally, systemically, and psychologically.
AIMS: We analyze mortality of first-time diabetic amputees by stratifying by level of amputation, differentiating short-term and long-term mortality.
METHODS: We evaluated 277 diabetic patients who received their first lower extremity amputation (LEA) during 1993-97. Subjects were followed until December 2003, and categorized by level of amputation. We compared the mortality difference by level for 0-10 years, 0-10 months, and 10 months-10 years, and examined the association of comorbid conditions and death for each level.
RESULTS: We found a significant difference in mortality by amputation level for 0-10 years (p<0.05) and <10 months (p<0.01) survival, but not for the one of 10 months-10 years. For major amputees deceased within 10 months, sepsis was as frequent a cause of death as cardiovascular disease. In distal amputees, CVD, CAD and ESRD were strongly associated with death, but only CAD was associated death among major amputees.
CONCLUSION: For diabetic patients undergoing first LEAs, the mortality of major amputees was worse than that of minor amputees due to the difference in first 10-month mortality. The history of comorbid conditions in first-time major amputees was less important than in minor amputees since sepsis was the frequent cause of death in major amputees in this early period.
Mortality after major amputation in diabetic patients with critical limb ischemia who did and did not undergo previous peripheral revascularization Data of a cohort study of 564 consecutive diabetic patients.
Faglia E, Clerici G, Caminiti M, Curci V, Clerissi J, Losa S, Casini A, Morabito A. J Diabetes Complications. 2009 Mar 26. [Epub ahead of print]
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BACKGROUND: To evaluate the survival after major lower limb amputation, at a level either below (BKA) or above (AKA) the knee, in diabetic patients admitted to hospital because of critical limb ischemia (CLI).
METHODS: From January 1999 to December 2003, 564 diabetic patients were consecutively admitted to our Foot Center because of CLI and followed up until December 2005. A revascularization procedure was performed in 537 patients (95.2%): in 420 with peripheral angioplasty, in 117 with peripheral bypass graft. Neither endoluminal nor surgical revascularization was practicable in 27 (4.8%) patients.
RESULTS: Major amputation was performed in a total of 55 (9.8%) patients. Among the clinical and demographic variables evaluated, age was significantly lower (67.3+/-10.1 vs. 76.7+/-10.4, P<.001), duration of diabetes was higher (17.1+/-11.1 vs. 13.4+/-10.0, P=.013), and current smoking was more frequent (38.5% vs. 25.0%, P<.001) in revascularized amputees. The amputation free median time for revascularized patients was 5.11 months, and for nonrevascularized patients, 0.33 months. The log-rank test for equality of survivor function without amputation between amputees with or without revascularization was 31.76 (P<.001). Among the 55 amputees, 11 (28.2%) out of the 39 revascularized patients and 13 (81.2%) out of the 16 nonrevascularized patients died. The log-rank test for equality of survivor function was 6.83 (P=.009). The Cox model performed to evaluate the association between the recorded variables and the mortality showed a significant hazard ratio only with age (hazard ratio for 1 year 1.11, P=.003, confidence interval 1.04-1.19).
CONCLUSIONS: Our data suggest that the revascularization allows to postpone the major amputation, and that the survival of revascularized amputees is better than that of nonrevascularized amputated patients. All these data offer further encouragement to revascularize all diabetic patients with CLI.
Mortality Risk of Charcot Arthropathy Compared With That of Diabetic Foot Ulcer and Diabetes Alone Diabetes Care 32:816-821, 2009
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OBJECTIVE— The purpose of this study was to compare mortality risks of patients with Charcot arthropathy with those of patients with diabetic foot ulcer and those of patients with diabetes alone (no ulcer or Charcot arthropathy).
RESEARCH DESIGN AND METHODS— A retrospective cohort of 1,050 patients with incident Charcot arthropathy in 2003 in a large health care system was compared with patients with foot ulcer and those with diabetes alone. Mortality was determined during a 5-year follow-up period. Patients with Charcot arthropathy were matched to individuals in the other two groups using propensity score matching based on patient age, sex, race, marital status, diabetes duration, and diabetes control.
RESULTS— During follow-up, 28.0% of the sample died; 18.8% with diabetes alone and 37.0% with foot ulcer died compared with 28.3% with Charcot arthropathy. Multivariable Cox regression shows that, compared with Charcot arthropathy, foot ulcer was associated with 35% higher mortality risk (hazard ratio 1.35 [95% CI 1.18–1.54]) and diabetes alone with 23% lower risk (0.77 [0.66–0.90]). Of the patients with Charcot arthropathy, 63% experienced foot ulceration before or after the onset of the Charcot arthropathy. Stratified analyses suggest that Charcot arthropathy is associated with a significantly increased mortality risk independent of foot ulcer and other comorbidities.
CONCLUSIONS— Charcot arthropathy was significantly associated with higher mortality risk than diabetes alone and with lower risk than foot ulcer. Patients with foot ulcers tended to have a higher prevalence of peripheral vascular disease and macrovascular diseases than patients with Charcot arthropathy. This finding may explain the difference in mortality risks between the two groups
A History of Foot ulcer increases Mortality among Persons with Diabetes. 10-year Follow-up of the Nord-Trondelag Health Study, Norway.
Iversen MM, Tell GS, Riise T, Hanestad BR, Ostbye T, Graue M, Midthjell K. Diabetes Care. 2009 Sep 3. [Epub ahead of print]
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Objective - To compare mortality rates for persons with diabetes with and without a history of foot ulcer (HFU) and with the non-diabetic population.
Research design and methods- This population-based study included 155 diabetic persons with a HFU, 1,339 diabetic persons without a HFU, and 63,632 non-diabetic persons who were all followed for 10 years with mortality as the end point.
Results - During the follow-up period, a total of 49.0% of diabetic persons with a HFU died, compared to 35.2% of diabetic persons without a HFU and 10.5% of those without diabetes. In Cox regression analyses adjusted for age, sex, education, current smoking, and waist circumference, having a HFU was associated with more than a twofold (2.29 [95% CI 1.82-2.88]) hazard risk for mortality compared to the non-diabetic group. In corresponding analyses comparing diabetic persons with and without a HFU, a HFU was associated with 47% increased mortality (1.47 [1.14-1.89]). Significant covariates were older age, being male and current smoking. After also including HbA(1c), insulin use, microalbuminuria, cardiovascular disease and depression scores in the model, each was significantly related to life expectancy.
Conclusions - A HFU increased mortality risk among community-dwelling adults and elderly people with diabetes. The excess risk persisted after adjusting for comorbidity and depression scores, indicating that close clinical monitoring might be warranted among persons with a HFU, who may be particularly vulnerable to adverse outcomes.
OBJECTIVE To compare mortality rates for individuals with diabetes with and without a history of foot ulcer (HFU) and with that for the nondiabetic population.
RESEARCH DESIGN AND METHODS This population-based study included 155 diabetic individuals with an HFU, 1,339 diabetic individuals without an HFU, and 63,632 nondiabetic individuals who were all followed for 10 years with mortality as the end point.
RESULTS During the follow-up period, a total of 49.0% of diabetic individuals with an HFU died, compared with 35.2% of diabetic individuals without an HFU and 10.5% of those without diabetes. In Cox regression analyses adjusted for age, sex, education, current smoking, and waist circumference, having an HFU was associated with more than a twofold (2.29 [95% CI 1.82–2.88]) hazard risk for mortality compared with that of the nondiabetic group. In corresponding analyses comparing diabetic individuals with and without an HFU, an HFU was associated with 47% increased mortality (1.47 [1.14–1.89]). Significant covariates were older age, male sex, and current smoking. After inclusion of A1C, insulin use, microalbuminuria, cardiovascular disease, and depression scores in the model, each was significantly related to life expectancy.
CONCLUSIONS AN HFU increased mortality risk among community-dwelling adults and elderly individuals with diabetes. The excess risk persisted after adjustment for comorbidity and depression scores, indicating that close clinical monitoring might be warranted among individuals with an HFU, who may be particularly vulnerable to adverse outcomes.
Mortality and diabetes related amputations
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