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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.
Renal failure and foot ulcer or lower extremity amputation in those patients with diabetes
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