Dialysis treatment is an independent risk factor for foot ulceration in patients with diabetes and stage 4 or 5 chronic kidney disease

Risk factors for amputation in patients with diabetic foot infection: a prospective study

There is a variety of diagnostic and therapeutic algorithms for diabetic foot infections (DFIs). Some of them are too difficult to be applied in routine clinical approach. In the routine clinical approach, it is necessary to find new risk factors and end up with a quick and easy assessment of DFIs. In this study, we aimed to evaluate the independent risk factors for osteomyelitis, amputation and major amputation in patients with DFI using standard scoring procedures. We prospectively studied 379 patients with DFI. The variables were analysed using logistic analysis. A total of 126 cases (33·2%) underwent amputation. The odds ratios in the amputation model were 3·09 for osteomyelitis (P < 0·001), 4·90 for arterial stenosis (AS) (P < 0·001), 3·67 for the history of DFI (P = 0·001), 2·47 for ulcer duration >60 days (P = 0·001), 3·10 for ulcer depth > 15 mm (P < 0·001) and 10·28 for fungal DFI (P = 0·015). In this study, the unusual result of well-known literature was fungal DFI as an independent risk factor for amputation in patients with DFI.

Opacity of big toenail predicts poor prognosis in patients with end-stage renal disease on hemodialysis

BACKGROUND

The impact of nail abnormalities on prognosis in hemodialysis patients is unknown. This study investigated whether toenail opacity as a readout of nail abnormalities predicted prognosis in hemodialysis patients.

METHODS

In this observational study, 494 eligible hemodialysis patients who received hemodialysis at Oyokyo Kidney Research Institute between September 2010 and December 2015 were included. The presence of nail abnormalities was objectively evaluated by big toenail opacity ratio measurement. Primary endpoint was overall survival, and secondary endpoints were lower limb amputation and determination of risk factors for poor prognosis among patient demographics, comorbidities, blood tests, and big toenail opacity. Overall survival and lower limb survival were evaluated using the Kaplan-Meier method with log-rank test. Multivariate Cox regression analyses assessed predictors for poor prognosis.

RESULTS

Big toenail opacity was found in 259 (52%) patients. Patients with big toenail opacity were significantly older, had shorter duration of dialysis, higher prevalence rates of diabetes mellitus (DM), cardiovascular disease (CVD), and higher mortality rates than those without opacity. Presence of big toenail opacity predicted poor prognosis for both overall and lower limb survival. Multivariate Cox regression analyses revealed serum albumin, the presence of DM and big toenail opacity were independent risk factors for both poor overall and lower limb survivals.

CONCLUSION

The prevalence of big toenail opacity was high in hemodialysis patients. Despite the short observation period, our findings indicated that big toenail opacity had significant predictive power for poor overall and lower limb survival.

Eye and foot checks in patients with diabetes on haemodialysis: Are they done, and who does them?

AIM

To determine if retinal and foot checks are carried out on patients with diabetes receiving haemodialysis.

METHODS

Eighty-four patients with diabetes receiving haemodialysis were asked if they recalled having eye and foot screening in the last year, and if so, by whom was the check done.

RESULTS

Seventy-seven (91.7%) patients recalled having an eye check in the preceding 12 mo. Of these, 52 (67.5%) did so in an ophthalmology clinic, 17 (22%) in retinal screening, three (3.9%) in an optician clinic. Three patients (3.9%) went to both ophthalmology and retinal screening, and two (2.6%) attended an ophthalmology and optician. Seventy (83.3%) patients recalled having a foot check in the preceding 12 mo. Of these, 33 (47.1%) were done by practice nurse, 14 (20%) by a diabetes nurse, 11 (15.7%) by a general practitioner, eight (11.4%) by a chiropodist, and four (5.7%) were each checked by renal nurse, diabetes consultant, junior doctor, or unknown person at a foot clinic.

CONCLUSION

Most patients with diabetes on haemodialysis are able to recall having an eye check in the last year, although 8.3% could not. A significant proportion of patients could not recall having a foot check (16.7%) in the last year. This baseline audit suggests that an improvement in the rate of foot screening is important to achieve in patients with diabetes on haemodialysis in our unit.

Factors associated with foot ulceration and amputation in adults on dialysis: a cross-sectional observational study

BACKGROUND

Adults on dialysis are at increased risk of foot ulceration, which commonly precedes more serious lower limb complications, including amputation. Limited data exist regarding the prevalence and factors associated with foot disease in this population. Hence, this study set out to investigate factors associated with foot ulceration and amputation in a dialysis cohort.

METHODS

This study presents a cross-sectional analysis of baseline data from a multi-center prospective cohort study. We recruited 450 adults with end-stage renal disease on dialysis from multiple satellite and home-therapy dialysis units in Melbourne, Australia from January to December 2014. Data collection consisted of a participant interview, medical record review, health-status questionnaire and non-invasive foot examination. Logistic regression analyses were conducted to evaluate associations between screened variables and study outcomes.

RESULTS

Mean age was 67.5 (SD, 13.2) years, 64.7% were male, 94% were on hemodialysis, median dialysis duration was 36.9 (IQR, 16.6 to 70.1) months, and 50.2% had diabetes. There was a high prevalence of previous ulceration (21.6%) and amputation (10.2%), 10% had current foot ulceration, and 50% had neuropathy and/or peripheral arterial disease. Factors associated with foot ulceration were previous amputation (OR, 10.19), peripheral arterial disease (OR, 6.16) and serum albumin (OR, 0.87); whereas previous and/or current ulceration (OR, 167.24 and 7.49, respectively) and foot deformity (OR, 15.28) were associated with amputation.

CONCLUSIONS

Dialysis patients have a high burden of lower limb complications. There are markedly higher risks of foot ulceration and/or amputation in those with previous and/or current ulceration, previous amputation, peripheral arterial disease, lower serum albumin, and foot deformity. Although not a major risk factor, diabetes in men was an important effect modifier for risk of ulceration.

Predictors of first ischemic lower limb ulcer in dialysis patients: an observational cohort study

BACKGROUND

Lower limb ischemia affects the quality of life, physical activity and life expectancy of dialysis patients. The aim of this study was to investigate the risk factors associated with ischemic foot ulcers considering clinical, laboratory and therapeutic domains.

METHODS

This observational cohort study was based on data from the Nephrology and Dialysis Department database of Alessandro Manzoni Hospital, Lecco (Italy). All of the incident patients who started dialysis between 1 January 1999 and 29 February 2012 were enrolled, excluding temporary guests, patients with acute renal failure and patients with previous limb ischemia or amputation. Multivariate Cox regression analysis identified the predictors in each domain, which were matched in the final model. A time-dependent approach was used to take into account the evolution of some of the prognostic covariates.

RESULTS

Of the 526 incident dialysis patients, 120 developed a lower limb ischemic lesion after a median of 13 months. The incidence of new ulcers was constant during the study period (6 per 100 person-years), but higher in the diabetics with a relative rate of 4.5. The variables significantly related to an increased risk of lower limb ulcers were age, male gender, diabetes, ischemic heart disease, treatment with proton pump inhibitors, iron, anticoagulants and calcium-based binders, and blood levels of phosphorus, triglycerides and C-reactive protein.

CONCLUSION

The incidence of lower limb ulcers was highest during the early dialysis follow-up and was associated with, in addition to diabetes, modifiable laboratory and therapeutic predictors such as anticoagulants, proton pump inhibitors, calcium-containing binders, calcimimetics and iron.

Relationship between limited joint mobility of the hand and diabetic foot risk in patients with type 2 diabetes

BACKGROUND

Foot ulceration is a serious problem for patients with type 2 diabetes (T2D), and the early detection of risks for this condition is important to prevent complications. The present cross-sectional study in T2D patients determined the relationship between limited joint mobility (LJM) of the hand and diabetic foot risk classified using the criteria of the International Working Group on the Diabetic Foot (IWGDF).

METHODS

Relationships between LJM of the hand and foot risk according to IWGDF category, HbA1c, age, body mass index, blood pressure, estimated glomerular filtration (eGFR), and diabetic complications (including diabetic peripheral neuropathy [DPN] and peripheral arterial disease [PAD]) were evaluated in 528 consecutive T2D patients. Poor glycemic control was defined as HbA1c ≥ 7%.

RESULTS

Patients with LJM of the hand were older and had a longer duration of diabetes, a higher prevalence of diabetic complications, including DPN and PAD, and a higher IWDGF category (all P < 0.001). Multivariate logistic regression analysis revealed that the foot risk assessed with IWDGF category was correlated with age (odds ratio [OR] 1.04; 95% confidence interval [CI] 1.01-1.06; P = 0.001), poor glycemic control (OR 1.66; 95% CI 1.00-2.77; P = 0.04), eGFR (OR 0.98; 95% CI 0.97-0.99; P = 0.02), and the presence of LJM of the hand (OR 3.86; 95% CI 2.21-6.86; P < 0.001).

CONCLUSIONS

The results demonstrate a correlation between LJM of the hand and foot risk. Diagnosis of diabetic hand is simple and non-invasive, and is thus a useful method for assessing the risk of diabetic foot in T2D patients.

Preliminary study of hypoxia-related cardiovascular mediator-markers in patients with end-stage renal disease with and without diabetes and the effects of haemodialysis

BACKGROUND

Evidence points to activation of pro-inflammatory and pro-thrombotic stimuli during the haemodialysis process in end-stage renal disease (ESRD) with potential to predispose to cardiovascular events. Diabetes is associated with a higher incidence of cardiovascular disease in haemodialysis patients. We tested the hypothesis that a range of mediators and markers that modulate cardiovascular risk are elevated in haemodialysis patients with diabetes compared to those without.

METHODS

Men and women with diabetes (n = 6) and without diabetes (n = 6) aged 18-90 years receiving haemodialysis were recruited. Blood samples were collected and analysed pre- and post-haemodialysis sessions for (platelet-monocyte conjugates (PMC), oxidised LDL (Ox-LDL), endothelin 1 (ET-1) and vascular endothelial growth factor (VEGF-A).

RESULTS

PMC levels significantly increased after haemodialysis in both groups (diabetes p = 0.047; non-diabetes p = 0.005). Baseline VEGF-A was significantly higher in people with diabetes (p = 0.009) and post-dialysis levels were significantly reduced in both groups (P = 0.002). Ox-LDL and CRP concentrations were not significantly different between groups nor affected in either group post-dialysis. Similarly, ET-1 concentrations were comparable in all patients at baseline, with no change post-dialysis in either group.

CONCLUSIONS

In this pilot study, we have confirmed that circulating PMCs are increased following dialysis irrespective of diabetes status. This is likely to be a mechanistic process and offers a potential explanation for high rates of vascular events associated with haemodialysis. The higher VEGF-A concentrations between patients with and without diabetes is a previously unreported finding in diabetic ESRD. Further research is merited to establish whether VEGF-A is a marker or mediator (or both) of cardiovascular risk in haemodialysis.

End-Stage Renal Disease Negatively Affects Physical Quality of Life in Patients With Diabetic Foot Complications

The aim of this study was to evaluate the impact of end-stage renal disease (ESRD) on health-related quality of life (QOL) in patients with diabetic foot disease. We compared a group of 30 diabetic patients with ESRD requiring dialysis to a group of 60 diabetic patients without ESRD. Both groups consisted of patients with active diabetic foot disease (ulcer, Charcot, infection) and were matched with regard to age and gender. Self-reported QOL was assessed using the Short Form-36 (SF-36) physical and mental component summary (PCS and MCS) scores and the region-specific Foot and Ankle Ability Measure (FAAM). Diabetic foot patients with ESRD requiring dialysis were found to have significantly higher creatinine levels, lower hemoglobin levels, lower albumin levels, higher rates of peripheral arterial disease, and lower rates of Charcot neuroarthropathy than patients without ESRD. The median PCS was significantly lower in the ESRD group; however, no significant difference was found when comparing the median MCS and FAAM. Patients who ultimately died had a tendency to report lower PCS scores at baseline compared with those patients who did not die ( P = .07). Patients who ultimately required major amputation also reported lower PCS scores at baseline. ESRD negatively affects physical QOL to a greater degree than mental QOL in patients with diabetic foot disease. The SF-36 may not be sensitive enough to capture impaired mental QOL because both groups had relatively high MCS scores. Low physical QOL may be associated with mortality and the eventual need for major amputation.

Diabetic foot ulcer development risk classifications' validation: A multicentre prospective cohort study

AIMS

To prospectively validate the existing classifications to stratify subjects with diabetes mellitus (DM) by their risk of diabetic foot ulcer (DFU), in high and low risk settings.

METHODS

A prospective multicentre cohort study was conducted, including 446 subjects with DM without active DFU followed in the hospital or primary care setting. Demographic, clinical characterization variables, and those included in the classifications were collected at baseline. Subjects were followed for 1year, until DFU or death.

RESULTS

In our sample, with a mean age of 65years, 52% were male; 32 developed a DFU, 7 required an amputation and 18 died. Differences were found between participants' characteristics and classifications' accuracy according to the setting. The great majority of the variables were associated with higher DFU risk. Globally, classifications were highly and equally valid, positive predictive values (PV) were inferior to 40%, negative PV superior to 90% and area under the receiver operating characteristic curve superior to 0.75.

DISCUSSION

All the existing classifications are valid to be applied in high risk clinical context and have a very high capacity to categorize as low risk those subjects that will not develop a DFU. Further research is needed in the primary care setting.

Vitamin K Antagonist Therapy Is a Risk Factor for Ulcer Development and Death Among Dialyzed Patients

Peripheral artery disease is a common complication among dialyzed patients. Since Vitamin K antagonists promote metastatic calcifications and these are the main determinants of vascular damage, we investigated their role in the development of lower limb ulcers in dialyzed patients. We retrospectively enrolled 316 dialyzed patients, aged 68 ± 15 years, 65% male, 32% diabetic, 43% with ischemic heart disease and followed them for 36 ± 25 months. 60 patients assumed Vitamin K antagonists: they were older, with a higher prevalence of heart disease, at greater risk of death and they developed more ulcers and underwent more lower limb amputations compared to the rest of our cohort. Peripheral artery disease, Vitamin K antagonists and diabetes were independent risk factors for foot lesions. In addition, Vitamin K antagonists were also an independent risk factor for death. Vitamin K antagonists are a potent independent risk factor for the development of the uremic foot syndrome and death.

Clinical outcomes and quality of life in hemodialysis diabetic patients versus non-diabetics

Background

Diabetes is the leading cause of end stage renal disease (ESRD) worldwide.

Objectives

We compared the clinical outcomes in diabetic patients on hemodialysis (HD) with non-diabetics.

Patients and Methods

Adult maintenance HD patients (N= 532) from 9 HD facilities were enrolled to this prospective cohort study in September 2012. Causes of death, hospitalization, and HD exit were recorded in a median 28 months follow up period.

Results

Forty-one percent of patients were diabetic. Diabetic patients compared to non-diabetics had significantly higher age (62.2 ± 11.2 versus 53.1 ± 16.7 years), lower dialysis duration (median: 23 versus 30 months), more cardiovascular comorbidities (64% versus 28%) , higher C-reactive protein (CRP) levels (median: 3.80 versus 2.25 mg/L), lower serum albumin (3.86 ± 0.35 versus 3.93 ± 0.35 g/dL), lower intact parathyroid hormone (iPTH) (median: 272 versus 374 ρg/mL), higher serum triglyceride (167 ± 91 versus 139 ± 67 mg/dL) and low density lipoprotein (LDL) (82.5 ± 24.5 versus 77.5 ± 23.8 mg/dL), and worse short form health survey (SF36) score (45.7 ± 20.9 versus 52.7 ± 20.5). Annual admission rate was higher in diabetics (median: 0.86 versus 0.43) and diabetic foot involved 16% of their admissions. Transplantation rate was 4 and 9 per 100 patient years in diabetics and non-diabetics, respectively. Death rate was two folds higher in diabetics (24 versus 12 per 100 patient years). Cardiovascular diseases ( ± infections/other causes) comprised 80.5% of death in diabetics and 54.5% in non-diabetics. In Cox regression proportional hazard multivariate analysis, hazard risk of death in diabetics was 1.9 times higher than non-diabetics.

Conclusions

Clinical outcomes and health related quality of life (HRQOL) are much worse in diabetic compared to non-diabetic HD patients mainly due to more frequent of cardiovascular diseases (CVDs).

Drug-Eluting Balloon Angioplasty for Below the Knee Lesions in End Stage Renal Disease Patients with Critical Limb Ischemia: Midterm Results

BACKGROUND

The 1-year restenosis rate after standard balloon angioplasty (BA) of long lesions in below-the-knee arteries may be as high as 70%. Our aim was to investigate the efficacy and safety of paclitaxel drug-eluting balloon (DEB) for treatment of below the knee lesions in end stage renal disease patients (ESRD) with critical limb ischemia (CLI).

METHODS

Our study is a retrospective, single-center study. Inclusion criteria were ESRD, critical limb ischemia (Rutherford class 4 or higher) and significant stenosis or occlusion of at least 1 below-the-knee vessel. Target vessel restenosis and reocclusion at 1-year follow-up was the primary end point. Major amputation, was the secondary end point.

RESULTS

From July 2012 to February 2015, 50 patients identified with ESRD, with CLI, treated with DEB angioplasty. Six patients were lost to follow-up, leaving 44 patients with 55 vessels (mean age, 58.0 ± 6.9 years; 54.5% male). The mean lesion length was 113.4 ± 55.4 mm. BA confined to the infra-popliteal segment alone in 81.8% of cases. Primary patency was 90.4% at 6 months and 62.2% at 12 months. At a mean follow-up of 13.9 ± 3.5 months all cause mortality was 8.1% (N = 3). The ankle brachial index increased from 0.45 ± 0.04 preoperative to 0.88 ± 0.07 postoperative. There was one major amputation (2.7%) and 5 minor amputations at one year (13.5%).

CONCLUSION

DEB is effective in the treatment of below the knee critical stenosis and occlusions in ESRD patients with critical limb ischemia.

Prevalence and Risk Factors of Lower Limb Amputation in Patients with End-Stage Renal Failure on Dialysis: A Systematic Review

Background. Renal dialysis has recently been recognised as a risk factor for lower limb amputation (LLA). However, exact rates and associated risk factors for the LLA are incompletely understood. Aim. Prevalence and risk factors of LLA in end-stage renal failure (ESRF) subjects on renal dialysis were investigated from the existing literature. Methods. Published data on the subject were derived from MEDLINE, PubMed, and Google Scholar search of English language literature from January 1, 1980, to July 31, 2015, using designated key words. Results. Seventy studies were identified out of which 6 full-text published studies were included in this systematic review of which 5 included patients on haemodialysis alone and one included patients on both haemodialysis and peritoneal dialysis. The reported findings on prevalence of amputation in the renal failure on dialysis cohort ranged from 1.7% to 13.4%. Five out of the six studies identified diabetes as the leading risk factor for amputation in subjects with ESRF on renal dialysis. Other risk factors identified were high haemoglobin A1c, elevated c-reactive protein, and low serum albumin. Conclusions. This review demonstrates high rate of LLA in ESRF patients receiving dialysis therapy. It has also identified diabetes and markers of inflammation as risk factors of amputation in ESRF subjects on dialysis.

Direct inpatient burden caused by foot-related conditions: a multisite point-prevalence study

OBJECTIVE

The aims of this point-prevalence study were to investigate a representative inpatient population to determine the prevalence of people admitted to hospital for the reason of a foot-related condition, and identify associated independent factors.

METHODS

Participants were adult inpatients in 5 different representative hospitals, admitted for any reason on the day of data collection. Maternity, mental health and cognitively impaired inpatients were excluded. Participants were surveyed on a range of self-reported demographic, social determinant, medical history, foot disease history, self-care, footwear, past foot treatment prior to hospitalisation and reason for admission variables. Physical examinations were performed to clinically diagnose a range of foot disease and foot risk factor variables. Independent factors associated with being admitted to hospital for the primary or secondary reason of a foot-related condition were analysed using multivariate logistic regression.

RESULTS

Overall, 733 participants were included; mean (SD) age 62 (19) years, male 55.8%. Foot-related conditions were the primary reason for admission in 54 participants (7.4% (95% CI 5.7% to 9.5%)); 36 for foot disease (4.9%), 15 foot trauma (2.1%). Being admitted for the primary reason of a foot-related condition was independently associated with foot infection, critical peripheral arterial disease, foot trauma and past foot treatment by a general practitioner and surgeon (p<0.01). Foot-related conditions were a secondary reason for admission in 28 participants (3.8% (2.6% to 5.6%)), and were independently associated with diabetes and current foot ulcer (p<0.01).

CONCLUSIONS

This study, the first in a representative inpatient population, suggests the direct inpatient burden caused by foot-related conditions is significantly higher than previously appreciated. Findings indicate 1 in every 13 inpatients was primarily admitted because of a foot-related condition with most due to foot disease or foot trauma. Future strategies are recommended to investigate and intervene in the considerable inpatient burden caused by foot-related conditions.

Non-traumatic lower limb amputation in patients with end-stage renal failure on dialysis: an Australian perspective

BACKGROUND

End-stage renal failure (ESRF) and dialysis have been identified as a risk factor for lower limb amputations (LLAs). High rate of ESRF amongst the Australian population has been reported, however till date no study has been published identifying magnitude and risk factors of LLA in subjects on renal dialysis.

OBJECTIVE

The study aims to document trends in the prevalence and identify risk factors of non-traumatic LLA in Australian patients on dialysis.

METHODS

A retrospective review of all patients (218) who attended the regional dialysis center between 1st January 2009 and 31st December 2013 was conducted. Demographic, clinical and biochemical data were analyzed.

RESULTS

We identified a high prevalence of 13.3% of LLAs amongst Australian patients with ESRF on dialysis at our center. The associated risk factors were the presence of diabetes (OR 1.67 [1.49-1.88] p < 0.001), history of foot ulceration (OR 81 [18.20-360.48] p < 0.001), peripheral arterial disease (OR 31.29 [9.02-108.56] p < 0.001), peripheral neuropathy (OR 31.29 [9.02-108.56] p < 0.001), foot deformity (OR 23.62 [5.82-95.93] p < 0.001), retinopathy (OR 6.08 [2.64-14.02] p < 0.001), dyslipidemia (OR 4.6 [1.05-20.05] p= 0.049) and indigenous background (OR 3.39 [1.38-8.33] p= 0.01). 75% of the amputees had aboriginal heritage. We also identified higher HbA1c and CRP levels as well as low serum albumin, hemoglobin and vitamin D levels to have a strong association with LLAs (p < 0.05).

CONCLUSION

There is high prevalence of LLAs amongst Australian indigenous patients with diabetes on dialysis in North Queensland. Other strongly associated risk factors include history of foot ulceration, foot deformity and peripheral neuropathy as well as high HbA1c levels and low serum albumin levels.

Prevalence of Diabetic Foot Disease in Patients with Diabetes Mellitus under Renal Replacement Therapy in Lleida, Spain

Aim. To assess the prevalence of diabetic foot and other associated conditions in patients with diabetes mellitus under renal replacement in the region of Lleida, Spain. Methods. This was an observational, cross-sectional study of 92 dialysis-treated diabetic patients. Besides a podiatric examination, we explored the presence of cardiovascular risk factors, late diabetes complications, including peripheral neuropathy, atherosclerotic disease, and peripheral artery disease. We assessed risk factors for foot ulceration and amputation by logistic regression. Results. Prevalent diabetic foot was found in 17.4% of patients, foot deformities were found in 54.3%, previous ulcer was found in 19.6%, and amputations were found in 16.3%; and 87% of them had some risk of suffering diabetic foot in the future. We observed a high prevalence of patients with peripheral neuropathy and peripheral artery disease (89.1% and 64.2%, resp.). Multivariable analysis identified diabetic retinopathy and advanced atherosclerotic disease (stenosing carotid plaques) as independent risk factors for foot ulceration (p = 0.004 and p = 0.023, resp.) and diabetic retinopathy also as an independent risk factor for lower-limb amputations (p = 0.013). Moreover, there was a temporal association between the initiation of dialysis and the incidence of amputations. Conclusion. Diabetic patients receiving dialysis therapy are at high risk of foot complications and should receive appropriate and intensive foot care.

Evaluation of the effect of nurse education on patient-reported foot checks and foot care behaviour of people with diabetes receiving haemodialysis

AIMS

To assess whether a programme of nurse education increased the frequency with which nurses conducted foot checks on people with diabetes undergoing haemodialysis and to evaluate whether this influenced self-reported foot care behaviour.

METHODS

A non-randomized stepped-wedge design was used to evaluate a nurse education programme implemented in four UK National Health Service dialysis units. People with diabetes undergoing haemodialysis were invited to complete a questionnaire on the frequency of foot examination by health professionals, on the presence of foot problems and on their own foot care behaviour, using the Nottingham Assessment of Functional Foot-care (NAFF). An education session for nurses, including procedures for foot examination, was conducted sequentially in each of four haemodialysis units. The questionnaire was repeated at 2-monthly intervals.

RESULTS

The education session resulted in a significant increase in the reported number of foot examinations by nurses (P = 0.007). There was also a significant improvement in reported foot care behaviour (P < 0.001), but this occurred between the first and second 2-monthly assessments and was unrelated to the timing of the intervention.

CONCLUSIONS

A single education session can improve the routine checking of the feet of people with diabetes undergoing haemodialysis. The administration of the Nottingham Assessment of Functional Foot-care questionnaire was associated with improved self-reported foot care behaviour, reflecting greater awareness of risk in this population.

Implementation of routine foot check in patients with diabetes on hemodialysis: associations with outcomes

OBJECTIVE

Patients with diabetes are at increased risk of foot ulcers, which may result in limb amputations. While regular foot care prevents ulcerations and amputation in those patients with diabetes not on dialysis, evidence is limited in diabetic hemodialysis patients. We investigated the association between the implementation of a routine foot check program in diabetic incident hemodialysis patients, and major lower limb amputations.

METHODS

In 1/2008, monthly intradialytic foot checks were implemented as part of standard clinic care in all Fresenius Medical Care North America hemodialysis facilities. Patients with diabetes who initiated hemodialysis between 1/2004 and 12/2007 constituted the preimplementation cohort, and patients starting hemodialysis between 1/2008 and 12/2011 comprised the postimplementation cohort. In addition, we conducted a sensitivity analysis where we excluded patients from the clinics with <10 patients in the postimplementation period and where percent difference in patient with diabetes number between postimplementation and preimplementation period was <20%. We compared lower limb amputation rates employing Poisson regression models with offset of exposure time in these two cohorts.

RESULTS

We studied 35 513 patients in the preimplementation and 25 779 patients in the postimplementation cohort. In the postimplementation cohort, amputation rate decreased by 17% (p=0.0034). The major lower limb amputation rate was 1.30 per 100 patient years in preimplementation and 1.07 in postimplementation cohort. These beneficial results were corroborated in the multivariate analysis (p=0.0175) and were even more pronounced in the sensitivity analysis (p=0.0083).

CONCLUSION

Monthly foot checks are associated with reduction of major lower limb amputations in diabetic incident hemodialysis patients.

Ageing Renal Patients: We Need More Collaboration between Geriatric Services and Nephrology Departments

There has been a significant increase in the number of frail older patients diagnosed with advanced chronic kidney disease (CKD) over the past thirty years. These elderly patients have high levels of comorbidity, and as a consequence the face of renal medicine is changing—There is an increasing need to focus on traditionally geriatric areas of expertise such as falls prevention and rehabilitation, and to shift our emphasis onto improving patient well-being rather than longevity. Over the past decade, many nephrologists have found that they are already acting as de facto “amateur geriatricians”. This denies patients both the benefits of specialist geriatric assessment, and equally importantly denies them access to the wider geriatric multidisciplinary team. This article describes the prevalence and underlying causes of the so-called “Geriatric Giants” in patients with advanced CKD, and discusses possible improvements in care that closer working with geriatricians could bring.

Preventing and treating foot complications associated with diabetes mellitus

Diabetes mellitus is associated with a series of macrovascular and microvascular changes that can manifest as a wide range of complications. Foot ulcerations affect ∼2-4% of patients with diabetes mellitus. Risk factors for foot lesions include peripheral and autonomic neuropathy, vascular disease and previous foot ulceration, as well as other microvascular complications, such as retinopathy and end-stage renal disease. Ulceration is the result of a combination of components that together lead to tissue breakdown. The most frequently occurring causal pathways to the development of foot ulcers include peripheral neuropathy and vascular disease, foot deformity or trauma. Peripheral vascular disease is often not diagnosed in patients with diabetes mellitus until tissue loss is evident, usually in the form of a nonhealing ulcer. Identification of patients with diabetes mellitus who are at high risk of ulceration is important and can be achieved via annual foot screening with subsequent multidisciplinary foot-care interventions. Understanding the factors that place patients with diabetes mellitus at high risk of ulceration, together with an appreciation of the links between different aspects of the disease process, is essential to the prevention and management of diabetic foot complications.

Risk factors for foot ulceration in adults with end-stage renal disease on dialysis: study protocol for a prospective observational cohort study

BACKGROUND

Adults with end-stage renal disease treated with dialysis experience a high burden of foot ulceration and lower extremity amputation. However, the risk factors for foot ulceration in the dialysis population are incompletely understood due to the lack of high-quality prospective evidence. This article outlines the design of a prospective observational cohort study, which aims to investigate the risk factors for foot ulceration in adults on dialysis.

METHODS/DESIGN

This study will recruit 430 participants with end-stage renal disease on dialysis from satellite and home-therapy dialysis units across multiple health organisations in Melbourne, Victoria, Australia. Data collection at baseline will include a participant interview, medical record review, completion of a health-status questionnaire and a non-invasive foot assessment. Twenty participants will also be recruited to a reliability study to evaluate the reproducibility of testing procedures. Primary outcome data includes: new foot ulcer(s). Secondary outcome data includes: number of new foot ulcers, time to onset of new foot ulcer(s), new lower extremity amputation(s), episodes of infection of the foot or lower extremity, episodes of osteomyelitis, foot-related hospitalisations, revascularisation procedure(s) of the lower extremity, new podiatry interventions, kidney transplantation, and mortality. Participants will be assessed at baseline, and at 12 months they will be evaluated for the primary and secondary outcomes. Multivariate Cox proportional hazards models will be used to assess predictors of new foot ulceration and time to event secondary outcomes. Logistic regression will be used for binary outcomes including prevalence of foot ulcerations.

DISCUSSION

This is the first multi-centre prospective observational cohort study to investigate risk factors for foot ulceration in adults with end-stage renal disease on dialysis. This study will improve on prior studies by using prospective methods, multi-centre recruitment, statistical methods to control for confounding variables, and a pre-specified sample size estimation. The findings can inform the design of future trials evaluating the effectiveness of clinical interventions, which may lead to improved patient outcomes in the dialysis setting.

The role of surgical off-loading to prevent recurrent ulcerations

Foot ulcerations in patients with diabetes are common. Most ulcers heal with conservative treatment, but recurrence is common. The pathway of ulcer development includes neuropathy, deformity, and trauma. The first attempt to avoid recurrence is by the use of shoes and insoles. When shoes and insoles fail, surgical correction of deformity leading to the ulcer can be attempted. This article reviews the most common procedures performed to heal ulcers or avoid recurrence.

Clinical Characteristics of Patients on Hemodialysis With Peripheral Arterial Disease

Patients on hemodialysis (HD; n = 210) were examined for peripheral arterial disease (PAD) using ankle-brachial index (ABI) and toe-brachial index (TBI). The prevalence of PAD was 38.1%. Among patients with PAD, 87.5% were newly diagnosed with PAD, 42.5% were diagnosed with TBI <0.6 despite ABI ≥ 0.9, and 68.7% had no lower limb symptoms. In patients with PAD, the prevalence rate of cerebrovascular disease was 36.3%, coronary artery disease was 42.5%, spinal stenosis was 33.2%, and vertebral fracture 15.0% and was significantly higher than those of the non-PAD patients. Low high-density lipoprotein cholesterol was the most important biomarker among patients with PAD. PAD has been underdiagnosed and untreated in patients on HD because most patients do not have symptoms that could be due to diabetic neuropathy or have insufficient daily activity to experience exertional leg symptoms. Screening for PAD using the ABI and TBI increased diagnostic efficiency in patients on HD and may lead to effective early treatments, including pharmacotherapy, revascularization therapy, and exercise rehabilitation to avoid the worst possible scenario such as lower limb amputation, cardiovascular event, and death.

Role of comorbidities as limiting factors to the effect of hyperbaric oxygen in diabetic foot patients: a retrospective analysis

INTRODUCTION

The effectiveness of hyperbaric oxygen therapy (HBOT) on selected diabetic foot wounds continues to be controversial. A holistic approach to diabetes and its comorbidities may be beneficial in the discussion of the proper application of this treatment modality. The aim of the current study is to evaluate the efficacy of HBOT on diabetic foot wounds and provide clinical data that may support this knowledge.

METHODS

The present study was a retrospective analysis of the effect of HBOT on diabetic foot lesions ranging 3-5 on the Wagner Grading System. Patients had been treated with HBOT and monitored for 12 months. The results were analyzed in relation to age, gender, diabetes duration and type, microangiopathic complications, peripheral arterial disease (PAD), history of coronary artery disease, stroke, hypertension, smoking habits, glycated hemoglobin, blood sedimentation rate, C-reactive protein, and number of HBOT sessions. Microangiopathies were evaluated as retinopathy, nephropathy, and neuropathy. PAD was determined by available color Doppler ultrasonography and/or angiographic data depending on a modified scoring system. The data of arteries from the aorta to the dorsal pedal artery were scored singly. Average scores of aorto-iliac, femoral, popliteal and pedal levels were also evaluated with this system to compare the healing results in relation to PAD.

RESULTS

One hundred and seventeen patients with 126 diabetic foot wounds were treated. Histories of coronary artery disease, stroke, and non-proliferative or proliferative retinopathy had negative effects on HBOT (P = 0.002, P = 0.015, P = 0.022, respectively). Depending on the scorings of PAD, the single arterial scores and average scores of aorto-iliac, popliteal and pedal levels had no relation to outcomes, while the average scores of the femoral arterial level affected the results (P = 0.048).

CONCLUSIONS

Diabetic foot patients with histories of coronary artery diseases or stroke and non-proliferative or proliferative retinopathy might resist HBOT. PAD at the femoral arterial level has been shown to have a significant negative effect on HBOT outcomes that should be first considered for surgery. In contrast, PAD below the knee does not seem to be an obstacle to the efficacy of HBOT.

A longitudinal study of foot ulceration and its risk factors in community-based patients with type 2 diabetes: the Fremantle Diabetes Study

AIMS

To determine the prevalence and associates of foot ulcer, and the subsequent incidence and predictors of first-ever hospitalisation for this complication, in well-characterised community-based patients with type 2 diabetes.

METHODS

Baseline foot ulceration was ascertained in 1296 patients (mean age 64 years, 48.6% male, median diabetes duration 4.0 years) recruited to the longitudinal Fremantle Diabetes Study between 1993 and 1996. Incident hospitalisation for foot ulceration was monitored through validated data linkage until end-December 2010.

RESULTS

At baseline, 16 participants (1.2%) had a foot ulcer which was independently associated with intermittent claudication, peripheral sensory neuropathy (PSN) and diabetes duration (P≤0.01). The incidence of hospitalisation for this complication in those without prior/prevalent foot ulceration was 5.21 per 1000 patient-years. This rate and other published data suggest that 1 in 7-10 foot ulcers require hospitalisation. In a Cox proportional hazards model, intermittent claudication and PSN were significant independent predictors of time to admission with foot ulceration, in addition to retinopathy, cerebrovascular disease, HbA1c, alcohol consumption, renal impairment, peripheral arterial disease and pulse pressure (P≤0.038).

CONCLUSIONS

These data confirm PSN as an important risk factor for foot ulceration but, in contrast to some other studies, peripheral arterial disease was also a major independent contributor. Associations between hospitalisation for foot ulcer and both retinopathy and raised pulse pressure suggest a role for local microvascular dysfunction, while alcohol may have non-neuropathic toxic effects on skin/subcutaneous structures. The multifactorial nature of foot ulceration complicating type 2 diabetes may have implications for its management.

Use of hand-to-hand measurements for body composition monitoring in patients with inaccessible or amputated feet

BACKGROUND

The body composition monitor (BCM) provides an objective assessment of fluid status, which has been shown to improve outcomes in patients undergoing haemodialysis. The models used by the BCM were developed and validated using standard wrist-to-ankle bioimpedance measurements, made between electrodes on the hand and foot. However, in patients with inaccessible or amputated feet it is not possible to use standard electrode configurations.

OBJECTIVE

To compare hydration measurements made with 'hand-to-hand' (H-H) and 'hand-to-foot' (H-F) electrode configurations in patients with accessible feet or no amputations.

METHODS

One hundred and one consecutive patients referred for a BCM measurement were recruited to have H-H measurements at the same time as the usual H-F measurement using the same height and weight. Patients with obvious localised oedema were excluded.

RESULTS

Compared with H-F, H-H measurements showed a bias of -0.1 L. For 61% of patients the difference between the readings was within 0.5 L; for 81% it was within 1.0 L.

CONCLUSION

The agreement between H-H and H-F measurements was close enough to encourage us to use H-H measurements in patients with inaccessible or amputated feet. Prior to amputation, height and weight are recorded. Target weight (TW) reductions are made gradually when close to normal hydration. Clinically, changes based on H-H measurements appear to be as appropriate as those using H-F. The desired hydration at TW can be established and then TW adjusted to maintain this hydration as the flesh weight fluctuates.

Treatment of peripheral arterial disease in diabetes: a consensus of the Italian Societies of Diabetes (SID, AMD), Radiology (SIRM) and Vascular Endovascular Surgery (SICVE)

Diabetic foot (DF) is a chronic and highly disabling complication of diabetes. The prevalence of peripheral arterial disease (PAD) is high in diabetic patients and, associated or not with peripheral neuropathy (PN), can be found in 50% of cases of DF. It is worth pointing out that the number of major amputations in diabetic patients is still very high. Many PAD diabetic patients are not revascularised due to lack of technical expertise or, even worse, negative beliefs because of poor experience. This despite the progress obtained in the techniques of distal revascularisation that nowadays allow to reopen distal arteries of the leg and foot. Italy has one of the lowest prevalence rates of major amputations in Europe, and has a long tradition in the field of limb salvage by means of an aggressive approach in debridement, antibiotic therapy and distal revascularisation. Therefore, we believe it is appropriate to produce a consensus document concerning the treatment of PAD and limb salvage in diabetic patients, based on the Italian experience in this field, to share with the scientific community.

Cost-effectiveness of revascularization for limb preservation in patients with end-stage renal disease

BACKGROUND

Limb revascularization in patients with end-stage renal disease (ESRD) has been criticized because of the low rates of limb preservation and overall survival that characterize this patient population. We undertook a formal cost-utility analysis to evaluate the role of revascularization in the ESRD population.

METHODS

A probabilistic Markov model was used to simulate the clinical outcomes and long-term outcomes after six different strategies for the management of nonhealing foot wounds in patients with critical limb ischemia and ESRD. All scenarios considered all-cause mortality and major amputation for failure of limb salvage. Parameter estimates of the costs, clinical events, and functional outcomes used in the model were derived from primary data or published literature. Costs are reported in 2011 U.S. dollars.

RESULTS

Local wound care alone had the lowest long-term total cost of the management strategies evaluated; primary amputation had the highest. Purely endovascular intervention yielded the highest limb salvage rates. Endovascular intervention had a cost of $15,403 per additional year of ambulation beyond that by local wound care alone. Endovascular intervention had the potential for cost-savings (ie, better health benefits at lower cost) only with very high 1-year wound healing rates. The 5-year survival rates ranged from 17% to 34% in all management strategies.

CONCLUSIONS

Endovascular intervention may be a cost-effective alternative to local wound care alone for patients with ESRD and ischemic foot wounds, but with small marginal health benefits at considerable cost. Local wound care alone may be preferable to primary amputation.

Implications of foot ulceration in hemodialysis patients: a 5-year observational study

Foot ulceration (FU) remains a serious concern for patients worldwide. We analyzed the incidence, risk factors, and outcome of FU in hemodialysis (HD) patients. A retrospective cohort study was conducted for 252 HD patients who were followed up for 5 years. Patients were categorized according to whether they developed FU or not. The FU group (17%) was older and had significantly higher incidence of nephropathy, retinopathy, peripheral (PAD), coronary artery disease (CAD), and diabetes mellitus (DM) as compared to no-FU group. FU group had higher frequency of major amputation (P = 0.001) and HD vascular access (P = 0.01). Patients with combined DM and PAD had a 10-fold increased risk of FU in comparison to those who had DM alone. Presence of PAD was the main independent predictor for development of FU in HD with an adjusted odd ratio (aOR) of 16.0 (95% CI: 4.41-62.18; P = 0.001). After adjusting for age, sex, and CAD, predictors for mortality were PAD (aOR 4.3), FU (aOR 3.6), and DM (aOR 2.6). FU is common in HD patients regardless of DM. However, the presence of PAD is significantly associated with more FU and mortality in HD. HD patients need intensive foot care and warrant progressive modification of vascular risk factors.

Cardiovascular complications in diabetic patients undergoing regular hemodialysis: a 5-year observational study

We aimed to study the vascular outcomes in hemodialysis (HD) patients based on their diabetic status. A cohort observational study was conducted among patients undergoing regular HD with a 5-year follow-up. Of the 252 consecutive HD patients, 60% were diabetic. Compared with nondiabetics, diabetics were 11 years older, 4 years lesser on HD, and more likely to have prior cerebrovascular and coronary artery disease (CAD). Overall 5-year follow-up showed that diabetic patients had higher rates of HD vascular accesses (57% vs 41%, P = .01), CAD (64% vs 33%, P = .001), major amputations (8.6% vs 0%, P = .003), and mortality (66% vs 23%, P = .001). On multivariate analysis, independent predictors of mortality included number of vascular accesses in nondiabetics and HD duration, CAD, and peripheral artery disease in diabetic patients. Diabetes mellitus is associated with a significant vascular burden and mortality among HD patients. Moreover, our finding highlights the vascular impact of renal failure and HD.

Diabetic neuropathy and foot complications

Foot ulceration and Charcot neuroarthropathy (CN) are well recognized and documented late sequelae of diabetic peripheral, somatic, and sympathetic autonomic neuropathy. The neuropathic foot, however, does not ulcerate spontaneously: it is a combination of loss of sensation due to neuropathy together with other factors such as foot deformity and external trauma that results in ulceration and indeed CN. The commonest trauma leading to foot ulcers in the neuropathic foot in Western countries is from inappropriate footwear. Much of the management of the insensate foot in diabetes has been learned from leprosy which similarly gives rise to insensitive foot ulceration. No expensive equipment is required to identify the high risk foot and recently developed tests such as the Ipswich Touch Test and the Vibratip have been shown to be useful in identifying the high risk foot. A comprehensive screening program, together with education of high risk patients, should help to reduce the all too high incidence of ulceration in diabetes. More recently another very high risk group has been identified, namely patients on dialysis, who are at extremely high risk of developing foot ulceration; this should be preventable. The most important feature in management of neuropathic foot ulceration is offloading as patients can easily walk on active foot ulcers due to the loss of pain sensation. Infection should be treated aggressively and if there is any evidence of peripheral vascular disease, arteriography and appropriate surgical management is also indicated. CN often presents with a unilateral hot, swollen foot and any patient presenting with these features known to have neuropathy should be treated as a Charcot until this is proven otherwise. Most important in the management of acute CN is offloading, often in a total contact cast.

A prospective study of risk factors for foot ulceration: the West of Ireland Diabetes Foot Study

BACKGROUND

This is the first study to examine risk factors for diabetic foot ulceration in Irish general practice.

AIM

To determine the prevalence of established risk factors for foot ulceration in a community-based cohort, and to explore the potential for estimated glomerular filtration rate (eGFR) to act as a novel risk factor.

DESIGN

A prospective observational study.

METHODS

Patients with diabetes attending 12 (of 17) invited general practices were invited for foot screening. Validated clinical tests were carried out at baseline to assess for vascular and sensory impairment and foot deformity. Ulcer incidence was ascertained by patient self-report and medical record. Patients were re-assessed 18 months later.

RESULTS

Of 828 invitees, 563 (68%) attended screening. On examination 23-25% had sensory dysfunction and 18-39% had evidence of vascular impairment. Using the Scottish Intercollegiate Guidelines Network risk stratification system we found the proportion at moderate and high risk of future ulceration to be 25% and 11%, respectively. At follow-up 16/383 patients (4.2%) developed a new foot ulcer (annual incidence rate of 2.6%). We observed an increasing probability of abnormal vascular and sensory test results (pedal pulse palpation, doppler waveform assessment, 10 g monofilament, vibration perception and neuropathy disability score) with declining eGFR levels. We were unable to show an independent association between new ulceration and reduced eGFR [Odds ratio 1.01; P = 0.64].

CONCLUSION

Our data show the extent of foot complications in a representative sample of diabetes patients in Ireland. Use of eGFR did not improve identification of patients at risk of foot ulceration.

The system of care for the diabetic foot: objectives, outcomes, and opportunities

Most cases of lower extremity limb loss in the United States occur among people with diabetes who have a diabetic foot ulcer (DFU). These DFUs and the associated limb loss that may occur lead to excess healthcare costs and have a large negative impact on mobility, psychosocial well-being, and quality of life. The strategies for DFU prevention and management are evolving, but the implementation of these prevention and management strategies remains challenging. Barriers to implementation include poor access to primary medical care; patient beliefs and lack of adherence to medical advice; delays in DFU recognition; limited healthcare resources and practice heterogeneity of specialists. Herein, we review the contemporary outcomes of DFU prevention and management to provide a framework for prioritizing quality improvement efforts within a resource-limited healthcare environment.

Amputations and foot-related hospitalisations disproportionately affect dialysis patients

Patients with diabetes have increased risk for foot ulcers, amputations and hospitalisations. We evaluated a closed cohort of patients with diabetes and established risk factors in two high risk groups: (i) dialysis patients and (ii) patients with previous foot ulceration. We used claims data for diabetes (ICD-9 250.X), ulceration (ICD-9 707·10, 707·14 and 707·15) and dialysis (CPT 90935-90937) from the Scott and White Health Plan to identify 150 consecutive patients with diabetes on dialysis (dialysis group) and 150 patients with a history of foot ulceration (ulcer history group). We verified these diagnoses by manually reviewing corresponding electronic medical records. Each patient was provided 30 months follow-up period. The incidence of foot ulcers was the same in dialysis patients and patients with an ulcer history (210 per 1000 person-years). The amputation incidence rate was higher in dialysis patients (58·0 versus 13·3, P < 0·001). Hospital admission was common in both study groups. The incidence of hospitalisation was higher in the ulcer history group (477·3 versus 381·3, P < 0·001); however, there were more foot-related hospital admissions in the dialysis group (32·9% versus 14·0%, P < 0·001) during the 30-month evaluation period. The incidence of ulcers, amputations and all-cause hospitalisations is high in persons with diabetes and a history of foot ulceration or on dialysis treatment; however, those on dialysis treatment have disproportionately higher rates of foot-related hospitalisations. Intervention strategies to reduce the burden of diabetic foot disease must target dialysis patients as a high-risk group.

Charcot neuroarthropathy in simultaneous kidney-pancreas transplantation: report of two cases

Charcot neuroarthropathy (CN) is considered a major complication in diabetes mellitus (DM), and it is estimated that 1% of diabetic patients may develop this complication. Simultaneous kidney–pancreas transplantation (SKPT) is one of the most effective therapies for patients with type 1 DM and end-stage diabetic nephropathy. Some cases with a Charcot-modified clinical presentation during the postoperative convalescence period after SKPT have been described. The clinical presentation may condition severe destructive lesions, and good practices include systematic follow-up. Based on the cases described, SKPT is one more entity that might lead to CN ‘foot-at-risk’. The aim of this article is to describe two cases of neuropathic arthropathy with rapid progression in the short term after SKPT.

Preventing the first or recurrent ulcers

Prevention is overlooked and underused, even in very high-risk patients. Prevention is best achieved within a multispecialty group of providers that have a common objective. Ideally, the team approach should include educators; physical therapists; nurses; internist; pedorthists; and vascular, orthopedic, and podiatric surgeons. The basic elements involve education, foot examination, risk classification, therapeutic shoes and insoles, and regular foot care. High-risk patients need additional assessment for vascular disease and intensive disease management, and corrective vascular and foot surgery when necessary. Basic interventions can reduce the incidence of foot ulcers by more than 50%.

The pathway to foot ulceration in diabetes

It should now be possible to achieve a reduction in the incidence of foot ulceration and amputations as knowledge about pathways that result in both these events increases. However, despite the universal use of patient education and the hope of reducing the incidence of ulcers in high-risk patients, there are no appropriately designed large, randomized controlled trials actually confirming that education works. It has been recognized for some years that education as part of a multidisciplinary approach to care of the diabetic foot can help to reduce the incidence of amputations in certain settings. Ultimately, however, a reduction in neuropathic foot problems will only be achieved if we remember that the patients with neuropathic feet have lost their prime warning signal—pain—that ordinarily brings patients to their doctor. Very little training is offered to health care professionals as to how to deal with such patients. Much can be learned about the management of such patients from the treatment of individuals with leprosy: if we are to succeed, we must realize that with loss of pain there is also diminished motivation in the healing of and prevention of injury.

Acute and chronic effects of therapeutic apheresis

In most patients only a few sessions of apheresis treatment are necessary to see the benefit. This is the case of immunological diseases when the production of a pathologic component is limited in time or in microcirculation disturbances when changes of vascular function may occur. In the first instance the acute effect is likely due to the removal of the corresponding antibody, while in the second case the improvement of the endothelium-dependent vasodilation and the reduction of blood viscosity play a major role. In long-term treatment, as in the case of patients affected by familial hypercholesterolemia, the chronic effects of apheresis may lead to the repair of morphological alterations in the vascular wall. We report the recovery from ulcers in two hemodialysis patients suffering from peripheral arterial disease as the result of twenty-two sessions of rheopheresis. The reasons that justify these chronic actions may involve pleiotropic effects that are different according to the apheresis technique used.

Reamputation after minor foot amputation in diabetic patients: risk factors leading to limb loss

The prevalence of lower extremity reamputation in diabetic patients has been well-documented. We sought to determine the risk factors for major lower extremity amputation (LEA) after minor foot amputation in diabetic patients. We studied 163 diabetic patients who had undergone an initial minor foot amputation and then had undergone at least 1 subsequent major or minor LEA. The patients were separated into a minor LEA group (initial minor LEA followed by at least 1 subsequent minor LEA) and a major LEA group (initial minor LEA followed by at least 1 subsequent major LEA). We then studied the possible risk factors for both groups. The possible risk factors analyzed were age, glycemic control, kidney function, previous kidney or kidney-pancreas transplantation, smoking history, and presence and severity of peripheral arterial disease (PAD). No statistical significance was found between the 2 groups for hemoglobin A1c, smoking status, chronic kidney disease, end-stage renal disease requiring dialysis, kidney or kidney-pancreas transplantation, or vascular intervention (peripheral arterial bypass). In the minor group, 22.23% had severe PAD. In the major group, 71.15% had severe PAD. This was statistically significant (p < .001). The average interval to major amputation in those without PAD, mild to moderate PAD, and severe PAD was 1,180.9, 591.0, and 559.6 days, respectively. This demonstrates the importance of assessing the peripheral vascular status in all diabetic patients with minor LEA. Early referral to a vascular surgeon might delay (or prevent) major LEA.

Prevalence of risk factors for foot ulceration in patients with end-stage renal disease on haemodialysis

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.

AIM

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 6-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 with 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 with 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 potentially to reduce the risk of foot ulcerations and LEAs.

Predictive factors for diabetic foot ulceration: a systematic review

Improving ability to predict and prevent diabetic foot ulceration is imperative because of the high personal and financial costs of this complication. We therefore conducted a systematic review in order to identify all studies of factors associated with DFU and assess whether available DFU risk stratification systems incorporate those factors of highest potential value. We performed a search in PubMed for studies published through April 2011 that analysed the association between independent variables and DFU. Articles were selected by two investigators-independently and blind to each other. Divergences were solved by a third investigator. A total of 71 studies were included that evaluated the association between diabetic foot ulceration and more than 100 independent variables. The variables most frequently assessed were age, gender, diabetes duration, BMI, HbA(1c) and neuropathy. Diabetic foot ulceration prevalence varied greatly among studies. The majority of the identified variables were assessed by only two or fewer studies. Diabetic neuropathy, peripheral vascular disease, foot deformity and previous diabetic foot ulceration or lower extremity amputation - which are the most common variables included in risk stratification systems - were consistently associated with diabetic foot ulceration development. Existing diabetic foot ulceration risk stratification systems often include variables shown repeatedly in the literature to be strongly predictive of this outcome. Improvement of these risk classification systems though is impaired because of deficiencies noted, including a great lack of standardization in outcome definition and variable selection and measurement.

Prevalence of risk factors for foot ulceration in a general haemodialysis population

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 of 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.

Health-related quality of life and all-cause mortality in patients with diabetes on dialysis

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.