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Özdemir VA, Nural N. Risk Factors and Frequency of Foot Ulceration in Patients Receiving Chronic Hemodialysis Treatment. Adv Skin Wound Care 2024; 37:203-210. [PMID: 38506581 DOI: 10.1097/asw.0000000000000117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
OBJECTIVE To determine the prevalence and risk factors of foot ulceration in patients receiving hemodialysis treatment. METHODS A total of 180 patients who received hemodialysis treatment in two state hospitals and a private health center between April 2017 and September 2017 were included in the study. The researchers collected data using a patient information form and by conducting physical evaluation of the lower extremities. They used the diabetic foot risk assessment algorithm to classify risk according to the data obtained. RESULTS Of the patients receiving hemodialysis treatment, 6.7% had foot ulceration, 19.4% had a history of foot ulceration, and 8.3% had a history of hospitalization associated with ulceration in a lower extremity. Infected foot ulceration was the most common (6.1%) cause of hospitalizations. In the group with current or past foot ulceration, diabetic nephropathy was the most common etiologic factor of end-stage kidney disease (48.6%); there was a significant between-group difference in diabetic nephropathy (P < .05). Etiologic factors had a significant effect on foot ulcerations: As determined by univariate logistic regression, diabetes (odds ratio [OR], 2.727; P < .05), presence of neuropathy (OR, 4.208; P < .05), low-density lipoprotein cholesterol (OR, 1.013; P < .05), and serum albumin (OR, 0.302; P < .036) all had a statistically significant effect on the presence of foot ulcerations. CONCLUSIONS Patients receiving hemodialysis treatment are at high risk for foot ulceration. Therefore, patient awareness strategies should be expanded to include individuals with end-stage renal disease regardless of diabetes status. Clinical and dialysis nurses should educate these patients about foot ulcerations and foot health to prevent ulcer development.
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Affiliation(s)
- Vacide Aşik Özdemir
- Vacide Aşik Özdemir, PhD, is Assistant Professor, Department of Internal Medicine Nursing, Faculty of Health Sciences, Recep Tayyip Erdogan University, Rize, Turkey. Nesrin Nural, PhD, is Professor, Department of Internal Medicine Nursing, Faculty of Health Sciences, Karadeniz Technical University, Trabzon, Turkey
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Bus SA, Sacco ICN, Monteiro-Soares M, Raspovic A, Paton J, Rasmussen A, Lavery LA, van Netten JJ. Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2023 update). Diabetes Metab Res Rev 2024; 40:e3651. [PMID: 37302121 DOI: 10.1002/dmrr.3651] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 04/17/2023] [Indexed: 06/13/2023]
Abstract
AIMS This is the 2023 International Working Group on the Diabetic Foot guideline on the prevention of foot ulcers in persons with diabetes, which updates the 2019 guideline. This guideline is targeted at clinicians and other healthcare professionals. MATERIALS AND METHODS We followed the Grading of Recommendations, Assessment, Development and Evaluations methodology to devise clinical questions and critically important outcomes in the PICO format, to conduct a systematic review of the medical-scientific literature including, where appropriate, meta-analyses, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where (sufficient) evidence was not available, and a weighing of the desirable and undesirable effects of an intervention, as well as patient preferences, costs, equity, feasibility and applicability. RESULTS We recommend screening a person with diabetes at very low risk of foot ulceration annually for the loss of protective sensation and peripheral artery disease, and screening persons at higher risk at higher frequencies for additional risk factors. For preventing a foot ulcer, educate persons at-risk about appropriate foot self-care, educate not to walk without suitable foot protection, and treat any pre-ulcerative lesion on the foot. Educate moderate-to-high risk people with diabetes to wear properly fitting, accommodative, therapeutic footwear, and consider coaching them to monitor foot skin temperature. Prescribe therapeutic footwear that has a demonstrated plantar pressure relieving effect during walking, to help prevent plantar foot ulcer recurrence. Consider advising people at low-to-moderate risk to undertake a, preferably supervised, foot-ankle exercise programme to reduce ulcer risk factors, and consider communicating that a total increase in weight-bearing activity of 1000 steps/day is likely safe with regards to risk of ulceration. In people with non-rigid hammertoe with pre-ulcerative lesion, consider flexor tendon tenotomy. We suggest not to use a nerve decompression procedure to help prevent foot ulcers. Provide integrated foot care for moderate-to-high-risk people with diabetes to help prevent (recurrence of) ulceration. CONCLUSIONS These recommendations should help healthcare professionals to provide better care for persons with diabetes at risk of foot ulceration, to increase the number of ulcer-free days and reduce the patient and healthcare burden of diabetes-related foot disease.
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Affiliation(s)
- Sicco A Bus
- Department of Rehabilitation Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Program Rehabilitation & Development, Amsterdam, The Netherlands
| | - Isabel C N Sacco
- Physical Therapy, Speech and Occupational Therapy Department, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Matilde Monteiro-Soares
- Portuguese Red Cross School of Health - Lisbon, Lisbon, Portugal
- MEDCIDS - Departamento de Medicina da Comunidade Informação e Decisão em Saúde, Faculty of Medicine of the University of Porto, Porto, Portugal
- RISE@CINTESIS, Faculty of Medicine Oporto University, Porto, Portugal
| | - Anita Raspovic
- Discipline of Podiatry, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Joanne Paton
- School of Health Professions, University of Plymouth, Plymouth, UK
| | | | - Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jaap J van Netten
- Department of Rehabilitation Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Program Rehabilitation & Development, Amsterdam, The Netherlands
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van Netten JJ, Raspovic A, Lavery LA, Monteiro-Soares M, Paton J, Rasmussen A, Sacco ICN, Bus SA. Prevention of foot ulcers in persons with diabetes at risk of ulceration: A systematic review and meta-analysis. Diabetes Metab Res Rev 2024; 40:e3652. [PMID: 37243880 DOI: 10.1002/dmrr.3652] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 04/17/2023] [Indexed: 05/29/2023]
Abstract
AIMS Prevention of foot ulcers in persons with diabetes is important to help reduce the substantial burden on both individual and health resources. A comprehensive analysis of reported interventions is needed to better inform healthcare professionals about effective prevention. The aim of this systematic review and meta-analysis is to assess the effectiveness of interventions to prevent foot ulcers in persons with diabetes who are at risk thereof. MATERIALS AND METHODS We searched the available scientific literature in PubMed, EMBASE, CINAHL, Cochrane databases and trial registries for original research studies on preventative interventions. Both controlled and non-controlled studies were eligible for selection. Two independent reviewers assessed risk of bias of controlled studies and extracted data. A meta-analysis (using Mantel-Haenszel's statistical method and random effect models) was done when >1 RCT was available that met our criteria. Evidence statements, including the certainty of evidence, were formulated according to GRADE. RESULTS From the 19,349 records screened, 40 controlled studies (of which 33 were Randomised Controlled Trials [RCTs]) and 103 non-controlled studies were included. We found moderate certainty evidence that temperature monitoring (5 RCTs; risk ratio [RR]: 0.51; 95% CI: 0.31-0.84) and pressure-optimised therapeutic footwear or insoles (2 RCTs; RR: 0.62; 95% CI: 0.26-1.47) likely reduce the risk of plantar foot ulcer recurrence in people with diabetes at high risk. Further, we found low certainty evidence that structured education (5 RCTs; RR: 0.66; 95% CI: 0.37-1.19), therapeutic footwear (3 RCTs; RR: 0.53; 95% CI: 0.24-1.17), flexor tenotomy (1 RCT, 7 non-controlled studies, no meta-analysis), and integrated care (3 RCTs; RR: 0.78; 95% CI: 0.58-1.06) may reduce the risk of foot ulceration in people with diabetes at risk for foot ulceration. CONCLUSIONS Various interventions for persons with diabetes at risk for foot ulceration with evidence of effectiveness are available, including temperature monitoring (pressure-optimised) therapeutic footwear, structured education, flexor tenotomy, and integrated foot care. With hardly any new intervention studies published in recent years, more effort to produce high-quality RCTs is urgently needed to further improve the evidence base. This is especially relevant for educational and psychological interventions, for integrated care approaches for persons at high risk of ulceration, and for interventions specifically targeting persons at low-to-moderate risk of ulceration.
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Affiliation(s)
- Jaap J van Netten
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Program Rehabilitation, Amsterdam, The Netherlands
| | - Anita Raspovic
- Discipline of Podiatry, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Matilde Monteiro-Soares
- Portuguese Red Cross School of Health - Lisbon, Lisbon, Portugal
- MEDCIDS - Departamento de Medicina da Comunidade Informação e Decisão em Saúde, Faculty of Medicine, University of Porto, Porto, Portugal
- RISE@CINTESIS, Faculty of Medicine, Oporto University, Porto, Portugal
| | - Joanne Paton
- School of Health Professions, Faculty of Health, University of Plymouth, Plymouth, UK
| | | | - Isabel C N Sacco
- Physical Therapy, Speech and Occupational Therapy Department, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Sicco A Bus
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Program Rehabilitation, Amsterdam, The Netherlands
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Yamazaki H, Matsufuji S, Nishikawa A, Ashida M, Yamaguchi M, Sato M, Tanimura N, Tsujimoto Y, Ubai T, Shoji T. Prosthesis use and the change in activities of daily living following below-knee amputation in patients undergoing hemodialysis. Hemodial Int 2024; 28:107-116. [PMID: 37793912 DOI: 10.1111/hdi.13116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/25/2023] [Accepted: 09/21/2023] [Indexed: 10/06/2023]
Abstract
INTRODUCTION Patients undergoing hemodialysis are at an increased risk of peripheral arterial disease, amputation of lower extremities, and decline of activities of daily living. Although a prosthesis is used to support activities of daily living, no previous study reported the association of prosthesis use with the change in activities of daily living following leg amputation in hemodialysis patients. The purpose of this study was to compare the changes in activities of daily living following amputation between those who created a prosthesis and those who did not. METHODS This study was a single-center, retrospective observational study. We screened medical records for hemodialysis patients who underwent below-knee amputation (BKA) and activities of daily living were examined two times with the functional independence measure (FIM) before BKA and at discharge. They were divided into two groups according to the creation of a prosthesis. FINDINGS We identified 28 eligible patients, among whom 12 patients used a prosthesis (prosthesis group), whereas 16 patients did not (non-prosthesis group). The FIM score was significantly decreased following BKA in the non-prosthesis group, whereas it was not significantly changed in the prosthesis group. The change in FIM score was significantly different between the two groups, and the difference remained significant after considering potential confounders. DISCUSSION The results of this study showed that use versus nonuse of a prosthesis was an independent factor associated with changes in activities of daily living in hemodialysis patients following BKA, supporting the important role of a prosthesis in maintaining activities of daily living in hemodialysis patients who need BKA.
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Affiliation(s)
| | | | - Aina Nishikawa
- Division of Rehabilitation, Inoue Hospital, Suita, Japan
- Department of Rehabilitation, Aijinkai Rehabilitation Hospital, Takatsuki, Japan
| | | | | | - Motohiko Sato
- Division of Orthopedics, Inoue Hospital, Suita, Japan
| | | | | | | | - Tetsuo Shoji
- Department of Vascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
- Vascular Science Center for Translational Research, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
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Luong B, Brown CM, Humphries MD, Maximus S, Kwong M. Assessing the Utility of Toe Arm Index and Toe Pressure in Predicting Wound Healing in Patients Undergoing Vascular Intervention. Ann Vasc Surg 2023; 97:221-235. [PMID: 37659650 DOI: 10.1016/j.avsg.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/06/2023] [Accepted: 08/15/2023] [Indexed: 09/04/2023]
Abstract
BACKGROUND Objective measures of perfusion such as an ankle-brachial index (ABI) and toe pressure remain important in prognosticating wound healing. However, the use of ABI is limited in patients with incompressible vessels and toe pressure may not be comparable across patients. While a toe arm index (TAI) may be of value in this setting, its role as clinical indicator of perfusion for healing in patients with lower-extremity wounds has not been well established. METHODS A retrospective review was performed of all vascular patients with lower-extremity wounds that underwent peripheral vascular intervention between 2014-2019. Data regarding patient demographics, comorbidities, TAI, ABI, toe pressures, and the wound, ischemia, and foot infection (WIfI) score were collected. Associations between patient variables and wound healing at various time points were evaluated. RESULTS A total of 173 patients (67.7 ± 10.9 years; 71.1% male) were identified with lower-extremity wounds. Most patients underwent endovascular intervention (77.5%). Patients were followed for a median of 416 (IQR 129-900) days. Mean postoperative TAI was 0.35 ± 0.19 and mean WIfI score was 2.60 ± 1.17. Nine percent (15) of patients healed within 1 month, 44.8% (69) healed within 6 months, and 65.5% (97) healed within 1 year of revascularization without need for major amputation. Those that healed within 1 year without any major amputation did not differ from those that did not heal based on age, gender, race, comorbidities, periprocedural medications, or procedures performed. However, patients that healed without major amputation had a higher postoperative TAI (0.38 vs. 0.30, P = 0.02), higher toe pressure (53 vs. 40 mm Hg, P = 0.004), and lower WIfI score (2.26 vs. 3.12, P < 0.001). Patients that healed with 1 year without requiring any amputation had similar associations with postoperative TAI, toe pressure, and WIfI. Additionally, they were more likely to be White (P = 0.019) and have an open surgical procedure (P < 0.001) and less likely to have chronic kidney disease (P = 0.001) or diabetes (P = 0.008). A Youden index was calculated and identified a TAI value of 0.30 that optimized sensitivity and specificity for wound healing. The area under the curve for TAI as a predictor of wound healing was 0.62. CONCLUSIONS Higher postoperative TAI is associated with higher odds of wound healing without need for major amputation. Toe arm index is therefore a useful tool to identify patients with adequate arterial perfusion to heal lower-extremity wounds. However, the area under the curve is poor for TAI when used as a sole predictor of wound healing potential suggesting that TAI should be one of multiple factors to considered when prognosticating wound healing potential.
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Affiliation(s)
- Brian Luong
- College of Biological Sciences, University of California, Davis, Sacramento, CA
| | - Christina M Brown
- College of Biological Sciences, University of California, Davis, Sacramento, CA
| | - Misty D Humphries
- Division of Vascular Surgery, Department of Surgery, University of California Davis School of Medicine, Sacramento, CA
| | - Steven Maximus
- Division of Vascular Surgery, Department of Surgery, University of California Davis School of Medicine, Sacramento, CA
| | - Mimmie Kwong
- Division of Vascular Surgery, Department of Surgery, University of California Davis School of Medicine, Sacramento, CA.
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Chen ZY, Yang J, Tian CY, Jia W. The Relationship Between Bone Metabolism and Peripheral Artery Disease in Patients on Hemodialysis: The Potential Role of Osteocalcin. Diabetes Metab Syndr Obes 2023; 16:3331-3337. [PMID: 37908632 PMCID: PMC10614643 DOI: 10.2147/dmso.s432345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 10/10/2023] [Indexed: 11/02/2023] Open
Abstract
Introduction To examine the factors associated with PAD, with a specific focus on bone metabolism factors such as osteocalcin. Methods This cross-sectional study examined factors about demographic, clinical, and laboratory parameters including bone metabolism biomarkers in hemodialysis patients. The ankle-brachial index (ABI) was measured in all patients, with PAD diagnosed as an ABI <0.9. Results Out of the 71 patients, PAD was found in 23 individuals. These patients had an average age of 63.5±13.0 years, with 59.2% being male. Compared to non-PAD patients, those with PAD were older, had a lower proportion of males, and had a higher prevalence of diabetes and coronary artery disease. Among the factors related to bone metabolism, only osteocalcin exhibited a significant increase in the PAD group compared to the non-PAD group. Conclusion PAD in patients on hemodialysis was independently linked to high levels of osteocalcin in the bloodstream, indicating the presence of bone metabolism disorders.
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Affiliation(s)
- Zi-Ye Chen
- Department of Nephrology, Beijing Jishuitan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Jie Yang
- Department of Nephrology, Beijing Jishuitan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Chen-Yang Tian
- Department of Vascular Surgery, Beijing Jishuitan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Wei Jia
- Department of Vascular Surgery, Beijing Jishuitan Hospital, Capital Medical University, Beijing, People’s Republic of China
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Rakestraw SL, Novak Z, Wang MY, Banks CA, Spangler EL, Levitan EB, Locke JE, Beck AW, Sutzko DC. Differences in Long-Term Outcomes in End-Stage Kidney Disease Patients with Chronic Limb-Threatening Ischemia. Ann Vasc Surg 2023; 95:162-168. [PMID: 37225013 PMCID: PMC10799672 DOI: 10.1016/j.avsg.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 05/05/2023] [Accepted: 05/07/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND End-stage kidney disease (ESKD) is a risk factor for peripheral arterial disease and major adverse limb events following infra-inguinal bypass. Despite comprising an important patient population, ESKD patients are rarely analyzed as a subgroup and are underrepresented in vascular surgery guidelines. This study aims to compare the long-term outcomes of patients with and without ESKD undergoing endovascular peripheral vascular intervention (PVI) for chronic limb-threatening ischemia (CLTI). METHODS CLTI patients with and without ESKD from 2007-2020 were identified in the Vascular Quality Initiative PVI dataset. Patients with prior bilateral interventions were excluded. Patients undergoing femoral-popliteal and tibial interventions were included. Mortality, reintervention, amputation, and occlusion rates at 21 months following intervention were examined. Statistical analyses were completed with the t-test, chi-square, and Kaplan-Meier curves. RESULTS The ESKD cohort was younger (66.4 ± 11.8 vs. 71.6 ± 12.1 years, P < 0.001) with higher rates of diabetes (82.2 vs. 60.9%, P < 0.001) the non-ESKD cohort. Long-term follow-up was available for 58.4% (N = 2,128 procedures) of ESKD patients and 60.8% (N = 13,075 procedures) of non-ESKD patients. At 21 months, ESKD patients had a higher mortality (41.7 vs. 17.4%, P < 0.001) and a higher amputation rate (22.3 vs. 7.1%, P < 0.001); however, they had a lower reintervention rate (13.2 vs. 24.6%, P < 0.001). CONCLUSIONS CLTI patients with ESKD have worse long-term outcomes at 2 years following PVI than non-ESKD patients. Mortality and amputation are higher with ESKD, while the reintervention rate is lower. Development of guidelines within the ESKD population has the potential to improve limb salvage.
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Affiliation(s)
| | - Zdenek Novak
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Michael Y Wang
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Charles A Banks
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Emily L Spangler
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Emily B Levitan
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Jayme E Locke
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Adam W Beck
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Danielle C Sutzko
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL.
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Seo MJ, Lee DG, Ko SY, Song GY, Lee GY, Kim SH, Kang DR, Kim J, Lee JY. Risk Factors for Lower Extremity Amputation in Patients with End-Stage Kidney Disease: A Nationwide Cohort Study. J Clin Med 2023; 12:5641. [PMID: 37685708 PMCID: PMC10488883 DOI: 10.3390/jcm12175641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/25/2023] [Accepted: 08/28/2023] [Indexed: 09/10/2023] Open
Abstract
Individuals with end-stage kidney disease (ESKD) on dialysis are at a high risk of developing foot ulcerations and undergoing subsequent lower extremity amputation (LEA), which can exert significant impacts on their quality of life and contribute to rising healthcare costs. We aimed to identify risk factors associated with LEA in patients with ESKD to predict LEA progression and eventually prevent it. We used 18 years (2002-2019) of data from the Korean National Health Insurance Service (KNHIS). Data were collected from patients with ESKD who underwent renal replacement therapy (RRT) and had no history of amputation caused by trauma or toxins. The risk factors were compared between patients with or without LEA. We collected data from 220,838 patients newly diagnosed with ESKD, including 6348 in the LEA group and 214,490 in the non-LEA group. The total incidence of LEA was 2.9%. Older age, male gender, lower income, non-metropolitan residence, diabetes mellitus, dialysis treatment (compared to kidney transplantation), microvascular disease, peripheral vascular disease, endovascular procedure, and endovascular operation were associated with an increased risk of LEA. Thus, individuals with ESKD who are at a higher risk for LEA should be closely monitored, and kidney transplantation should be considered as a preventative measure.
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Affiliation(s)
- Min Jun Seo
- Department of Plastic Surgery, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea; (M.J.S.); (D.G.L.)
| | - Dong Geon Lee
- Department of Plastic Surgery, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea; (M.J.S.); (D.G.L.)
| | - Se Yun Ko
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea; (S.Y.K.); (G.Y.S.); (G.Y.L.)
| | - Ga Yeong Song
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea; (S.Y.K.); (G.Y.S.); (G.Y.L.)
| | - Geon Yeong Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea; (S.Y.K.); (G.Y.S.); (G.Y.L.)
| | - Sung Hwa Kim
- National Health Big Data Clinical Research Institute, Wonju 26426, Republic of Korea; (S.H.K.); (D.R.K.)
- Department of Biostatistics, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
| | - Dae Ryong Kang
- National Health Big Data Clinical Research Institute, Wonju 26426, Republic of Korea; (S.H.K.); (D.R.K.)
- Department of Precision Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
| | - Jiye Kim
- Department of Plastic Surgery, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea; (M.J.S.); (D.G.L.)
| | - Jun Young Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea; (S.Y.K.); (G.Y.S.); (G.Y.L.)
- National Health Big Data Clinical Research Institute, Wonju 26426, Republic of Korea; (S.H.K.); (D.R.K.)
- Transplantation Center, Wonju Severance Christian Hospital, Wonju 26426, Republic of Korea
- Center of Evidence Based Medicine, Institute of Convergence Science, Yonsei University, Seoul 03722, Republic of Korea
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Fu EL, D'Andrea E, Wexler DJ, Patorno E, Paik JM. Safety of Sodium-Glucose Cotransporter-2 Inhibitors in Patients with CKD and Type 2 Diabetes: Population-Based US Cohort Study. Clin J Am Soc Nephrol 2023; 18:592-601. [PMID: 36827225 PMCID: PMC10278835 DOI: 10.2215/cjn.0000000000000115] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 02/14/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND Limited information exists regarding the safety of sodium-glucose cotransporter-2 inhibitors (SGLT2i) in patients with CKD treated in routine care. We evaluated the safety of SGLT2i in patients with CKD and type 2 diabetes treated in US routine practice. METHODS Using claims data from Medicare and two large US commercial databases (April 2013-December 2021), we included 96,128 adults with CKD stages 3-4 and type 2 diabetes who newly filled prescriptions for SGLT2i versus glucagon-like peptide-1 receptor agonists (GLP-1RA). Safety outcomes included diabetic ketoacidosis (DKA), lower limb amputations, nonvertebral fractures, genital infections, hypovolemia, AKI, hypoglycemia, and severe urinary tract infections (UTIs). Hazard ratios (HRs) and incidence rate differences per 1000 person-years were estimated after 1:1 propensity score matching, adjusted for >120 baseline characteristics. RESULTS Compared with GLP-1RA, SGLT2i initiators had a higher risk of nonvertebral fractures (HR, 1.30 [95% confidence interval (CI), 1.03 to 1.65]; incidence rate difference, 2.13 [95% CI, 0.28 to 3.97]), lower limb amputations (HR, 1.65 [95% CI, 1.22 to 2.23]; incidence rate difference, 2.46 [95% CI, 1.00 to 3.92]), and genital infections (HR, 3.08 [95% CI, 2.73 to 3.48]; incidence rate difference, 41.26 [95% CI, 37.06 to 45.46]). Similar risks of DKA (HR, 1.07 [95% CI, 0.74 to 1.54]; incidence rate difference, 0.29 [95% CI, -0.89 to 1.46]), hypovolemia (HR, 0.99 [95% CI, 0.86 to 1.14]; incidence rate difference, 0.20 [95% CI, -2.85 to 3.25]), hypoglycemia (HR, 1.08 [95% CI, 0.92 to 1.26]; incidence rate difference, 1.46 [95% CI, -1.31 to 4.23]), and severe UTI (HR, 1.02 [95% CI, 0.87 to 1.19]; incidence rate difference, 0.35 [95% CI, -2.51 to 3.21]) were observed. SGLT2i had lower risk for AKI (HR, 0.93 [95% CI, 0.87 to 0.99]; incidence rate difference, -6.75 [95% CI, -13.69 to 0.20]). CONCLUSIONS In US patients with CKD and type 2 diabetes receiving routine care, SGLT2i use was associated with higher risks of genital infections and potentially lower limb amputations and nonvertebral fractures.
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Affiliation(s)
- Edouard L. Fu
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Elvira D'Andrea
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Deborah J. Wexler
- Diabetes Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Julie M. Paik
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Renal (Kidney) Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston, Massachusetts
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Wada Y, Otaka Y, Senju Y, Hosokawa H, Tohyama T, Maeda H, Mukaino M, Shibata S, Hirano S. REHABILITATION OUTCOMES IN PATIENTS WITH LOWER LIMB AMPUTATION RECEIVING HAEMODIALYSIS: A RETROSPECTIVE COHORT STUDY. JOURNAL OF REHABILITATION MEDICINE. CLINICAL COMMUNICATIONS 2022; 5:2525. [PMID: 36458181 PMCID: PMC9707531 DOI: 10.2340/jrmcc.v5.2525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/03/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE To compare the functional outcomes of patients with lower limb amputations receiving haemodialysis and those not receiving haemodialysis. DESIGN A retrospective cohort study. PATIENTS Patients with lower limb amputation who were admitted to a convalescent rehabilitation ward between January 2018 and December 2021. METHODS The primary outcome was the effectiveness of the Functional Independence Measure (FIM) during hospitalisation in the ward. Secondary outcomes included the total and subtotal (motor/cognitive) FIM scores at discharge, gain in the total and subtotal (motor/cognitive) FIM scores, K-level at discharge, length of hospital stay in the ward, rehabilitation time, and discharge destination. Outcomes were compared between the non-haemodialysis and haemodialysis groups. RESULTS A total of 28 patients (mean [standard deviation] age, 67.0 [11.9] years; men, 20) were enrolled in this study. Among them, 11 patients underwent haemodialysis. The FIM effectiveness was significantly higher in the non-haemodialysis group than in the haemodialysis group (median [interquartile range], 0.78 [0.72 - 0.81] vs 0.65 [0.28 - 0.75], p = 0.038). The amount of rehabilitation and all secondary outcomes were not significantly different between the groups (p > 0.05). CONCLUSION Patients with lower limb amputation who were receiving haemodialysis had poorer FIM effectiveness than those not receiving haemodialysis.
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Affiliation(s)
- Yoshitaka Wada
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Japan
| | - Yohei Otaka
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Japan
| | - Yuki Senju
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Japan
| | - Hiroshi Hosokawa
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Japan
| | - Takamichi Tohyama
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Japan
| | - Hirofumi Maeda
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Japan
| | - Masahiko Mukaino
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Japan
| | - Seiko Shibata
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Japan
| | - Satoshi Hirano
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Japan
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Lin CW, Armstrong DG, Huang CH, Lin CH, Hung SY, Liu PH, Huang YY. Diabetic foot disease in subjects with End-stage renal Disease: A nationwide study over 14 years highlighting an emerging threat. Diabetes Res Clin Pract 2022; 193:110134. [PMID: 36349589 DOI: 10.1016/j.diabres.2022.110134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 10/03/2022] [Accepted: 10/20/2022] [Indexed: 11/17/2022]
Abstract
AIMS To disclose prevalence, demographic, foot characteristics as well as management and lower-extremity amputations (LEAs) of subjects with end-stage renal disease (ESRD) on diabetic foot diseases (DFDs). METHODS Data were derived from the Taiwan National Health Insurance Research Database between 2004 and 2017. DFDs were defined as ulcers, infections, or severe peripheral arterial diseases (PADs) in patients with type 2 diabetes. Clinical characteristics were analyzed between subjects with and without ESRD. RESULTS Subjects with ESRD have increased impacts on the DFD population either from annual prevalence (2.7 % to 10.42 %, P for trend < 0.001), or proportional representation in LEAs (7.91 % to 26.37 %, P < 0.001) over 14 years. The annual trends for major-LEAs rates have decreased in both subjects with and without ESRD (13.67 % to 5.82 % and 3.48 % to 1.47 %, both P < 0.001). Notably, the concomitant increase of endovascular treatments (EVTs) (7.09 % to 29.41 %, P < 0.001) was associated with the decrease of major-LEAs (P for interaction < 0.001) in subjects with ESRD. CONCLUSIONS As the annual prevalence of subjects with ESRD has increased 3.9-fold over years, they now account for more than 30% of annual major-LEA of the total DFD population. Interdisciplinary team approach and aggressive EVTs might reduce major-LEAs in these patients.
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Affiliation(s)
- Cheng-Wei Lin
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
| | - David G Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California (USC), Los Angeles, USA (D.G.A.)
| | - Chung-Huei Huang
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
| | - Chia-Hung Lin
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
| | - Shih-Yuan Hung
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
| | - Pi-Hua Liu
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan; Clinical Informatics and Medical Statistics Research Center, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - Yu-Yao Huang
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan; College of Medicine, Chang Gung University, Taoyuan City, Taiwan; Department of Medical Nutrition Therapy, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.
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12
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Klein KR, Flythe JE. Seeing the Light: Improving Diabetic Retinopathy Outcomes by Bringing Screening to the Dialysis Clinic. KIDNEY360 2022; 3:1474-1476. [PMID: 36245657 PMCID: PMC9528370 DOI: 10.34067/kid.0003752022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 06/22/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Klara R. Klein
- Division of Endocrinology and Metabolism, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Jennifer E. Flythe
- Division of Nephrology and Hypertension, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
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13
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Health Education Programmes to Improve Foot Self-Care Knowledge and Behaviour among Older People with End-Stage Kidney Disease (ESKD) Receiving Haemodialysis (A Systematic Review). Healthcare (Basel) 2022; 10:healthcare10061143. [PMID: 35742194 PMCID: PMC9222212 DOI: 10.3390/healthcare10061143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/13/2022] [Accepted: 06/14/2022] [Indexed: 11/17/2022] Open
Abstract
Background: ESKD is a total or near-permanent failure in renal function. It is irreversible, progressive and ultimately fatal without peritoneal dialysis (PD), haemodialysis (HD) or kidney transplantation. Dialysis treatments can create new and additional problems for patients, one of which is foot amputation, as a result of non-healing wounds and vascular complications. The association between dialysis therapy and foot ulceration is linked to several factors: physical and psychological health; peripheral arterial disease (PAD); mobility; tissue oxygenation; manual dexterity; neuropathy; visual acuity; anaemia; nutrition; leg oedema; hypoalbuminemia; infection; inadequacy of dialysis; and leg/foot support during dialysis. The potential risk factors for foot ulceration may include: not routinely receiving foot care education; incorrect use of footwear; diabetes duration; neuropathy; and peripheral arterial disease. Aim: The aim of this review is to examine the factors that help or hinder successful implementation of foot care education programmes for ESKD patients receiving haemodialysis. Method: A comprehensive literature search was completed using five electronic databases. Medline; CINAHL; Embase; PsycINFO; and Cochrane Library. The Joanna Briggs Institute checklist (JBI) was used to quality appraise full text papers included in the review. The systematic review was not limited to specific categories of interventions to enable optimal comparison between interventions and provide a comprehensive overview of the evidence in this important field of foot care. Results: We found no previously published studies that considered foot care education programmes for haemodialysis patients who are not diabetic; thus, the present systematic review examined four studies on diabetic patients receiving haemodialysis exposed to foot care education programmes from various types of intervention designs. Conclusions: This systematic review has provided evidence that it is possible to influence foot care knowledge and self-care behaviours in both diabetic patients receiving haemodialysis and healthcare professionals.
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14
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Risks and Risk Factors for Contralateral Amputation in Patients who have Undergone Amputation for Chronic Limb Threatening Ischemia. Eur J Vasc Endovasc Surg 2022; 64:111-118. [DOI: 10.1016/j.ejvs.2022.03.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 03/14/2022] [Accepted: 03/28/2022] [Indexed: 11/23/2022]
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Schembri N, Formosa C. Dialysis Treatment is an Independent Risk Factor for Foot Morbidity. INT J LOW EXTR WOUND 2022:15347346221074111. [PMID: 35037518 DOI: 10.1177/15347346221074111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aim: To determine the prevalence of foot morbidity among patients with ESRD on dialysis. Methods: A prospective, non-experimental, quantitative time series design was employed. Forty-seven participants were recruited in the study. Medical records were reviewed followed by non-invasive foot assessments which included: Neurological, Arterial, Biomechanical, and Dermatological Assessment. Participants were assessed twice during the study. Results: Foot morbidity was found to be high among participants with ESRD on dialysis. 95.74% of participants presented with foot deformities, 76.60% had skin and nail conditions. 15% of participants had a history of ulceration and amputation. Moreover, active ulceration and history of revascularisation were also observed. Findings demonstrated overall poor foot health and footcare behavior within this population with 40.43% of participants having inappropriate footwear. The majority of participants did not check feet regularly, did not attend to podiatry appointments, and were unable to reach their feet for self-care. The Toe Brachial Pressure Index (TBPI), Spectral Doppler Waveform Analysis, and the Quantitative Sensory Testing (QST) were re-measured at each visit. Monophasic continuous doppler waveforms increased while triphasic waveforms decreased during the study period. Protective sensation did not decrease during the study period. The mean TBPI decreased during the study period. The relationship between the TBPI and duration of dialysis was found to be significant. Both DM and dialysis duration were identified as significant predictors of reduction in TBPI. Conclusion: This study demonstrates a high prevalence of foot morbidity among patients with ESRD on dialysis. This study highlighted the importance of expanding practice by introducing a podiatry service within the renal unit to provide foot screening, foot assessments, and foot care education, with the aim to reduce severe foot complications.
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16
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Kofod DH, Almdal TP, Sørensen VR, Feldt‐Rasmussen B, Hornum M. Micro‐ and macrovascular complications and risk factors for foot ulceration and amputation in individuals receiving dialysis with and without diabetes. Endocrinol Diabetes Metab 2022; 5:e00305. [PMID: 34658171 PMCID: PMC8754241 DOI: 10.1002/edm2.305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 09/28/2021] [Accepted: 10/04/2021] [Indexed: 11/21/2022] Open
Abstract
Introduction This study examined the prevalence of microvascular and macrovascular complications in people receiving dialysis with and without diabetes and investigated independent risk factors for foot ulcers and lower‐extremity amputations. Methods We performed a cross‐sectional study of 119 individuals with diabetes and 219 individuals without diabetes receiving chronic dialysis during June 2019 at the Department of Nephrology, Rigshospitalet, University of Copenhagen, Denmark. Effects of diabetes and other risk factors were assessed by log‐binomial regression. Prevalence data were compared with a historical control group of 38 individuals with diabetes receiving dialysis examined in 2004 in the same department. Results We found that persons with diabetes had a twofold higher risk ratio of current (unadjusted risk ratio 2.2 [95% CI 1.1, 4.7]) and previous foot ulcer (2.5 [1.7, 3.7]) and a fourfold higher risk ratio of lower‐extremity amputation (4.2 [2.1, 8.6]) in comparison with persons without diabetes (all p < .05). Furthermore, persons with diabetes had a 70% increased risk ratio of myocardial infarction (1.7 [1.0–2.8], p = .041). In multivariable‐adjusted analysis, current foot ulcer was independently associated with previous foot ulcer (adjusted risk ratio 4.0 [95% CI 1.8, 8.9]), while lower‐extremity amputation was independently associated with diabetes (3.8 [1.8, 8.2]) and male sex (4.1 [1.5, 11.3]) (all p < .01). Conclusions Individuals with diabetes receiving dialysis had a higher prevalence of foot ulcer, lower‐extremity amputation and myocardial infarction compared to individuals without diabetes. Previous foot ulcer was the most important risk factor for current foot ulcer, while diabetes and male sex were important risk factors for lower‐extremity amputation.
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Affiliation(s)
- Dea Haagensen Kofod
- Department of Nephrology RigshospitaletUniversity of Copenhagen Copenhagen Denmark
| | - Thomas Peter Almdal
- Department of Endocrinology RigshospitaletUniversity of Copenhagen Copenhagen Denmark
- Department of Clinical Medicine Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark
| | | | - Bo Feldt‐Rasmussen
- Department of Nephrology RigshospitaletUniversity of Copenhagen Copenhagen Denmark
- Department of Clinical Medicine Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark
| | - Mads Hornum
- Department of Nephrology RigshospitaletUniversity of Copenhagen Copenhagen Denmark
- Department of Clinical Medicine Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark
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17
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Bonnet JB, Sultan A. Narrative Review of the Relationship Between CKD and Diabetic Foot Ulcer. Kidney Int Rep 2021; 7:381-388. [PMID: 35257052 PMCID: PMC8897302 DOI: 10.1016/j.ekir.2021.12.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/23/2021] [Accepted: 12/14/2021] [Indexed: 01/22/2023] Open
Abstract
Diabetic foot ulcer (DFU) and chronic kidney disease (CKD) are 2 significant complications of diabetes mellitus (DM). Up to 40% of patients with DM are expected to also develop CKD, and 19% to 34% will suffer from DFU during their lifetimes. However, data on the link between podiatric risk and the extent of CKD are scarce. Neuropathy, a key element of the International Working Group on the Diabetic Foot (IWGDF) classification, nevertheless appears to be related to the CKD stage. The incidence of DFU and its poor evolution also appear to be linked to the stage of CKD, with mortality reaching its peak in patients with end-stage renal disease (ESRD). Whatever, the decrease in the rate of diabetic foot amputation observed worldwide, especially for major amputations, is also observed in patients with ESRD. Specific actions taken for patients undergoing dialysis seems to improve the DFU prognosis. CKD and DFU share a number of elements of pathophysiology, the first of which is peripheral arterial disease (PAD). Uremic neuropathy and nutritional status also seem to create a link between the development of the 2 complications. This literature review provides an update on the complex and dynamic relationship between DFU and CKD. It examines the epidemiologic link between CKD and diabetic foot risk, CKD and DFU occurrence, and CKD and DFU prognosis. It focuses on the pathophysiological links between these 2 complications. Finally, it highlights the actions taken to improve management in the ESRD population that have reduced the rate of major amputations in this population by more than half.
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18
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Hallström S, Svensson AM, Pivodic A, Ólafsdóttir AF, Löndahl M, Wedel H, Lind M. Risk factors and incidence over time for lower extremity amputations in people with type 1 diabetes: an observational cohort study of 46,088 patients from the Swedish National Diabetes Registry. Diabetologia 2021; 64:2751-2761. [PMID: 34494137 PMCID: PMC8563633 DOI: 10.1007/s00125-021-05550-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 06/14/2021] [Indexed: 01/30/2023]
Abstract
AIMS/HYPOTHESIS The aim of this work was to study the incidence over time of lower extremity amputations and determine variables associated with increased risk of amputations in people with type 1 diabetes. METHODS Individuals with type 1 diabetes registered in the Swedish National Diabetes Registry with no previous amputation from 1 January 1998 and followed to 2 October 2019 were included. Time-updated Cox regression and gradient of risk per SD were used to evaluate the impact of risk factors on the incidence of amputation. Age- and sex-adjusted incidences were estimated over time. RESULTS Of 46,088 people with type 1 diabetes with no previous amputation (mean age 32.5 years [SD 14.5], 25,354 [55%] male sex), 1519 (3.3%) underwent amputation. Median follow-up was 12.4 years. The standardised incidence for any amputation in 1998-2001 was 2.84 (95% CI 2.32, 3.36) per 1000 person-years and decreased to 1.64 (95% CI 1.38, 1.90) per 1000 person-years in 2017-2019. The incidence for minor and major amputations showed a similar pattern. Hyperglycaemia and renal dysfunction were the strongest risk factors for amputation, followed by older age, male sex, cardiovascular comorbidities, smoking and hypertension. Glycaemic control and age- and sex-adjusted renal function improved during the corresponding time period as amputations decreased. CONCLUSIONS/INTERPRETATION The incidence of amputation and of the most prominent risk factors for amputation, including renal dysfunction and hyperglycaemia, has improved considerably during recent years for people with type 1 diabetes. This finding has important implications for quality of life, health economics and prognosis regarding CVD, indicating a trend shift in the treatment of type 1 diabetes.
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Affiliation(s)
- Sara Hallström
- Department of Internal Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden.
| | - Ann-Marie Svensson
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
- Center of Registers in Region Västra Götaland, Gothenburg, Sweden
| | - Aldina Pivodic
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Statistiska Konsultgruppen, Gothenburg, Sweden
| | - Arndís F Ólafsdóttir
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, NU-Hospital Group, Uddevalla, Sweden
| | - Magnus Löndahl
- Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden
- Department of Endocrinology, Skane University Hospital, Lund, Sweden
| | - Hans Wedel
- Department of Health Metrics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Marcus Lind
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, NU-Hospital Group, Uddevalla, Sweden
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Akturk A, van Netten JJ, Vermeer M, Kruse RR, Schaper NC, van Gemert-Pijnen LJEWC, van Baal JG. Improved outcomes in patients with diabetic foot ulcers despite of differences in baseline characteristics. Wound Repair Regen 2021; 29:912-919. [PMID: 34665904 DOI: 10.1111/wrr.12976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 09/11/2021] [Accepted: 10/05/2021] [Indexed: 11/30/2022]
Abstract
The incidence of diabetes is increasing worldwide with concomitant raising number of patients with diabetic foot disease. Diabetic foot disease treatment has received more attention in the past decades, culminating in the creation of multidisciplinary outpatient clinics, but at the same time, complexity of patients seems to have increased. The aim of this article is to study differences in patient characteristics and outcomes (ulcer healing and ulcer-free survival days) in patients with a diabetic foot ulcer in two prospective cohorts with 15 years in between. Prospective cohort study of all patients in one diabetic foot centre of expertise in 2003-2004 and 2014-2018. Clinical outcomes were determined after a follow-up period of 12 months. Outcomes were differences in baseline characteristics and comorbidities, and differences in ulcer-related outcomes between both cohorts. We included all consecutive diabetic foot ulcer patients from our centre for the period 2003-2004 (n = 79) and 2014-2018 (n = 271). Age (67.0 ± 14.3 vs. 71.6 ± 11.5, p = 0.003) and prevalence of end-stage renal disease (1.3% vs. 7.7%, p = 0.036) were significantly higher in the more recent population. The more recent population had higher healing rate (53.2% vs. 76.4%, p < 0.001), higher median ulcer-free survival days once an ulcer had healed [173 days (IQR 85.3-295.5) vs. 257.0 (IQR 157.0-318.0), p = 0.026], and fewer minor amputations (20.3% vs. 8.1%, p = 0.002). People with diabetic foot ulcers treated in 2014-2018 were older and more frequently diagnosed with ESRD, compared to this population in 2003-2004, while other characteristics were similar; ulcer-related outcomes were better.
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Affiliation(s)
- Afram Akturk
- Department of Surgery, Ziekenhuisgroep Twente (ZGT), Almelo and Hengelo, The Netherlands
| | - Jaap J van Netten
- Department of Surgery, Ziekenhuisgroep Twente (ZGT), Almelo and Hengelo, The Netherlands.,Department of Rehabilitation, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,School of Public Health, Queensland University of Technology, Brisbane, Australia
| | - Marloes Vermeer
- ZGT Academy, Ziekenhuisgroep Twente (ZGT), Almelo and Hengelo, The Netherlands
| | - Rombout R Kruse
- Department of Surgery, Ziekenhuisgroep Twente (ZGT), Almelo and Hengelo, The Netherlands
| | - Nicolaas C Schaper
- Division of Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, The Netherlands
| | | | - Jeff G van Baal
- Department of Surgery, Ziekenhuisgroep Twente (ZGT), Almelo and Hengelo, The Netherlands.,ZGT Academy, Ziekenhuisgroep Twente (ZGT), Almelo and Hengelo, The Netherlands.,University of Cardiff, Cardiff, UK
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20
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Salim M. Clinical outcomes among patients with chronic kidney disease hospitalized with diabetic foot disorders: A nationwide retrospective study. Endocrinol Diabetes Metab 2021; 4:e00277. [PMID: 34277993 PMCID: PMC8279616 DOI: 10.1002/edm2.277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/18/2021] [Accepted: 05/22/2021] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Diabetic foot ulcerations or infections (DFUs/DFIs) are common complications of patients with diabetes. This study aimed to explore the impact of non-dialysis and dialysis CKD on hospitalized patients with DFUs/DFIs. METHODS A retrospective cohort study was conducted using the National Inpatient Sample database for the years 2017 and 2018. Patients hospitalized for DFUs/DFIs were included in the study. The primary outcome was lower limb amputations. The secondary outcomes were inpatient mortality, sepsis, length of stay (LOS), total hospitalization charges (THC) and disposition. RESULTS A total of 121,815 hospitalizations were included (26.1% non-dialysis CKD; 8.4% dialysis CKD). There was no significant difference in amputation rates between those on non-dialysis CKD (adjusted odds ratio [aOR]: 0.96; 95% confidence interval [CI]: 0.87-1.06) and dialysis CKD (aOR: 1.04, [95% CI: 0.91-1.12]) when compared to non-CKD group. Dialysis CKD group had increased odds of undergoing major amputation (aOR: 1.74, [95% CI: 1.32-2.29]), in-hospital mortality (aOR: 3.77 [95% CI: 1.94-7.31]), sepsis (aOR: 1.83 [95% CI: 1.27-2.62]), longer LOS (adjusted mean difference [aMD]: 1.46 [95 CI: 1.12-1.80) and higher THC (adjusted mean difference [aMD]: $20,148 [95% CI: $15,968-$24,327]). Non-dialysis CKD group had increased odds of sepsis (aOR: 1.36 [95% CI: 1.02-1.82]), less likely to be discharged home (aOR: 0.87 [95% CI: 0.80-0.95]), longer LOS (aMD: 0.91 [95% CI 0.69-1.13]) and higher THC (aMD: $20,148 [95% CI: $15,968-$24,327]). CONCLUSION Patients with CKD on dialysis had higher odds of undergoing major amputation. CKD increased the odds of in-hospital morbidity and resource utilization, with the most significant is for those on dialysis.
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Affiliation(s)
- Michael Salim
- Department of Internal MedicineMount Sinai HospitalChicagoILUSA
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21
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Yovera-Aldana M, Sáenz-Bustamante S, Quispe-Landeo Y, Agüero-Zamora R, Salcedo J, Sarria C, Gonzales-Grandez N, Briceño-Alvarado M, Antezana-Román A, Manrique H, Armstrong DG. Nationwide prevalence and clinical characteristics of inpatient diabetic foot complications: A Peruvian multicenter study. Prim Care Diabetes 2021; 15:480-487. [PMID: 33664012 DOI: 10.1016/j.pcd.2021.02.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/23/2021] [Accepted: 02/21/2021] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To evaluate the burden of diabetic foot complications amongst inpatients in Peru. MATERIALS AND METHODS Cross-sectional multicenter study, performed in public hospitals, in one-day enrollment between October and December 2018. RESULTS We included 8346 patients from 39 national hospitals. Diabetic foot (DF) inpatient point prevalence was 2.8% (CI 95% 2.4-3.1), and DF point prevalence among Diabetes Mellitus (DM) inpatients was 18.9% (CI 95% 16.7-21.1). DF prevalence was higher in jungle and coastal hospitals than highlands ones, and there was no difference according to its care complexity level. Of the 234 patients with DF, 73% were males, age average was 62 ± 12 years, with DM mean time duration of 15 ± 9.9 years. Regarding to DF etiology, 91% and 68% had some degree of peripheral neuropathy and peripheral artery disease, respectively. According to the Infectious Diseases Society of America criteria, 61% presented moderate to severe infections, and 40% had bone involvement. Debridement within 48 h was performed in 36% of sepsis cases. CONCLUSION Peru has a substantial burden of DF disease, with a greater share of that burden falling on less equipped hospitals in the country's jungle and coastal regions. Interdisciplinary teams and pathways may improve the time of surgical debridement in the highest risk patients.
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Affiliation(s)
- Marlon Yovera-Aldana
- Grupo de Investigación en Neurociencia, Efectividad Clínica y Salud Pública, Universidad Científica del Sur, Lima, Peru; Servicio de Endocrinología, Hospital María Auxiliadora, Lima, Peru; Alianza para el Salvataje del Pie Diabético, Lima, Peru.
| | - Sofia Sáenz-Bustamante
- Servicio de Endocrinología, Centro Médico Naval "Cirujano Mayor Santiago Távara", Lima, Peru; Alianza para el Salvataje del Pie Diabético, Lima, Peru; Escuela de Post grado, Universidad Peruana Cayetano Heredia, Lima, Peru.
| | - Yudith Quispe-Landeo
- Alianza para el Salvataje del Pie Diabético, Lima, Peru; Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru; Facultad de Medicina, Universidad San Martin de Porres, Lima, Peru.
| | - Rosa Agüero-Zamora
- Escuela de Post grado, Universidad Peruana Cayetano Heredia, Lima, Peru; Servicio de Endocrinolgía, Hospital Regional Docente Clínico Quirúrgico "Daniel Alcides Carrión", Junín, Peru.
| | - Julia Salcedo
- Facultad de Medicina, Universidad Peruana Cayetano Heredia, Lima, Peru.
| | - Carolina Sarria
- Servicio de Endocrinología, Hospital Nacional Arzobispo Loayza, Lima, Peru; Escuela de Post grado, Universidad Peruana Cayetano Heredia, Lima, Peru.
| | | | - Manolo Briceño-Alvarado
- Alianza para el Salvataje del Pie Diabético, Lima, Peru; Departamento de Cirugía de Tórax y Cardiovascular, Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru.
| | - Augusto Antezana-Román
- Alianza para el Salvataje del Pie Diabético, Lima, Peru; Departamenteo de Medicina, Hospital Hipólito Unanue, Tacna, Peru.
| | - Helard Manrique
- Alianza para el Salvataje del Pie Diabético, Lima, Peru; Facultad de Medicina, Universidad Peruana Cayetano Heredia, Lima, Peru.
| | - David G Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA.
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22
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Clemens KK, Ouédraogo AM, Garg AX, Silver SA, Nash DM. Opportunities To Improve Diabetes Care in the Hemodialysis Unit: A Cohort Study in Ontario, Canada. KIDNEY360 2021; 2:653-665. [PMID: 35373046 PMCID: PMC8791316 DOI: 10.34067/kid.0007082020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 02/09/2021] [Indexed: 02/04/2023]
Abstract
Background Patients with diabetes receiving chronic, in-center hemodialysis face healthcare challenges. We examined the prevalence of gaps in their diabetes care, explored regional differences, and determined predictors of care gaps. Methods We conducted a population-based, retrospective study between January 1, 2016 and January 1, 2018 in Ontario, Canada. We included adults with prevalent diabetes mellitus receiving in-center hemodialysis as of January 1, 2018 and examined the proportion with (1) insufficient or excessive glycemic monitoring, (2) suboptimal screening for diabetes-related complications (retinopathy and cardiovascular screening), (3) hospital encounters for hypo- or hyperglycemia, and (4) hospital encounters for hypertension in the 2 years prior (January 1, 2016 to January 1, 2018). We then identified patient, provider, and health-system factors associated with more than one care gap and used multivariable logistic regression to determine predictors. Further, we used geographic information systems to explore spatial variation in gaps. Results There were 4173 patients with diabetes receiving in-center hemodialysis; the mean age was 67 years, 39% were women, and the majority were of lower socioeconomic status. Approximately 42% of patients had more than one diabetes care gap, the most common being suboptimal retinopathy screening (53%). Significant predictors of more than one gap included younger age, female sex, shorter duration of diabetes, dementia, fewer specialist visits, and not seeing a physician for diabetes. There was evidence of spatial variation in care gaps across our region. Conclusions There are opportunities to improve diabetes care in patients receiving in-center hemodialysis, particularly screening for retinopathy. Focused efforts to bring diabetes support to high-risk individuals might improve their care and outcomes.
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Affiliation(s)
- Kristin K. Clemens
- Division of Endocrinology and Metabolism, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- ICES, Ontario, Canada
- Center for Diabetes, Endocrinology and Metabolism, St. Joseph's Health Care London, London, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada
| | | | - Amit X. Garg
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- ICES, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada
- Division of Nephrology, Western University, London, Ontario, Canada
| | - Samuel A. Silver
- ICES, Ontario, Canada
- Division of Nephrology, Queen's University, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Danielle M. Nash
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- ICES, Ontario, Canada
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23
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Iseli RK, Duncan G, Lee EK, Lewis E, Maier AB. Incorporating foot assessment in the comprehensive geriatric assessment. BMC Geriatr 2021; 21:223. [PMID: 33794805 PMCID: PMC8015740 DOI: 10.1186/s12877-021-02164-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 03/18/2021] [Indexed: 12/16/2022] Open
Abstract
Background Foot problems are common in older adults and associated with poorer physical function, falls, frailty and reduced quality of life. Comprehensive Geriatric Assessment (CGA), a multidisciplinary process that is considered the gold standard of care for older adults, does not routinely include podiatry assessment and intervention in hospitalized older adults. Aims To introduce foot assessment to inpatient CGA to determine prevalence of foot disease, foot disease risk factors and inappropriate footwear use, assess inter-rater reliability of foot assessments, determine current podiatry input and examine associations between patient characteristics and foot disease risks. Methods Prospective, observational cohort study of older adults on geriatric rehabilitation wards. Foot assessment completed using the Queensland Foot Disease Form (QFDF) in addition to routine CGA. Results Fifty-two patients (median age [inter-quartile range] 86.4 [79.2–90.3] years, 54% female) were included. Six patients (12%) had foot disease and 13 (25%) had a ‘high risk’ or ‘at risk’ foot. Foot disease risk factor prevalence was peripheral arterial disease 9 (17%); neuropathy 10 (19%) and foot deformity 11 (22%). Forty-one patients (85%) wore inappropriate footwear. Inter-rater agreement was substantial on presence of foot disease and arterial disease, fair to moderate on foot deformity and fair on neuropathy and inappropriate footwear. Eight patients (15%) saw a podiatrist during admission: 5 with foot disease, 1 ‘at risk’ and 2 ‘low risk’ for foot disease. Patients with an at risk foot or foot disease had significantly longer median length of hospital stay (25 [13.7–32.1] vs 15.2 [8–22.1] days, p = 0.01) and higher median Malnutrition Screening Test scores (2 [0–3] vs 0 [0–2], p = 0.03) than the low-risk group. Patients with foot disease were most likely to see a podiatrist (p < 0.001). Conclusion Foot disease, foot disease risk factors and inappropriate footwear are common in hospitalized older adults, however podiatry assessment and intervention is mostly limited to patients with foot disease. Addition of routine podiatry assessment to the multidisciplinary CGA team should be considered. Examination for arterial disease and risk of malnutrition may be useful to identify at risk patients for podiatry review. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02164-3.
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Affiliation(s)
- Rebecca K Iseli
- Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia. .,Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia.
| | - Gregory Duncan
- Eastern Health Clinical School, Monash University
- , Box Hill, Victoria, Australia
| | - Elton K Lee
- Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Ellen Lewis
- Podiatry Department, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Andrea B Maier
- Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Human Movement Sciences, @AgeAmsterdam, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands.,Healthy Longevity Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Centre for Healthy Longevity, National University Health System, Singapore, Singapore
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24
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Naazie IN, Mwinyogle A, Nejim B, Al-Nouri O, Cajas-Monson L, Malas MB. The association of estimated glomerular filtration rate with outcomes following infrainguinal bypass for peripheral arterial disease. J Vasc Surg 2021; 74:788-797.e1. [PMID: 33647436 DOI: 10.1016/j.jvs.2021.01.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 01/23/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Chronic kidney disease (CKD) is a recognized predictor of long-term survival, frequently coexisting with peripheral arterial disease (PAD). Estimated glomerular filtration rate (eGFR) is a more accurate marker of renal function than creatinine. This study sought to determine the graded impact of CKD, defined by eGFR, on infrainguinal lower extremity bypass (LEB) outcomes. METHODS This retrospective study examined 44,332 patients from the Vascular Quality Initiative database who underwent LEB between January 2003 and November 2019. The GFR was estimated using the Modification of Diet in Renal Disease equation. Multivariable logistic regression was used to study perioperative mortality and Kaplan-Meier survival estimation and multivariable Cox regression were used to evaluate 5-year mortality, 1-year major amputation, and major amputation/death. RESULTS The 30-day mortality odds was increased for CKD 3 (odds ratio [OR], 1.58; 95% confidence interval [CI], 1.32-1.91; P < .001) and CKD 5 (OR, 3.08; 95% CI, 2.45-3.87; P < .001) relative to CKD 1 to 2. Comparing CKD stages 3, 4, and 5 with CKD 1 and 2, there was a stepwise increase in the adjusted hazard of 5-year mortality (hazard ratio [HR], 1.18; 95% CI, 1.09-1.27; P < .001), (HR, 1.73; 95% CI; 1.47-2.03; P < .001) and (HR, 2.58; 95% CI, 2.33-3.84; P < .001), respectively. Although the risk of 1-year death or major amputation did not differ for CKD 3 compared with CKD 1, this was 50% higher for CKD 4 (HR, 1.50; 95% CI, 1.26-1.78; P < .001) and doubled for CKD 5 (HR, 2.07; 95% CI, 1.87-2.29; P < .001) compared with CKD 1 and 2. The adjusted HR for major amputation in 1 year was 0.81 (95% CI, 0.71-0.92; P = .002), 1.14 (95% CI, 0.84-1.54; P = .396) and 1.56 (95% CI,1.31-1.84; P < .001) for CKD 3, 4, and 5, respectively, compared with CKD 1 and 2. CONCLUSIONS The estimated GFR is a useful predictor of postoperative mortality, overall survival, and/or amputation after LEB in patients with PAD. It should be considered in the preoperative risk-benefit analysis process to guide patient selection in the population with concomitant PAD and CKD being considered for LEB.
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Affiliation(s)
- Isaac N Naazie
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego Health System, San Diego, Calif
| | | | - Besma Nejim
- Department of Vascular Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pa
| | - Omar Al-Nouri
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego Health System, San Diego, Calif
| | - Luis Cajas-Monson
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego Health System, San Diego, Calif
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego Health System, San Diego, Calif.
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25
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Ogurtsova K, Morbach S, Haastert B, Dubský M, Rümenapf G, Ziegler D, Jirkovska A, Icks A. Cumulative long-term recurrence of diabetic foot ulcers in two cohorts from centres in Germany and the Czech Republic. Diabetes Res Clin Pract 2021; 172:108621. [PMID: 33316312 DOI: 10.1016/j.diabres.2020.108621] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/27/2020] [Accepted: 12/08/2020] [Indexed: 11/30/2022]
Abstract
AIMS Our aim was to comprehensively estimate the incidence of diabetic foot ulcer (DFU) recurrence and corresponding risk factors in two cohorts. METHODS Prospective data from patients with active DFU from two diabetes centres in Germany (GER, n = 222) and the Czech Republic (CZ, n = 99) were analysed. Crude cumulative incidences were obtained. Additionally, time to recurrence and risk factors were investigated using multivariate Cox models. RESULTS 69%(154) of patients in GER and 70%(69) in CZ experienced at least one DFU recurrence; 25%(56) in DEU and 15%(15) in CZ died; 5%(11) and 9%(9) were lost to follow-up. The crude cumulative incidence in the first year was 28% in GER and 25% in CZ; 68%/70% within ten years, and 69%/70% in 15 years. In GER, renal replacement therapy was associated with shorter time to recurrence (HR = 3.71, 95%CI:1.26-10.87); no history of DFU before the index lesion with longer time to recurrence (HR = 0.62, 0.42-0.92). In CZ, type 2 diabetes (HR = 2.57, 1.18-5.62) and index ulcer treatment by minor amputation (HR = 2.11, 1.03-4.33) were associated with shorter time to recurrence. CONCLUSIONS Cumulative DFU recurrence was approximately 70% in 15 years in both cohorts. We found a significantly higher risk of future recurrence in patients having a consecutive ulcer compared with the first ever ulcer.
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Affiliation(s)
- Katherine Ogurtsova
- Institute for Health Services Research and Health Economics, German Diabetes Center, Düsseldorf, Germany; German Centre for Diabetes Research (DZD), Neuherberg, Germany.
| | - Stephan Morbach
- Department of Diabetes and Angiology, Marienkrankenhaus, Soest, Germany; Institute for Health Services Research and Health Economics, Faculty of Medicine, Heinrich-Heine- University, Düsseldorf, Germany
| | - Burkhard Haastert
- Institute for Health Services Research and Health Economics, Faculty of Medicine, Heinrich-Heine- University, Düsseldorf, Germany; mediStatistica, Neuenrade, Germany
| | - Michal Dubský
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Gerhard Rümenapf
- Department of Vascular Surgery, Centre of Vascular Medicine Oberrhein, Diakonissen-Stiftungs-Krankenhaus, Speyer, Germany
| | - Dan Ziegler
- Institute for Clinical Diabetology, German Diabetes Center and Division of Endocrinology and Diabetology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Alexandra Jirkovska
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Andrea Icks
- Institute for Health Services Research and Health Economics, German Diabetes Center, Düsseldorf, Germany; German Centre for Diabetes Research (DZD), Neuherberg, Germany; Institute for Health Services Research and Health Economics, Faculty of Medicine, Heinrich-Heine- University, Düsseldorf, Germany
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26
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Li K, Ferguson T, Embil J, Rigatto C, Komenda P, Tangri N. Risk of Kidney Failure, Death, and Cardiovascular Events After Lower Limb Complications in Patients With CKD. Kidney Int Rep 2020; 6:381-388. [PMID: 33615063 PMCID: PMC7879126 DOI: 10.1016/j.ekir.2020.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 11/03/2020] [Accepted: 11/10/2020] [Indexed: 12/30/2022] Open
Abstract
Objective Lower limb complications are major adverse events in patients with peripheral artery disease (PAD) and chronic kidney disease (CKD). These complications can lead to morbidity, disability, reduced quality of life, and higher health care costs. We sought to determine how interim lower limb complications modify the subsequent risk of progression to kidney failure, all-cause mortality before kidney failure, and cardiovascular (CV) events in a cohort of patients with CKD stages G3 to G5. Methods We performed a retrospective cohort study using patient-level data obtained by linking several administrative databases from Manitoba, Canada. We used Fine and Gray regression models for the primary outcomes of (1) kidney failure adjusted for the competing risk of all-cause mortality, (2) death before kidney failure, and (3) cardiovascular-related hospitalization with the competing risk of non-CV death. Results A total of 92,618 patients were included in the final cohort, with a median follow-up time of 2.56 years. Compared with patients who did not experience an interim lower limb complication, there was a higher risk of kidney failure (adjusted hazard ratio [HR] 2.51, 95% confidence interval [CI] 2.10-3.00), all-cause mortality before kidney failure (adjusted HR 2.73, 95% CI 2.55-2.92), and CV events (adjusted HR 2.12, 95% CI 1.90-2.38). Conclusions Interim lower limb complications are associated with an increased risk of kidney failure, all-cause mortality before kidney failure, and cardiovascular-related hospitalization. Clinical trials of screening and treatment strategies for patients with CKD at risk for lower limb complications may help determine optimal strategies to manage this risk.
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Affiliation(s)
- Kevin Li
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
| | - Thomas Ferguson
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
| | - John Embil
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Section of Infectious Diseases, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Claudio Rigatto
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada.,Section of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Paul Komenda
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada.,Section of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Navdeep Tangri
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada.,Section of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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27
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Pérez Pico AM, Dorado P, Santiesteban MÁ, Mingorance-Alvarez E, García-Bernalt Funes V, Mayordomo R. Prevalence of foot disorders according to chronic kidney disease stage. J Ren Care 2020; 47:17-26. [PMID: 33216453 DOI: 10.1111/jorc.12342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 06/15/2020] [Accepted: 07/01/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) is a public health disease that affects 15.1% of the adult population. Although a high prevalence (94.1%) of skin disorders has been detected in people on haemodialysis or with advanced CKD, few studies have analysed foot disorders at initial CKD stages. OBJECTIVES To analyse the prevalence of foot disorders according to CKD stage. PARTICIPANTS A total of 209 people with a mean age of 73.2 ± 13.8 years (52.0% women) in the nephrology department of Virgen del Puerto Hospital, Plasencia (Spain) were examined from January 2018 to April 2019. MEASUREMENTS CKD stages were determined by nephrologists according to the Kidney Disease Improving Global Outcomes Guideline. An expert podiatrist identified foot disorders. Data were statistically treated with the IBM SPSS Statistics. Comparisons between variables were analysed by the χ2 test or Fisher's exact test, with a significance level of less than 5%. RESULTS The prevalence of foot disorders was high for skin disorders (97.6% dermatopathies and 66.0% keratopathies), nail disorders (98.5% onychopathies) and toe deformities (97.1%). People at initial and intermediate stages presented more keratopathies (hyperkeratosis at G1 and G3a and pinch callus at G3a). Stage G1 showed fewer changes in nail colour and half and half nails. Stage G4 showed more claw toes and hematoma and stage G5 more Beau's lines, changes in skin colour, hematomas and thin shiny skin. CONCLUSIONS The high prevalence of foot disorders detected in people with CKD requires specific and personalised professional care to relieve symptoms and avoid complications, helping to improve the quality of life of people with this condition.
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Affiliation(s)
- Ana M Pérez Pico
- Department of Nursing, University of Extremadura, Plasencia, Spain
| | - Pedro Dorado
- Department of Medical and Surgery Therapy, University of Extremadura, Plasencia, Spain.,University Institute of Biosanitary Research of Extremadura (INUBE), Universidad de Extremadura, Badajoz, España, Spain
| | - Miguel Á Santiesteban
- Department of Nephrology, Virgen del Puerto Hospital, Servicio Extremeño de Salud, Plasencia, Spain
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28
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Allison GM, Flanagin E. How ESKD complicates the management of diabetic foot ulcers: The vital role of the dialysis team in prevention, early detection, and support of multidisciplinary treatment to reduce lower extremity amputations. Semin Dial 2020; 33:245-253. [PMID: 32277523 DOI: 10.1111/sdi.12875] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Diabetic foot ulcers do not heal as well in ESKD as in the absence of kidney failure, and rates of recurrent foot ulcers, as well as lower extremity amputation, are higher. This review of the literature highlights the vital role of the dialysis team in prevention, early detection, and support of treatment of diabetic foot ulcers. Our review has five goals-(a) increase nephrologists' understanding of the high morbidity and mortality associated with chronic foot ulcers and (lower extrimity) LE amputations in ESKD; (b) promote nephrologists' understanding of grading systems for diabetic foot ulcer severity, in order to expedite communication with local diabetic foot experts; (c) promote collaboration between nephrologists and infectious disease specialists regarding the dose, route, and delivery logistics of intravenous antibiotics for infected chronic foot ulcers, in particular in the presence of osteomyelitis and other deep-seated infections; (d) increase the awareness of dialysis nurses, technicians, dietitians, social workers and administrators regarding evidence-based and multidisciplinary approaches to patients' diabetic foot ulcers; (e) encourage the application of published works integrating patient-centered diabetic foot education into the dialysis setting to reduce lower extremity amputations.
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Affiliation(s)
- Genève M Allison
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, MA, USA.,Center for Wound Healing and Hyperbaric Medicine, Tufts Medical Center, Boston, MA, USA
| | - Erin Flanagin
- Division of Nephrology, Tufts Medical Center, Boston, MA, USA
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29
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van Netten JJ, Raspovic A, Lavery LA, Monteiro-Soares M, Rasmussen A, Sacco ICN, Bus SA. Prevention of foot ulcers in the at-risk patient with diabetes: a systematic review. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3270. [PMID: 31957213 DOI: 10.1002/dmrr.3270] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 09/01/2019] [Accepted: 09/19/2019] [Indexed: 12/26/2022]
Abstract
Prevention of foot ulcers in patients with diabetes is important to help reduce the substantial burden on both patient and health resources. A comprehensive analysis of reported interventions is needed to better inform healthcare professionals about effective prevention. The aim of this systematic review is to investigate the effectiveness of interventions to help prevent both first and recurrent foot ulcers in persons with diabetes who are at risk for this complication. We searched the available medical scientific literature in PubMed, EMBASE, CINAHL, and the Cochrane databases for original research studies on preventative interventions. We screened trial registries for additional studies not found in our search and unpublished trials. Two independent reviewers assessed data from controlled studies for methodological quality, and extracted and presented this in evidence and risk of bias tables. From the 13,490 records screened, 35 controlled studies and 46 non-controlled studies were included. Few controlled studies, which were of generally low to moderate quality, were identified on the prevention of a first foot ulcer. For the prevention of recurrent plantar foot ulcers, there is benefit for the use of daily foot skin temperature measurements, and for therapeutic footwear with demonstrated plantar pressure relief, provided it is consistently worn by the patient. For prevention of ulcer recurrence, there is some evidence for providing integrated foot care, and no evidence for a single session of education.Surgical interventions have been shown effective in selected patients, but the evidence base is small. Foot-related exercises do not appear to prevent a first foot ulcer. A small increase in the level of weight-bearing daily activities does not seem to increase the risk for foot ulceration. The evidence base to support the use of specific self-management and footwear interventions for the prevention of recurrent plantar foot ulcers is quite strong. The evidence is weak for the use of other, sometimes widely applied, interventions, and is practically non-existent for the prevention of a first foot ulcer and non-plantar foot ulcer.
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Affiliation(s)
- Jaap J van Netten
- Amsterdam UMC, University of Amsterdam, Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Meibergdreef 9, Amsterdam, The Netherlands
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
- Diabetic Foot Clinic, Department of Surgery, Ziekenhuisgroep Twente, Almelo, The Netherlands
| | - Anita Raspovic
- Discipline of Podiatry, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Matilde Monteiro-Soares
- MEDCIDES: Departamento de Medicina da Comunidade Informação e Decisão em Saúde & CINTESIS - Center for Health Technology and Services Research, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | | | - Isabel C N Sacco
- Physical Therapy, Speech and Occupational Therapy Department, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Sicco A Bus
- Amsterdam UMC, University of Amsterdam, Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Meibergdreef 9, Amsterdam, The Netherlands
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Bus SA, Lavery LA, Monteiro-Soares M, Rasmussen A, Raspovic A, Sacco ICN, van Netten JJ. Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2019 update). Diabetes Metab Res Rev 2020; 36 Suppl 1:e3269. [PMID: 32176451 DOI: 10.1002/dmrr.3269] [Citation(s) in RCA: 154] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the prevention of foot ulceration in persons with diabetes and updates the 2015 IWGDF prevention guideline. We followed the GRADE methodology to devise clinical questions and critically important outcomes in the PICO format, to conduct a systematic review of the medical-scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. We recommend to screen a person at very low risk for ulceration annually for loss of protective sensation and peripheral artery disease and persons at higher risk at higher frequencies for additional risk factors. For preventing a foot ulcer, educate the at-risk patient about appropriate foot self-care and treat any pre-ulcerative sign on the foot. Instruct moderate-to-high risk patients to wear accommodative properly fitting therapeutic footwear, and consider instructing them to monitor foot skin temperature. Prescribe therapeutic footwear that has a demonstrated plantar pressure relieving effect during walking to prevent plantar foot ulcer recurrence. In patients that fail non-surgical treatment for an active or imminent ulcer, consider surgical intervention; we suggest not to use a nerve decompression procedure. Provide integrated foot care for high-risk patients to prevent ulcer recurrence. Following these recommendations will help health care professionals to provide better care for persons with diabetes at risk of foot ulceration, to increase the number of ulcer-free days, and to reduce the patient and health care burden of diabetic foot disease.
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Affiliation(s)
- Sicco A Bus
- Amsterdam UMC, University of Amsterdam, Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Matilde Monteiro-Soares
- MEDCIDES: Departamento de Medicina da Comunidade Informação e Decisão em Saúde and CINTESIS-Center for Health Technology and Services Research, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | | | - Anita Raspovic
- Discipline of Podiatry, School of Allied Health, La Trobe University, Melbourne, Victoria, Australia
| | - Isabel C N Sacco
- Physical Therapy, Speech and Occupational Therapy department, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Jaap J van Netten
- Amsterdam UMC, University of Amsterdam, Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam, The Netherlands
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia
- Diabetic Foot Clinic, Department of Surgery, Ziekenhuisgroep Twente, Almelo and Hengelo, The Netherlands
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Rani P, Aliahmad B, Kumar DK. The association of temperature of Diabetic Foot Ulcers with Chronic Kidney Disorder. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2019:2817-2820. [PMID: 31946479 DOI: 10.1109/embc.2019.8856401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The area of the diabetic foot ulcer (DFU) and its reduction over weeks is used for assessment in clinical practices; however, literature reports that this is not reliable parameter. This work has investigated the association of change in the mean temperature of the ulcers with three clinical conditions relevant to wound healing, i.e. peripheral vascular disease (PVD), chronic kidney disease (CKD) and ischemic heart disease (IHD). Thermal and RGB images of 23 DFUs of the first two weeks of ulceration were studied. One-way ANOVA was performed on the change in mean temperature of the ulcers and change in area and it was found that the weekly change in mean temperature was higher for patients with CKD (p-value=0.009). Also, change in area measured from RGB images did not show any association with the clinical conditions. The application of this work is that the temperature obtained from thermal image of the ulcer can be used as a prognostic parameter for its assessment.
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Sigl M, Noe T, Ruemenapf G, Kraemer BK, Morbach S, Borggrefe M, Amendt K. Outcomes of severe limb ischemia with tissue loss and impact of revascularization in haemodialysis patients with wound, ischemia, and foot infection (WIfI) stage 3 or 4. VASA 2020; 49:63-71. [DOI: 10.1024/0301-1526/a000819] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Summary. Background: With growing prevalence, end-stage renal disease (ESRD) as well as critical limb ischemia (CLI) are both conditions associated with high morbidity and mortality rates. Patients and methods: A retrospective single-centre study provided data of a German interdisciplinary vascular centre. Seventy-seven consecutive haemodialysis (HD) inpatients (median age, 73.6 years) with 91 threatened limbs with Wound, Ischemia, and foot Infection (WIfI) clinical stage 3 or 4 were evaluated for in-hospital treatment of peripheral arterial disease, limb salvage rates, major amputation (MA)-free and overall survival. Results: The 1-year MA-free limb salvage rate was 82 %. On multivariate analysis, a higher WIfI clinical stage (hazard ratio [HR], 7.54; p = 0.008) indicated a higher risk of MA, while at least one-vessel run-off to the foot after revascularization of any kind was associated with a lower risk of MA (HR, 0.17; p = 0.001). In the composite endpoint analysis, the 1-year MA-free overall survival rate was 65 %. Patients with limbs in WIfI clinical stage 4 versus stage 3 carried a more than two-fold increased hazard of death or MA (HR, 2.63; p = 0.028), while revascularization was associated with reduced risk (HR, 0.40; p = 0.021). One-year overall survival (78 %) was not associated with WIfI stage or revascularization but was worse in patients with previous symptomatic coronary artery disease (HR, 3.25; p = 0.039). During long-term follow-up over 12 years, MA-free survival probability was significantly lower in the WIfI stage 4 versus WIfI stage 3 group (HR, 1.58; p = 0.048) without significant differences in overall survival (HR, 1.10; p = 0.696). Conclusions: Lower-extremity CLI with tissue loss in HD patients is associated with high morbidity and mortality rates. WIfI clinical stage was predictive of 1-year MA-free survival, while revascularization significantly reduced MA risk but did not influence overall survival.
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Affiliation(s)
- Martin Sigl
- First Department of Medicine, University Medical Centre Mannheim (UMM), Mannheim, Germany
| | | | - Gerhard Ruemenapf
- Department of Vascular Surgery, Diakonissen-Stiftungs-Krankenhaus Speyer, Gefäßzentrum Oberrhein, Speyer, Germany
| | - Bernhard K. Kraemer
- Vth. Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM), University of Heidelberg, Germany
| | - Stephan Morbach
- Department of Diabetology and Angiology, Marienkrankenhaus Soest and Institute for Health Services Research and Health Economics, Research Centre for Health and Society, Heinrich Heine University Düsseldorf, Germany
| | - Martin Borggrefe
- Vth. Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM), University of Heidelberg, Germany
| | - Klaus Amendt
- Department of Angiology, Cardiology and Diabetes associated diseases, Diakonissenkrankenhaus Mannheim, Gefäßzentrum Oberrhein, Germany
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Kaminski MR, Lambert KA, Raspovic A, McMahon LP, Erbas B, Mount PF, Kerr PG, Landorf KB. Risk factors for foot ulceration in adults with end-stage renal disease on dialysis: a prospective observational cohort study. BMC Nephrol 2019; 20:423. [PMID: 31752749 PMCID: PMC6868750 DOI: 10.1186/s12882-019-1594-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 10/15/2019] [Indexed: 12/30/2022] Open
Abstract
Background Dialysis patients experience high rates of foot ulceration. Although risk factors for ulceration have been extensively studied in patients with diabetes, there is limited high-quality, longitudinal evidence in the dialysis population. Therefore, this study investigated risk factors for foot ulceration in a stable dialysis cohort. Methods We prospectively collected clinical, demographic, health status, and foot examination information on 450 adults with end-stage renal disease from satellite and home-therapy dialysis units in Melbourne, Australia over 12 months. The primary outcome was foot ulceration. Cox proportional hazard modelling and multinomial regression were used to investigate risk factors. Results Among 450 dialysis patients (mean age, 67.5 years; 64.7% male; 94% hemodialysis; 50.2% diabetes), new cases of foot ulceration were identified in 81 (18%) participants. Overall, risk factors for foot ulceration were neuropathy (HR 3.02; 95% CI 1.48 to 6.15) and previous ulceration (HR 2.86; CI 1.53 to 5.34). In those without history of ulceration, nail pathology (RR 3.85; CI 1.08 to 13.75) and neuropathy (RR 2.66; CI 1.04 to 6.82) were risk factors. In those with history of ulceration, neuropathy (RR 11.23; CI 3.16 to 39.87), peripheral arterial disease (RR 7.15; CI 2.24 to 22.82) and cerebrovascular disease (RR 2.08; CI 1.04 to 4.16) were risk factors. There were 12 (2.7%) new amputations, 96 (21.3%) infections, 24 (5.3%) revascularizations, 42 (9.3%) foot-related hospitalizations, and 52 (11.6%) deaths. Conclusions Neuropathy and previous ulceration are major risk factors for foot ulceration in dialysis patients. Risk factors differ between those with and without prior ulceration. The risk factors identified will help to reduce the incidence of ulceration and its associated complications.
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Affiliation(s)
- Michelle R Kaminski
- Discipline of Podiatry, School of Allied Health, Health Services and Sport, La Trobe University, Melbourne, Victoria, 3086, Australia.
| | - Katrina A Lambert
- Department of Public Health, School of Psychology and Public Health, La Trobe University, Victoria, 3086, Australia
| | - Anita Raspovic
- Discipline of Podiatry, School of Allied Health, Health Services and Sport, La Trobe University, Melbourne, Victoria, 3086, Australia
| | - Lawrence P McMahon
- Departments of Renal Medicine & Obstetric Medicine, Eastern Health Clinical School, Monash University, Melbourne, Victoria, 3128, Australia
| | - Bircan Erbas
- Department of Public Health, School of Psychology and Public Health, La Trobe University, Victoria, 3086, Australia
| | - Peter F Mount
- Department of Nephrology, Austin Health, University of Melbourne, Heidelberg, Victoria, 3084, Australia
| | - Peter G Kerr
- Department of Nephrology, Monash Health, Melbourne, Victoria, 3168, Australia
| | - Karl B Landorf
- Discipline of Podiatry, School of Allied Health, Health Services and Sport, La Trobe University, Melbourne, Victoria, 3086, Australia.,La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Health Services and Sport, La Trobe University, Victoria, 3086, Australia
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Morillo Gallego N, Merino Martínez RM, Sánchez Cabezas AM, Alcántara Crespo M. Alteraciones de la piel del paciente con enfermedad renal crónica avanzada. Una revisión sistemática. ENFERMERÍA NEFROLÓGICA 2019. [DOI: 10.4321/s2254-28842019000300002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Objetivo: Conocer las principales alteraciones de la piel, así como su prevalencia, en los pacientes con Enfermedad Renal Crónica Avanzada.
Material y Método: Se ha realizado una revisión sistemática a través de las bases de datos de PubMed, Cochrane, Scopus y Google Académico. Se incluyeron artículos científicos escritos en inglés y español. Se analizaron los artículos que trataban sobre las alteraciones en la piel en el paciente con Enfermedad Renal Crónica Avanzada y/o en tratamiento con diálisis.
Resultados: Se han incluido 32 artículos publicados entre el año 2008 y 2018: 7 revisiones sistemáticas, 3 de tipo experimental y 22 de tipo observacional. Las alteraciones cutáneas aparecen en la mayoría de los pacientes en prediálisis y en tratamiento con diálisis, en mayor o menor grado. La mayoría de alteraciones de la piel descritas han sido, xerosis, prurito e hiperpigmentación. La mayor complicación relacionada con la alteración de la piel ha sido la calcifilaxis; siendo las variables más influyentes en la aparición de estas lesiones, el tipo de tratamiento dialítico, las enfermedades asociadas y falta de adherencia a la dieta prescrita.
Conclusiones: Las alteraciones en la piel están presentes en la mayoría de los pacientes con Enfermedad Renal Crónica Avanzada y en diálisis, predominando la xerosis como la alteración más frecuente, siguiéndole el prurito y la hiperpigmentación. La complicación más grave relacionada con las alteraciones de la piel es la calcifilaxis, encontrándose asociada a altos niveles de fósforo sérico. No existen protocolos estandarizados para el manejo de las alteraciones cutáneas en estos pacientes.
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Kim SY, Kim TH, Choi JY, Kwon YJ, Choi DH, Kim KC, Kim MJ, Hwang HK, Lee KB. Predictors for Amputation in Patients with Diabetic Foot Wound. Vasc Specialist Int 2018; 34:109-116. [PMID: 30671420 PMCID: PMC6340693 DOI: 10.5758/vsi.2018.34.4.109] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 10/15/2018] [Accepted: 10/26/2018] [Indexed: 11/20/2022] Open
Abstract
Purpose Diabetic foot wound (DFW) is known as a major contributor of nontraumatic lower extremity amputation. We aimed to evaluate overall amputation rates and risk factors for amputation in patients with DFW. Materials and Methods From January 2014 to December 2017, 141 patients with DFW were enrolled. We determined rates and risk factors of major amputation in DFW and in DFW with peripheral arterial occlusive disease (PAOD). In addition, we investigated rates and predictors for amputation in diabetic foot ulcer (DFU). Results The overall rate of major amputation was 26.2% in patients with DFW. Among 141 DFWs, 76 patients (53.9%) had PAOD and 29 patients (38.2%) of 76 DFWs with PAOD underwent major amputation. Wound state according to Wagner classification, congestive heart failure, leukocytosis, dementia, and PAOD were the significant risk factors for major amputation. In DFW with PAOD, Wagner classification grades and leukocytosis were the predictors for major amputation. In addition, amputation was performed for 28 patients (38.4%) while major amputation was performed for 5 patients (6.8%) of 73 DFUs. Only the presence of osteomyelitis (OM) showed significant difference for amputation in DFU. Conclusion This study represented that approximately a quarter of DFWs underwent major amputation. Moreover, over half of DFW patients had PAOD and about 38.2% of them underwent major amputation. Wound state and PAOD was major predictors for major amputation in DFW. Systemic factors, such as CHF, leukocytosis, and dementia were identified as risk factors for major amputation. In terms of DFU, 38.4% underwent amputation and the presence of OM was a determinant for amputation.
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Affiliation(s)
- Se-Young Kim
- Department of Surgery, Seoul Medical Center, Seoul, Korea
| | - Tae Hoon Kim
- Department of Surgery, Seoul Medical Center, Seoul, Korea
| | - Jun-Young Choi
- Department of Surgery, Seoul Medical Center, Seoul, Korea
| | - Yu-Jin Kwon
- Department of Surgery, Seoul Medical Center, Seoul, Korea
| | - Dong Hui Choi
- Department of Surgery, Seoul Medical Center, Seoul, Korea
| | - Ki Chun Kim
- Department of Orthopedic Surgery, Seoul Medical Center, Seoul, Korea
| | - Min Ji Kim
- Department of Radiology, Seoul Medical Center, Seoul, Korea
| | - Ho Kyung Hwang
- Department of Radiology, Seoul Medical Center, Seoul, Korea
| | - Kyung-Bok Lee
- Department of Surgery, Seoul Medical Center, Seoul, Korea
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36
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Franz D, Zheng Y, Leeper NJ, Chandra V, Montez-Rath M, Chang TI. Trends in Rates of Lower Extremity Amputation Among Patients With End-stage Renal Disease Who Receive Dialysis. JAMA Intern Med 2018; 178:1025-1032. [PMID: 29987332 PMCID: PMC6143114 DOI: 10.1001/jamainternmed.2018.2436] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Patients with end-stage renal disease (ESRD) who receive dialysis are at high risk of lower extremity amputation. Recent studies indicate decreasing rates of lower extremity amputation in non-ESRD populations, but contemporary data for patients with ESRD who receive dialysis are lacking. OBJECTIVES To assess rates of lower extremity amputation among patients with ESRD who receive dialysis during a recent 15-year period; to analyze whether those rates differed by age, sex, diabetes, or geographic region; and to determine 1-year mortality rates in this population after lower extremity amputation. DESIGN, SETTING, AND PARTICIPANTS This retrospective study of 3 700 902 records obtained from a US national registry of patients with ESRD who receive dialysis assessed cross-sectional cohorts for each calendar year from 2000 through 2014. Adult patients with prevalent ESRD treated with hemodialysis or peritoneal dialysis covered by Medicare Part A and B on January 1 of each cohort year were included. Data analysis was conducted from August 2017 to April 2018. EXPOSURES Age, sex, diabetes, and hospital referral region. MAIN OUTCOMES AND MEASURES Annual rates per 100 person-years of nontraumatic major (above- or below-knee) and minor (below-ankle) amputations. RESULTS For each annual cohort, there were fewer women (47.5% in 2000, 46.2% in 2005, 44.9% in 2010, and 44.0% in 2014) than men, more than half the patients were white individuals (58.1% in 2000, 56.9% in 2005, 56.9% in 2010, and 56.7% in 2014), and a small proportion were employed (13.9% in 2000, 15.1% in 2005, 16.1% in 2010, and 16.5% in 2014). The rate of lower extremity amputations for patients with ESRD who receive dialysis decreased by 51.0% from 2000 to 2014, driven primarily by a decrease in the rate of major amputations (5.42 [95% CI, 5.28-5.56] in 2000 vs 2.66 [95% CI, 2.59-2.72] per 100 person-years in 2014). Patients with diabetes had amputation rates more than 5 times as high as patients without diabetes. Patients younger than 65 years had higher adjusted amputation rates than older patients, and men had consistently higher adjusted amputation rates than women. Adjusted 1-year mortality rates after lower extremity amputation for patients with ESRD who receive dialysis decreased from 52.2% (95% CI, 50.9%-53.4%) in 2000 to 43.6% (95% CI, 42.5%-44.8%) in 2013. In general, amputation rates decreased among all regions from 2000 to 2014, but regional variability persisted across time despite adjustment for differences in patient demographics and comorbid conditions. CONCLUSIONS AND RELEVANCE Although rates of lower extremity amputations among US patients with ESRD who receive dialysis decreased by 51% during a recent 15-year period, mortality rates remained high, with nearly half of patients dying within a year after lower extremity amputation. Our results highlight the need for more research on ways to prevent lower extremity amputation in this extremely high-risk population.
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Affiliation(s)
- Douglas Franz
- Division of Nephrology, Department of Medicine, Stanford University, Stanford, California
| | - Yuanchao Zheng
- Division of Nephrology, Department of Medicine, Stanford University, Stanford, California
| | - Nicholas J Leeper
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, California.,Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California
| | - Venita Chandra
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, California
| | - Maria Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University, Stanford, California
| | - Tara I Chang
- Division of Nephrology, Department of Medicine, Stanford University, Stanford, California
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Boyko EJ, Seelig AD, Ahroni JH. Limb- and Person-Level Risk Factors for Lower-Limb Amputation in the Prospective Seattle Diabetic Foot Study. Diabetes Care 2018; 41:891-898. [PMID: 29439130 DOI: 10.2337/dc17-2210] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 01/18/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Diabetes is the leading cause of nontraumatic lower-limb amputations in the U.S., but no research has prospectively examined associations between limb-specific measurements and amputation risk among patients without foot ulcer. We investigated amputation risk by limb in relation to the same limb- and person-level factors. RESEARCH DESIGN AND METHODS We conducted a 22-year prospective study among 1,461 male patients with diabetes without foot ulcer (mean age 62.4 years), with 2,893 lower limbs among subjects recruited between 1990 and 2002 from one Department of Veterans Affairs general internal medicine clinic. The following information was collected: demographic, lifestyle, and diabetes characteristics; visual acuity; kidney function (estimated glomerular filtration rate [eGFR]); and lower-limb measurements including presence of Charcot deformity, sensory neuropathy by 10-g monofilament, dorsal foot transcutaneous oximetry (TcPO2) at 44°C, and ankle-brachial index (ABI). RESULTS Over 25,735 limb-years, 136 amputations occurred. A multivariable Cox model identified multiple independent risk factors: sensory neuropathy (hazard ratio 3.09 [95% CI 2.02-4.74]), ABI ≤0.5 vs. >0.9 to <1.3 (3.98 [2.31-6.85]), ABI ≥1.3 vs. >0.9 to <1.3 (2.20 [1.18-4.09]), 1-SD decrease in eGFR (1.18 [1.00-1.38]), poor vision (1.70 [1.05-2.73]), body weight in 21.4-kg increments (0.78 [0.61-0.98]), and age >70 years vs. <57 years (0.13 [0.04-0.38]). Although TcPO2 was not significantly associated with amputation overall, TcPO2 <26 mmHg significantly predicted a higher risk in the ABI ≥1.3 category. CONCLUSIONS Arterial disease and neuropathy emerged as the only limb-specific risk factors for amputation, but these and several person-level factors may be amenable to prevention or treatment interventions to potentially reduce diabetic amputation risk.
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Affiliation(s)
- Edward J Boyko
- Seattle Epidemiologic Research and Information Center, Seattle, WA .,VA Puget Sound Health Care System - Seattle Division, Seattle, WA
| | - Amber D Seelig
- Seattle Epidemiologic Research and Information Center, Seattle, WA.,VA Puget Sound Health Care System - Seattle Division, Seattle, WA
| | - Jessie H Ahroni
- VA Puget Sound Health Care System - Seattle Division, Seattle, WA
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Winocour PH. Diabetes and chronic kidney disease: an increasingly common multi-morbid disease in need of a paradigm shift in care. Diabet Med 2018; 35:300-305. [PMID: 29247554 DOI: 10.1111/dme.13564] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/12/2017] [Indexed: 12/28/2022]
Abstract
Diabetes is considered the commonest cause of end-stage renal disease. The increasing incidence of obesity and an ageing population, together, will lead to a greater number of people with diabetes associated with chronic kidney disease that could either be secondary to diabetic nephropathy or of different aetiology. Ageing and obesity influence approaches to the management of diabetes and accurate assessment of kidney disease. People with diabetes and chronic kidney disease consume a disproportionate component of expenditure on medical care. Guidelines on managing diabetes and kidney disease do not recognize the complex multi-morbid nature of the process. In addition to managing glycaemia and monitoring renal function, the assessment and management of cardiovascular disease risk factors and cardiovascular disease itself need to be factored into care. People with diabetes and diabetic nephropathy are more vulnerable to retinopathy and foot complications requiring coordinated care. People with diabetes and chronic kidney disease are more prone to anaemia and metabolic bone disease than those without diabetes at similar stages of chronic kidney disease, further increasing their vulnerability to acute complications from cardiovascular disease, foot emergencies and fractures. People with diabetes and chronic kidney disease are also more prone to hospitalization with infections and acute kidney injury. Given the 30-40% prevalence of kidney disease amongst people with diabetes, potentially >2% of the adult population would fit into this category, making it vital that new surveillance models of supported care are provided for those living with diabetes and kidney disease and for primary care teams who manage the vast majority of such people.
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Affiliation(s)
- P H Winocour
- East and North Herts Institute of Diabetes and Endocrinology (ENHIDE), Howlands Clinic, QEII Hospital, Welwyn Garden City, UK
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Miller AJ, Takahashi EA, Harmsen WS, Mara KC, Misra S. Treatment of Superficial Femoral Artery Restenosis. J Vasc Interv Radiol 2017; 28:1681-1686. [PMID: 28935472 DOI: 10.1016/j.jvir.2017.07.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 07/25/2017] [Accepted: 07/29/2017] [Indexed: 10/18/2022] Open
Abstract
PURPOSE To determine the predictors of restenosis, major adverse limb events (MALEs), postoperative death (POD), and all-cause mortality after repeat endovascular treatment of superficial femoral artery (SFA) restenosis. MATERIALS AND METHODS This was a retrospective review of 440 patients with 518 SFA lesions who were treated between January 2002 and October 2011. Ninety-six limbs were treated for restenosis with bare metal stents (BMSs) or percutaneous transluminal angioplasty (PTA), of which 28 limbs developed another restenosis requiring a third procedure. The interaction measured in this study was between the second and third intervention. Predictors of SFA patency, MALEs, POD, and all-cause mortality after SFA restenosis treatment were identified. RESULTS Patients who were treated with BMSs (n = 51) had similar rates of restenosis compared with patients who were treated with PTA (n = 45) (hazard ratio [HR] 1.40; 95% confidence interval [CI] 0.68-2.90; P = .37). Patients in the BMS group who took statins had a significantly lower risk of restenosis than patients who did not take statins (HR 0.13; 95% CI 0.04-0.41; P < .001). Stage 4-5 chronic kidney disease (CKD) (n = 12) was associated with a significantly higher risk of MALE + POD (HR 6.17; 95% CI 1.45-26.18; P = .014) and all-cause mortality (HR 2.83; 95% CI 1.27-6.33; P = .01). Clopidogrel was protective against all-cause mortality (HR 0.41; 95% CI 0.20-0.80; P = .01). CONCLUSIONS Patients in the BMS group who took statins at the time of intervention had a significantly lower risk of developing restenosis. Stage 4-5 CKD was a risk factor for MALE + POD and all-cause mortality, while clopidogrel decreased all-cause mortality risk.
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Affiliation(s)
- Andrew J Miller
- Department of Radiology, Mayo Clinic, Rochester, Minnesota; Division of Vascular and Interventional Radiology, Mayo Clinic, Rochester, Minnesota
| | | | - William S Harmsen
- Department of Radiology, Mayo Clinic, Rochester, Minnesota; Department of Clinical Statistics, Mayo Clinic, Rochester, Minnesota
| | - Kristin C Mara
- Department of Clinical Statistics, Mayo Clinic, Rochester, Minnesota
| | - Sanjay Misra
- Department of Radiology, Mayo Clinic, Rochester, Minnesota; Division of Vascular and Interventional Radiology, Mayo Clinic, Rochester, Minnesota.
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Kaminski MR, Raspovic A, McMahon LP, Lambert KA, Erbas B, Mount PF, Kerr PG, Landorf KB. Factors associated with foot ulceration and amputation in adults on dialysis: a cross-sectional observational study. BMC Nephrol 2017; 18:293. [PMID: 28886703 PMCID: PMC5591526 DOI: 10.1186/s12882-017-0711-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 09/04/2017] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Michelle R. Kaminski
- Discipline of Podiatry, School of Allied Health, La Trobe University, Melbourne, VIC 3086 Australia
| | - Anita Raspovic
- Discipline of Podiatry, School of Allied Health, La Trobe University, Melbourne, VIC 3086 Australia
| | - Lawrence P. McMahon
- Departments of Renal Medicine & Obstetric Medicine, Eastern Health Clinical School, Monash University, Melbourne, VIC 3128 Australia
| | - Katrina A. Lambert
- College of Science, Health and Engineering, School of Psychology and Public Health, Department of Public Health, La Trobe University, Melbourne, VIC 3086 Australia
| | - Bircan Erbas
- College of Science, Health and Engineering, School of Psychology and Public Health, Department of Public Health, La Trobe University, Melbourne, VIC 3086 Australia
| | - Peter F. Mount
- Department of Nephrology, Austin Health, Melbourne, VIC 3084 Australia
| | - Peter G. Kerr
- Department of Nephrology, Monash Health, Melbourne, VIC 3168 Australia
| | - Karl B. Landorf
- Discipline of Podiatry, School of Allied Health, La Trobe University, Melbourne, VIC 3086 Australia
- Melbourne Health, 300 Grattan Street, Parkville, Melbourne, VIC 3050 Australia
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Monteiro-Soares M, Ribas R, Pereira da Silva C, Bral T, Mota A, Pinheiro Torres S, Morgado A, Couceiro R, Ribeiro R, Dias V, Moreira M, Mourão P, Oliveira MJ, Madureira M, Paixão-Dias V, Dinis-Ribeiro M. Diabetic foot ulcer development risk classifications' validation: A multicentre prospective cohort study. Diabetes Res Clin Pract 2017; 127:105-114. [PMID: 28340359 DOI: 10.1016/j.diabres.2017.02.034] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 02/27/2017] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- M Monteiro-Soares
- MEDCIDES/CINTESIS - Departamento de Medicina da Comunidade Informação e Decisão em Saúde, Oporto University Faculty of Medicine, Oporto U753-FCT, Portugal.
| | - R Ribas
- Unidade de Saúde Familiar Aquae Flaviae, Chaves, Portugal
| | | | - T Bral
- Unidade de Saúde Familiar Aquae Flaviae, Chaves, Portugal
| | - A Mota
- Unidade de Saúde Familiar Aquae Flaviae, Chaves, Portugal
| | | | - A Morgado
- Unidade de Saúde Familiar Aquae Flaviae, Chaves, Portugal
| | - R Couceiro
- Unidade de Saúde Familiar Aquae Flaviae, Chaves, Portugal
| | - R Ribeiro
- Unidade de Saúde Familiar Aquae Flaviae, Chaves, Portugal
| | - V Dias
- Unidade de Saúde Familiar Santo André de Canidelo, Vila Nova de Gaia, Portugal
| | - M Moreira
- Unidade de Saúde Familiar Santo André de Canidelo, Vila Nova de Gaia, Portugal
| | - P Mourão
- Unidade de Saúde Familiar Santo André de Canidelo, Vila Nova de Gaia, Portugal
| | - M J Oliveira
- Diabetic Foot Clinic, Endocrinology, Diabetes and Metabolism Department, Centro Hospitalar de Vila Nova de Gaia/Espinho EPE, Vila Nova de Gaia, Portugal
| | - M Madureira
- Diabetic Foot Clinic, Internal Medicine Department, Centro Hospitalar de Vila Nova de Gaia/Espinho EPE, Vila Nova de Gaia, Portugal
| | - V Paixão-Dias
- Diabetic Foot Clinic, Internal Medicine Department, Centro Hospitalar de Vila Nova de Gaia/Espinho EPE, Vila Nova de Gaia, Portugal
| | - M Dinis-Ribeiro
- MEDCIDES/CINTESIS - Departamento de Medicina da Comunidade Informação e Decisão em Saúde, Oporto University Faculty of Medicine, Oporto U753-FCT, Portugal
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Hodge M, McArthur E, Garg AX, Tangri N, Clemens KK. Hypoglycemia Incidence in Older Adults by Estimated GFR. Am J Kidney Dis 2017; 70:59-68. [PMID: 28139395 DOI: 10.1053/j.ajkd.2016.11.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 11/07/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Bedside estimates of the risk for hypoglycemia by estimated glomerular filtration rate (eGFR), urine albumin-creatinine ratio (ACR), and use of antihyperglycemic medications would be helpful. STUDY DESIGN Population-based cohort study. SETTING & PARTICIPANTS Older adults (mean age, 75 years) in Ontario, Canada, from April 2002 through March 2013. FACTORS eGFR stage, ACR stage, and use of antihyperglycemic medications. OUTCOME 3-year incidence rate of a hospital encounter with hypoglycemia (emergency department or inpatient encounter). RESULTS In users and nonusers of antihyperglycemic medications, there was a graded increase in risk for hypoglycemia by eGFR stage. Incidence rates in antihyperglycemic medication users were 82 (95% CI, 71-94), 122 (95% CI, 115-130), 235 (95% CI, 218-254), 379 (95% CI, 349-413), 596 (95% CI, 524-678), and 785 (95% CI, 689-894) encounters per 10,000 person-years when eGFR was ≥90, 60 to <90, 45 to <60, 30 to <45, 15 to <30, and <15mL/min/1.73m2 or the patient was receiving dialysis, respectively (P<0.001). Corresponding values in nonusers were 2 (95% CI, 2-4), 3 (95% CI, 3-4), 3 (95% CI, 2-4), 7 (95% CI, 5-9), 14 (95% CI, 9-22), and 55 (95% CI, 43-71) encounters/10,000 person-years, respectively (P<0.001). A similar relationship was evident by eGFR and ACR risk category. LIMITATIONS Only hypoglycemia episodes that were associated with a hospital encounter were assessed. Results cannot be generalized to younger patients. CONCLUSIONS In older adults, the risk for hypoglycemia is higher in those with lower kidney function. Our results may aid the patient-provider dialogue and inform future studies to prevent hypoglycemia in an at-risk population.
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Affiliation(s)
- Meryl Hodge
- School of Health Studies, Western University, London, Ontario, Canada
| | - Eric McArthur
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Amit X Garg
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Navdeep Tangri
- Division of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada; Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
| | - Kristin K Clemens
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Division of Endocrinology and Metabolism, Department of Medicine, Western University, London, Ontario, Canada.
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Garimella PS, Wang W, Lin SF, Hymes J, Lacson E. Incident diabetic foot ulcers and mortality in hemodialysis patients. Hemodial Int 2016; 21:145-147. [PMID: 27624300 DOI: 10.1111/hdi.12490] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Indexed: 11/30/2022]
Affiliation(s)
| | - Weiling Wang
- Fresenius Medical Care North America, Waltham, Massachusetts, 02451, USA
| | - Shu-Fang Lin
- Fresenius Medical Care North America, Waltham, Massachusetts, 02451, USA
| | - Jeffrey Hymes
- Fresenius Medical Care North America, Waltham, Massachusetts, 02451, USA
| | - Eduardo Lacson
- Tufts, Medical Center, Boston, Massachusetts, 02111, USA
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Prevalence of Diabetic Foot Disease in Patients with Diabetes Mellitus under Renal Replacement Therapy in Lleida, Spain. BIOMED RESEARCH INTERNATIONAL 2016; 2016:7217586. [PMID: 27190996 PMCID: PMC4848423 DOI: 10.1155/2016/7217586] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 03/30/2016] [Accepted: 03/31/2016] [Indexed: 12/13/2022]
Abstract
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.
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Kaminski MR, Raspovic A, McMahon LP, Erbas B, Landorf KB. Risk factors for foot ulceration in adults with end-stage renal disease on dialysis: study protocol for a prospective observational cohort study. J Foot Ankle Res 2015; 8:53. [PMID: 26388946 PMCID: PMC4575467 DOI: 10.1186/s13047-015-0110-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 09/10/2015] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- Michelle R Kaminski
- Discipline of Podiatry and Lower Extremity and Gait Studies Program, School of Allied Health, La Trobe University, Melbourne, VIC 3086 Australia ; Department of Podiatry, Eastern Health, Melbourne, VIC 3156 Australia
| | - Anita Raspovic
- Discipline of Podiatry and Lower Extremity and Gait Studies Program, School of Allied Health, La Trobe University, Melbourne, VIC 3086 Australia
| | - Lawrence P McMahon
- Departments of Renal Medicine and Obstetric Medicine, Eastern Health Clinical School, Monash University, Melbourne, VIC 3128 Australia
| | - Bircan Erbas
- Department of Public Health, College of Science, Health and Engineering, School of Psychology and Public Health, La Trobe University, Melbourne, VIC 3086 Australia
| | - Karl B Landorf
- Discipline of Podiatry and Lower Extremity and Gait Studies Program, School of Allied Health, La Trobe University, Melbourne, VIC 3086 Australia
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