1
|
Yin J, Fu X, Luo Y, Leng Y, Ao L, Xie C. A Narrative Review of Diabetic Macroangiopathy: From Molecular Mechanism to Therapeutic Approaches. Diabetes Ther 2024; 15:585-609. [PMID: 38302838 PMCID: PMC10942953 DOI: 10.1007/s13300-024-01532-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 01/11/2024] [Indexed: 02/03/2024] Open
Abstract
Diabetic macroangiopathy, a prevalent and severe complication of diabetes mellitus, significantly contributes to the increased morbidity and mortality rates among affected individuals. This complex disorder involves multifaceted molecular mechanisms that lead to the dysfunction and damage of large blood vessels, including atherosclerosis (AS) and peripheral arterial disease. Understanding the intricate pathways underlying the development and progression of diabetic macroangiopathy is crucial for the development of effective therapeutic interventions. This review aims to shed light on the molecular mechanism implicated in the pathogenesis of diabetic macroangiopathy. We delve into the intricate interplay of chronic inflammation, oxidative stress, endothelial dysfunction, and dysregulated angiogenesis, all of which contribute to the vascular complications observed in this disorder. By exploring the molecular mechanism involved in the disease we provide insight into potential therapeutic targets and strategies. Moreover, we discuss the current therapeutic approaches used for treating diabetic macroangiopathy, including glycemic control, lipid-lowering agents, and vascular interventions.
Collapse
Affiliation(s)
- Jiacheng Yin
- Hospital of Chengdu University of Traditional Chinese Medicine No, 39 Shi-er-Qiao Road, Chengdu, 610072, Sichuan Province, People's Republic of China
| | - Xiaoxu Fu
- Hospital of Chengdu University of Traditional Chinese Medicine No, 39 Shi-er-Qiao Road, Chengdu, 610072, Sichuan Province, People's Republic of China
- TCM Regulating Metabolic Diseases Key Laboratory of Sichuan Province, No. 39 Shi-er-Qiao Road, Chengdu, 610072, Sichuan Province, People's Republic of China
- Department of Endocrinology, Hospital of Chengdu University of Traditional Chinese Medicine, No. 39 Shi-er-Qiao Road, Chengdu, 610072, Sichuan Province, People's Republic of China
| | - Yue Luo
- Hospital of Chengdu University of Traditional Chinese Medicine No, 39 Shi-er-Qiao Road, Chengdu, 610072, Sichuan Province, People's Republic of China
| | - Yuling Leng
- Hospital of Chengdu University of Traditional Chinese Medicine No, 39 Shi-er-Qiao Road, Chengdu, 610072, Sichuan Province, People's Republic of China
| | - Lianjun Ao
- Hospital of Chengdu University of Traditional Chinese Medicine No, 39 Shi-er-Qiao Road, Chengdu, 610072, Sichuan Province, People's Republic of China
| | - Chunguang Xie
- Hospital of Chengdu University of Traditional Chinese Medicine No, 39 Shi-er-Qiao Road, Chengdu, 610072, Sichuan Province, People's Republic of China.
- TCM Regulating Metabolic Diseases Key Laboratory of Sichuan Province, No. 39 Shi-er-Qiao Road, Chengdu, 610072, Sichuan Province, People's Republic of China.
- Department of Endocrinology, Hospital of Chengdu University of Traditional Chinese Medicine, No. 39 Shi-er-Qiao Road, Chengdu, 610072, Sichuan Province, People's Republic of China.
| |
Collapse
|
2
|
Yan S, Yao D, Wang Y, Zhang J. Risk factors of foot ulcers in patients with end-stage renal disease on dialysis: A meta-analysis. Int Wound J 2024; 21:e14348. [PMID: 37667546 PMCID: PMC10782048 DOI: 10.1111/iwj.14348] [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: 07/05/2023] [Revised: 07/27/2023] [Accepted: 07/29/2023] [Indexed: 09/06/2023] Open
Abstract
The present study aims to assess the risk factors for foot ulcers in patients undergoing dialysis for end-stage renal disease (ESRD) and to provide evidence-based guidance for prevention and treatment. A systematic search was conducted on PubMed, EMBASE, Cochrane Library, China National Knowledge Infrastructure, Chinese Biomedical Literature Database and Wanfang Data from the database inception until May 2023 to identify relevant studies investigating the risk factors for foot ulcers in dialysis patients with ESRD. Two independent researchers conducted the literature screening and data extraction. The meta-analysis was performed using STATA 17.0 software. Ultimately, six articles comprising 1620 patients were included for analysis. The meta-analysis revealed that male (OR, 1.464; 95% CI: 1.082-1.980, p = 0.013), hypertension (OR, 1.781; 95% CI: 1.293-2.4550, p < 0.001), peripheral artery disease (PAD) (OR, 5.014; 95% CI: 2.514-9.998, p < 0.001), type 1 diabetes mellitus (T1DM) (OR, 2.993; 95% CI: 1.477-6.065, p = 0.002) and type 2 diabetes mellitus (T2DM) (OR, 2.498; 95% CI:1.466-4.256, p = 0.001) were risk factors for foot ulcers in dialysis patients with ESRD. Conversely, the female sex (OR, 0.683; 95% CI: 0.505-0.924, p = 0.013) was a protective factor against foot ulcers. Our analysis revealed that male sex, hypertension, PAD, T1DM and T2DM were risk factors for foot ulcers in patients undergoing dialysis for ESRD. Conversely, the female sex was a protective factor against foot ulcers. Therefore, it is crucial to strengthen health education that targets patients with these risk factors and regularly screen high-risk individuals. Early detection and treatment can help delay disease progression.
Collapse
Affiliation(s)
- Shanshan Yan
- Department of NephrologyFourth Medical Center of Chinese PLA General HospitalBeijingChina
| | - Dongfang Yao
- Department of Emergency MedicineFourth Medical Center of Chinese PLA General HospitalBeijingChina
| | - Ya Wang
- Department of NephrologyFourth Medical Center of Chinese PLA General HospitalBeijingChina
| | - Jian Zhang
- Department of NephrologyFirst Medical Center of Chinese PLA General HospitalBeijingChina
| |
Collapse
|
3
|
Wang JJ, Yu YY, Wang PY, Huang XM, Chen X, Chen XG. Sequential treatment for diabetic foot ulcers in dialysis patients: A case report. World J Diabetes 2023; 14:1323-1329. [PMID: 37664469 PMCID: PMC10473955 DOI: 10.4239/wjd.v14.i8.1323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/16/2023] [Accepted: 07/14/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Diabetic foot ulcers (DFUs) are common in patients with diabetes, especially those undergoing hemodialysis. In severe cases, these ulcers can cause damage to the lower extremities and lead to amputation. Traditional treatments such as flap transposition and transfemoral amputation are not always applicable in all cases. Therefore, there is a need for alternative treatment methods. CASE SUMMARY This report describes a 62-year-old female patient who was admitted to the hospital with plantar and heel ulcers on her left foot. The patient had a history of renal failure and was undergoing regular hemodialysis. Digital subtraction angiography showed extensive stenosis and occlusion in the left superficial femoral artery, left peroneal artery and left posterior tibial artery. Following evaluation by a multidisciplinary team, the patient was diagnosed with type 2 DFUs (TEXAS 4D). Traditional treatments were deemed unsuitable, and the patient was treated with endovascular surgery in the affected area, in addition to supportive medical treatment, local debridement, and sequential repair using split-thickness skin and tissue-engineered skin grafts combined with negative pressure treatment. After four months, the wound had completely healed, and the patient was able to walk with a walking aid. CONCLUSION This study demonstrates a new treatment method for DFUs was successful, using angioplasty, skin grafts, and negative pressure.
Collapse
Affiliation(s)
- Jin-Jun Wang
- College of Marine Life Science, Ocean University of China, Qingdao 266003, Shandong Province, China
- Department of Vascular Surgery, Qingdao Haici Hospital Affiliated to Qingdao University, Qingdao 266033, Shandong Province, China
| | - Yuan-Yuan Yu
- Department of Vascular Surgery, Qingdao Haici Hospital Affiliated to Qingdao University, Qingdao 266033, Shandong Province, China
| | - Pin-Yi Wang
- Department of Vascular Surgery, Qingdao Haici Hospital Affiliated to Qingdao University, Qingdao 266033, Shandong Province, China
| | - Xian-Ming Huang
- Department of Vascular Surgery, Qingdao Haici Hospital Affiliated to Qingdao University, Qingdao 266033, Shandong Province, China
| | - Xiao Chen
- Department of Vascular Surgery, Qingdao Haici Hospital Affiliated to Qingdao University, Qingdao 266033, Shandong Province, China
| | - Xi-Guang Chen
- College of Marine Life Science, Ocean University of China, Qingdao 266003, Shandong Province, China
| |
Collapse
|
4
|
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.
Collapse
|
5
|
Herrera Herrera JL, Oyola López E, Llorente Pérez YJ. Factores asociados a las úlceras en miembros inferiores del paciente con enfermedad renal crónica en un centro de diálisis. INVESTIGACIÓN EN ENFERMERÍA: IMAGEN Y DESARROLLO 2021. [DOI: 10.11144/javeriana.ie23.faum] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Introducción: las personas adultas con enfermedad renal crónica (ERC) tienen mayor riesgo de presentar úlceras, especialmente en las extremidades inferiores. Sin embargo, existen datos limitados sobre la prevalencia y los factores asociados. Objetivo: determinar la prevalencia de úlceras en miembros inferiores y sus factores asociados en pacientes con enfermedad renal crónica que asisten a una institución de IV nivel de complejidad. Método: estudio de tipo observacional, transversal y analítico, la muestra fue de 561 participantes. Los instrumentos fueron una cha de datos sociodemográcos y de antecedentes, y el índice tobillo brazo (ITB). Resultados: los participantes fueron en su mayoría hombres (67%), con promedio de edad de 62 años; se encontró signicancia estadística (p < 0,05) entre las variables antecedente de diabetes, ITB bajo, haber tenido úlcera previa y presencia de úlcera en miembros inferiores. Conclusiones: estudiar este tipo de fenómenos en unidades de cuidado renal se convierte en una necesidad debido a la alta prevalencia y a los factores de riesgo asociados. Esto permite la planicación de estrategias encaminadas a la prevención.
Collapse
|
6
|
Dòria M, Betriu À, Belart M, Rosado V, Hernández M, Sarro F, Real J, Castelblanco E, Pacheco LR, Fernández E, Franch-Nadal J, Gratacòs M, Mauricio D. High Incidence of Adverse Outcomes in Haemodialysis Patients with Diabetes with or without Diabetic Foot Syndrome: A 5-Year Observational Study in Lleida, Spain. J Clin Med 2021; 10:jcm10071368. [PMID: 33810545 PMCID: PMC8037880 DOI: 10.3390/jcm10071368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/21/2021] [Accepted: 03/23/2021] [Indexed: 11/24/2022] Open
Abstract
Background: We evaluated whether, in subjects receiving haemodialysis (HD), the presence of diabetic foot syndrome (DFS) was associated with increased mortality compared with subjects with diabetes mellitus (DM) without DFS and with non-diabetic subjects. Methods: Retrospective, observational study in 220 subjects followed for six years. We calculated and compared the frequency and 5-year cumulative incidence of all-cause mortality, cardiovascular (CV) mortality, CV events, major adverse CV events (MACE), and new foot ulcer (FU) or amputation. We also examined prognostic factors of all-cause and CV mortality based on baseline characteristics. Results: DM patients had a 1.98 times higher probability of all-cause mortality than those without DM (p = 0.001) and 2.42 times higher likelihood of CV mortality and new FU or amputation (p = 0.002 and p = 0.008, respectively). In the DM cohort, only the risk of a new FU or amputation was 2.69 times higher among those with previous DFS (p = 0.021). In patients with DM, older age was the only predictor of all-cause and CV mortality (p = 0.001 and p = 0.014, respectively). Conclusions: Although all-cause and CV mortality were increased on HD subjects with DM, the presence of DFS did not modify the excess risk. Additional studies are warranted to further explore the impact of DFS in subjects with DM undergoing HD.
Collapse
Affiliation(s)
- Montserrat Dòria
- Department of Endocrinology & Nutrition, University Hospital Arnau de Vilanova and Santa Maria, 25198 Lleida, Spain; (M.D.); (V.R.); (M.H.); (L.R.P.)
- Department of Endocrinology and Nutrition, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, 08041 Barcelona, Spain
| | | | | | - Verónica Rosado
- Department of Endocrinology & Nutrition, University Hospital Arnau de Vilanova and Santa Maria, 25198 Lleida, Spain; (M.D.); (V.R.); (M.H.); (L.R.P.)
| | - Marta Hernández
- Department of Endocrinology & Nutrition, University Hospital Arnau de Vilanova and Santa Maria, 25198 Lleida, Spain; (M.D.); (V.R.); (M.H.); (L.R.P.)
- Lleida Institute for Biomedical Research Dr. Pifarré Foundation IRBLleida, University of Lleida, 25198 Lleida, Spain;
| | - Felipe Sarro
- Department of Nephrology, University Hospital Arnau de Vilanova and Santa Maria, 25198 Lleida, Spain;
| | - Jordi Real
- DAP-Cat group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), 08006 Barcelona, Spain; (J.R.); (E.C.); (J.F.-N.); (M.G.)
- Centre for Biomedical Research on Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), 08041 Barcelona, Spain
| | - Esmeralda Castelblanco
- DAP-Cat group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), 08006 Barcelona, Spain; (J.R.); (E.C.); (J.F.-N.); (M.G.)
- Centre for Biomedical Research on Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), 08041 Barcelona, Spain
| | - Linda Roxana Pacheco
- Department of Endocrinology & Nutrition, University Hospital Arnau de Vilanova and Santa Maria, 25198 Lleida, Spain; (M.D.); (V.R.); (M.H.); (L.R.P.)
| | - Elvira Fernández
- Lleida Institute for Biomedical Research Dr. Pifarré Foundation IRBLleida, University of Lleida, 25198 Lleida, Spain;
| | - Josep Franch-Nadal
- DAP-Cat group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), 08006 Barcelona, Spain; (J.R.); (E.C.); (J.F.-N.); (M.G.)
- Centre for Biomedical Research on Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), 08041 Barcelona, Spain
- Primary Health Care Center Raval Sud, Gerència d’Atenció Primaria, Institut Català de la Salut, 08001 Barcelona, Spain
| | - Mònica Gratacòs
- DAP-Cat group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), 08006 Barcelona, Spain; (J.R.); (E.C.); (J.F.-N.); (M.G.)
| | - Dídac Mauricio
- Department of Endocrinology and Nutrition, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, 08041 Barcelona, Spain
- DAP-Cat group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), 08006 Barcelona, Spain; (J.R.); (E.C.); (J.F.-N.); (M.G.)
- Centre for Biomedical Research on Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), 08041 Barcelona, Spain
- Faculty of Medicine, University of Vic (UVIC/UCC), 08500 Vic, Spain
- Correspondence: ; Tel.: +34-935-565-661
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
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.
Collapse
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
| |
Collapse
|
9
|
Hickson LJ, Rule AD, Thorsteinsdottir B, Shields RC, Porter IE, Fleming MD, Ubl DS, Crowson CS, Hanson KT, Elhassan BT, Mehrotra R, Arya S, Albright RC, Williams AW, Habermann EB. Predictors of early mortality and readmissions among dialysis patients undergoing lower extremity amputation. J Vasc Surg 2018; 68:1505-1516. [PMID: 30369411 DOI: 10.1016/j.jvs.2018.03.408] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 03/09/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Patients receiving dialysis are at increased risk for lower extremity amputations (LEAs) and postoperative morbidity. Limited studies have examined differences in 30-day outcomes of mortality and health care use after amputation or the preoperative factors that relate to worsened outcomes in dialysis patients. Our objective was to examine dialysis dependency and other preoperative factors associated with readmission or death after LEA. METHODS A retrospective cohort study was conducted of dialysis-dependent and nondialysis patients undergoing major LEA in the 2012 to 2013 American College of Surgeons National Surgical Quality Improvement Program. Primary outcomes included death and hospital readmission within 30 days of amputation. RESULTS Of 6468 patients, 1166 (18%) were dialysis dependent. The dialysis cohort had more blacks (39% vs 23%), diabetes (76% vs 58%), below-knee amputations (62% vs 55%), and in-hospital deaths (8% vs 3%; all P < .001). The 30-day postoperative death rates (15% vs 7%) and readmission rates (35% vs 20% per 30 person-days; both P < .001) were higher in dialysis patients. Among the live discharges, the rate of any readmission or death within 30 days from amputation was highest in those aged ≥50 years (40% per 30 person-days). Multivariable analyses in the dialysis cohort revealed increased age, above-knee amputation, decreased physical status, heart failure, high preoperative white blood cell count, and low platelet count to be associated with death (P < .05; C statistic, 0.75). The only preoperative factor associated with readmission in dialysis patients was race (P = .04; C statistic, 0.58). CONCLUSIONS Readmission or death after amputation is increased among dialysis patients. Predicting which dialysis patients are at highest risk for death is feasible, whereas predicting which will require readmission is less so. Risk factor identification may improve risk stratification, inform reimbursement policies, and allow targeted interventions to improve outcomes.
Collapse
Affiliation(s)
- LaTonya J Hickson
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn.
| | - Andrew D Rule
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Bjorg Thorsteinsdottir
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn; Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minn
| | | | - Ivan E Porter
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, Fla
| | - Mark D Fleming
- Division of Vascular Surgery, Department of Surgery, Mayo Clinic, Rochester, Minn
| | - Daniel S Ubl
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn; Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minn
| | - Cynthia S Crowson
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minn
| | - Kristine T Hanson
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn; Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minn
| | - Bassem T Elhassan
- Division of Orthopedic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minn
| | - Rajnish Mehrotra
- Division of Nephrology, Kidney Research Institute and Harborview Medical Center, University of Washington, Seattle, Wash
| | - Shipra Arya
- Division of Vascular Surgery, Emory University, Atlanta, Ga
| | - Robert C Albright
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Amy W Williams
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Elizabeth B Habermann
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn; Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minn
| |
Collapse
|
10
|
Triebswetter S, Gutjahr-Lengsfeld LJ, Schmidt KR, Drechsler C, Wanner C, Krane V. Long-Term Survivor Characteristics in Hemodialysis Patients with Type 2 Diabetes. Am J Nephrol 2018; 47:30-39. [PMID: 29320770 DOI: 10.1159/000485842] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 11/29/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Data concerning long-term mortality predictors among large, purely diabetic hemodialysis collectives are scarce. METHODS We used data from a multicenter, prospective, randomized trial among 1,255 hemodialysis patients with type 2 diabetes mellitus (T2DM) and its observational follow-up study. The association of 10 baseline candidate variables with mortality was assessed by Cox proportional hazards regression. RESULTS Overall, 103 participants survived the median follow-up of 11.5 years. Significant predictors of mortality were age (hazard ratio [HR] 1.03, 95% CI 1.02-1.04), cardiovascular (HR 1.42, 95% CI 1.25-1.62) and peripheral vascular disease (HR 1.55, 95% CI 1.36-1.76), higher hemoglobin A1c (HbA1c; HR 1.08, 95% CI 1.03-1.14), and loss of self-dependency (HR 1.20, 95% CI 1.03-1.39). Higher albumin (HR 0.72, 95% CI 0.59-0.89) and body mass index (BMI; HR 0.98, 95% CI 0.96-0.99) had protective associations. There was no significant association with sex, diabetes duration, and cerebrovascular diseases. Subgroup analyses by age and diabetes duration showed stronger associations of cardiovascular disease, HbA1c, albumin, BMI, and loss of self-dependency in younger patients and/or shorter diabetes duration. Loss of self-dependency and energy resources (albumin, BMI) increased mortality more severely in women, whilst the impact of cardiovascular and peripheral vascular diseases was more pronounced in men. CONCLUSION Long-term mortality risk in patients with T2DM on hemodialysis was associated with higher age, vascular diseases, HbA1c, loss of self-dependency, and low energy resources. Interestingly, it does not vary between sexes. Further individualized prognosis estimation and therapy should strongly depend on age, diabetes duration, and gender.
Collapse
Affiliation(s)
- Susanne Triebswetter
- Department of Internal Medicine I, Division of Nephrology, University of Würzburg, Würzburg, Germany
| | - Lena J Gutjahr-Lengsfeld
- Department of Internal Medicine I, Division of Nephrology, University of Würzburg, Würzburg, Germany
- Comprehensive Heart Failure Centre, University of Würzburg, Würzburg, Germany
| | - Kay-Renke Schmidt
- Department of Internal Medicine I, Division of Nephrology, University of Würzburg, Würzburg, Germany
- Comprehensive Heart Failure Centre, University of Würzburg, Würzburg, Germany
| | - Christiane Drechsler
- Department of Internal Medicine I, Division of Nephrology, University of Würzburg, Würzburg, Germany
- Comprehensive Heart Failure Centre, University of Würzburg, Würzburg, Germany
| | - Christoph Wanner
- Department of Internal Medicine I, Division of Nephrology, University of Würzburg, Würzburg, Germany
- Comprehensive Heart Failure Centre, University of Würzburg, Würzburg, Germany
| | - Vera Krane
- Department of Internal Medicine I, Division of Nephrology, University of Würzburg, Würzburg, Germany
- Comprehensive Heart Failure Centre, University of Würzburg, Würzburg, Germany
| |
Collapse
|
11
|
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
| |
Collapse
|
12
|
Prevalence and Risk Factors of Lower Limb Amputation in Patients with End-Stage Renal Failure on Dialysis: A Systematic Review. Int J Nephrol 2016; 2016:4870749. [PMID: 27529033 PMCID: PMC4978825 DOI: 10.1155/2016/4870749] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 06/30/2016] [Indexed: 01/22/2023] Open
Abstract
Background. Renal dialysis has recently been recognised as a risk factor for lower limb amputation (LLA). However, exact rates and associated risk factors for the LLA are incompletely understood. Aim. Prevalence and risk factors of LLA in end-stage renal failure (ESRF) subjects on renal dialysis were investigated from the existing literature. Methods. Published data on the subject were derived from MEDLINE, PubMed, and Google Scholar search of English language literature from January 1, 1980, to July 31, 2015, using designated key words. Results. Seventy studies were identified out of which 6 full-text published studies were included in this systematic review of which 5 included patients on haemodialysis alone and one included patients on both haemodialysis and peritoneal dialysis. The reported findings on prevalence of amputation in the renal failure on dialysis cohort ranged from 1.7% to 13.4%. Five out of the six studies identified diabetes as the leading risk factor for amputation in subjects with ESRF on renal dialysis. Other risk factors identified were high haemoglobin A1c, elevated c-reactive protein, and low serum albumin. Conclusions. This review demonstrates high rate of LLA in ESRF patients receiving dialysis therapy. It has also identified diabetes and markers of inflammation as risk factors of amputation in ESRF subjects on dialysis.
Collapse
|
13
|
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.
Collapse
|
14
|
Hicks CW, Selvarajah S, Mathioudakis N, Sherman RE, Hines KF, Black JH, Abularrage CJ. Burden of Infected Diabetic Foot Ulcers on Hospital Admissions and Costs. Ann Vasc Surg 2016; 33:149-58. [PMID: 26907372 DOI: 10.1016/j.avsg.2015.11.025] [Citation(s) in RCA: 170] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 08/10/2015] [Accepted: 11/22/2015] [Indexed: 01/13/2023]
Abstract
BACKGROUND Costs related to diabetic foot ulcer (DFU) care are greater than $1 billion annually and rising. We sought to describe the impact of diabetes mellitus (DM) on foot ulcer admissions in the United States, and to investigate potential explanations for rising hospital costs. METHODS The Nationwide Inpatient Sample (2005-2010) was queried using International Classification of Diseases, 9th Revision (ICD-9) codes for a primary diagnosis of foot ulceration. Multivariable analyses were used to compare outcomes and per-admission costs among patients with foot ulceration and DM versus non-DM. RESULTS In total, 962,496 foot ulcer patients were admitted over the study period. The overall rate of admissions was relatively stable over time, but the ratio of DM versus non-DM admissions increased significantly (2005: 10.2 vs. 2010: 12.7; P < 0.001). Neuropathy and infection accounted for 90% of DFU admissions, while peripheral vascular disease accounted for most non-DM admissions. Admissions related to infection rose significantly among DM patients (2005: 39,682 vs. 2010: 51,660; P < 0.001), but remained stable among non-DM patients. Overall, DM accounted for 83% and 96% of all major and minor amputations related to foot ulcers, respectively, and significantly increased cost of care (DM: $1.38 vs. non-DM: $0.13 billion/year; P < 0.001). Hospital costs per DFU admission were significantly higher for patients with infection compared with all other causes ($11,290 vs. $8,145; P < 0.001). CONCLUSIONS Diabetes increases the incidence of foot ulcer admissions by 11-fold, accounting for more than 80% of all amputations and increasing hospital costs more than 10-fold over the 5 years. The majority of these costs are related to the treatment of infected foot ulcers. Education initiatives and early prevention strategies through outpatient multidisciplinary care targeted at high-risk populations are essential to preventing further increases in what is already a substantial economic burden.
Collapse
Affiliation(s)
- Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Shalini Selvarajah
- Center for Surgical Trials and Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Nestoras Mathioudakis
- Division of Endocrinology & Metabolism, Department of Medicine, The Johns Hopkins Hospital, Baltimore, MD; Diabetic Foot and Wound Service, The Johns Hopkins Hospital, Baltimore, MD
| | - Ronald E Sherman
- Diabetic Foot and Wound Service, The Johns Hopkins Hospital, Baltimore, MD; Department of Orthopedic Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Kathryn F Hines
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD; Diabetic Foot and Wound Service, The Johns Hopkins Hospital, Baltimore, MD
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Christopher J Abularrage
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD; Center for Surgical Trials and Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD; Diabetic Foot and Wound Service, The Johns Hopkins Hospital, Baltimore, MD.
| |
Collapse
|
15
|
Kaminski MR, Raspovic A, McMahon LP, Strippoli GF, Palmer SC, Ruospo M, Dallimore S, Landorf KB. Risk factors for foot ulceration and lower extremity amputation in adults with end-stage renal disease on dialysis: a systematic review and meta-analysis. Nephrol Dial Transplant 2015; 30:1747-66. [DOI: 10.1093/ndt/gfv114] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 03/17/2015] [Indexed: 12/30/2022] Open
|
16
|
Matsuzawa R, Aoyama N, Yoshida A. Clinical Characteristics of Patients on Hemodialysis With Peripheral Arterial Disease. Angiology 2015; 66:911-7. [PMID: 25694516 DOI: 10.1177/0003319715572678] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Patients on hemodialysis (HD; n = 210) were examined for peripheral arterial disease (PAD) using ankle-brachial index (ABI) and toe-brachial index (TBI). The prevalence of PAD was 38.1%. Among patients with PAD, 87.5% were newly diagnosed with PAD, 42.5% were diagnosed with TBI <0.6 despite ABI ≥ 0.9, and 68.7% had no lower limb symptoms. In patients with PAD, the prevalence rate of cerebrovascular disease was 36.3%, coronary artery disease was 42.5%, spinal stenosis was 33.2%, and vertebral fracture 15.0% and was significantly higher than those of the non-PAD patients. Low high-density lipoprotein cholesterol was the most important biomarker among patients with PAD. PAD has been underdiagnosed and untreated in patients on HD because most patients do not have symptoms that could be due to diabetic neuropathy or have insufficient daily activity to experience exertional leg symptoms. Screening for PAD using the ABI and TBI increased diagnostic efficiency in patients on HD and may lead to effective early treatments, including pharmacotherapy, revascularization therapy, and exercise rehabilitation to avoid the worst possible scenario such as lower limb amputation, cardiovascular event, and death.
Collapse
Affiliation(s)
- Ryota Matsuzawa
- Department of Rehabilitation, Kitasato University Hospital, Sagamihara, Japan
| | - Naoyoshi Aoyama
- Department of Cardio-angiology, Kitasato University, School of Medicine, Sagamihara, Japan
| | | |
Collapse
|