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

Risk factors of foot ulcers in patients with end-stage renal disease on dialysis: A meta-analysis

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.

The effect of non-contrast enhanced MRA on patients with renal insufficiency and foot pain

To investigate the feasibility of non-contrast magnetic resonance angiography of arteries and veins (NATIVE) sampling perfection with application optimized contrasts by using different flip angle evolution (SPACE) and quiescent interval single shot (QISS) in assessing foot arteries of patients with renal insufficiency and foot pain. Fifty-three patients (mean age = 44.2 ± 11.4 years, male: female = 27:26) underwent QISS and NATIVE-SPACE. The source images were reconstructed to maximum intensity projection and volume render. The image quality of QISS and NATIVE-SPACE was rated (0-3, poor to excellent), and was compared using Wilcoxon test. True or false positive was determined by comparing the findings of QISS and NATIVE-SPACE. The relative signal intensity of artery was obtained for each case, and was compared between QISS and NATIVE-SPACE using Mann Whitney test. The acquisition time of NATIVE-SPACE was significantly longer than that of QISS (178.4 ± 35.7 seconds vs 45.4 ± 8.9 seconds, P < .001). QISS had significantly lower image quality score versus NATIVE-SPACE (1.4 ± 0.5 vs 2.4 ± 0.6, P = .02). Fifteen percentage (8/53) NATIVE-SPACE cases had poor image quality due to the similarity of peak flow and minimum flow. The relative signal intensity was significantly lower in QISS versus NATIVE-SPACE (9.7 ± 1.3 vs 68.2 ± 12.4, P < .001). NATIVE-SPACE is valuable in evaluating foot arteries of patients with renal insufficiency. QISS can serve as an alternative test to NATIVE-SPACE.

Prevalence of diabetic foot at risk of ulcer development and its components stratification according to the international working group on the diabetic foot (IWGDF): A systematic review with metanalysis

AIMS

To determine the overall prevalence of diabetic foot at risk according to the International Working Group on the Diabetic Foot stratification.

MATERIALS AND METHODS

We searched PubMed/Medline, Scopus, Web of Science, and Embase. We included cross-sectional studies or cohorts from 1999 to March 2022. We performed a meta-analysis of proportions using a random-effects model. We assessed heterogeneity through subgroup analysis by continent and other characteristics.

RESULTS

We included 36 studies with a total population of 11,850 people from 23 countries. The estimated overall prevalence of diabetic foot at risk was 53.2% (95% CI: 45.1-61.3), I2 = 98.7%, p < 0.001. In the analysis by subgroups, South and Central America had the highest prevalence and Africa the lowest. The factors explaining the heterogeneity were the presence of chronic kidney disease, diagnostic method for peripheral arterial disease, and quality. The estimates presented very low certainty of evidence.

CONCLUSIONS

The overall prevalence of diabetic foot at risk is high. The high heterogeneity between continents can be explained by methodological aspects and the type of population. However, using the same classification is necessary for standardization of the way of measuring the components, as well as better designed general population-based studies.

[Clinical Characteristics and Prognosis of Diabetic Foot Ulcers Patients of Different Renal Function Statuses]

Objective

To explore the clinical characteristics and the prognosis of diabetic foot ulcers (DFU) inpatients of different renal function statuses.

Methods

A retrospective analysis of 962 inpatients with DFU was conducted. The patients were divided into three groups according to their renal function statuses, and the clinical characteristics of the three groups were compared to identify differences. In addition, the patients were followed up in outpatient clinics or by telephone and their prognostic status and risk factors for death were analyzed.

Results

Analysis of the clinical characteristics showed that, compared with diabetic patients with normal renal function or mild renal function impairment, diabetic patients with moderate and severe renal function impairment had a longer course of disease ( P<0.001). Patients with foot ulcers of Wagner grade 4 predominates the moderate and severe renal function impairment groups ( P<0.05). Patients in the moderate and severe renal function impairment groups had a relatively higher proportion of comorbidities, including hypertension, coronary heart disease, and peripheral arterial disease ( P<0.05). These patients had relatively lower levels of glycosylated hemoglobin and hemoglobin (all P<0.05) and relatively higher levels of neutrophil ratio and procalcitonin (all P<0.05). Of the two groups, patients in the moderate renal function impairment group were older ( P<0.001) and had lower ankle-brachial index ( P<0.001). The severe renal function impairment group had a higher proportion of patients with foot ulcers of Wagner grades 3 and 5 (all P<0.05). For the purpose of conducting prognostic analysis, 748 patients were followed up in outpatient clinics or by telephone for a median length of 41 months. Among them, 239 died. The all-cause mortality was 31.9%, and the mortality in the three groups was 25.8%, 46.2% ( P<0.001), and 59.4% ( P<0.001), respectively. The survival rate of patients in the moderate and severe renal function impairment groups was significantly lower than those in the normal renal function and mild renal function impairment groups ( P<0.001). Univariate Cox regression analysis showed that age, concomitant coronary heart disease and peripheral arterial disease, degree of renal function impairment, and foot ulcers of Wagner grade 4 and 5 were associated with all-cause deaths. Furthermore, multivariate Cox regression analysis showed that moderate and severe renal function impairment was an independent risk factor for all-cause deaths in DFU patients ( P<0.001).

Conclusions

As renal function impairment worsens, patients with DFU present clinical characteristics of greater complexity, higher risks of cardiovascular events, and higher mortality. It is essential to prevent kidney damage and foot ulcers, to pay attention to the cardiovascular risks of DFU patients with moderate and severe renal function impairment, and to reduce mortality.

The prevalence of foot ulcers in diabetic patients in Pakistan: A systematic review and meta-analysis

We aimed to determine the pooled prevalence of diabetic foot ulcers in Pakistan. MEDLINE (PubMed), Web of Science, Google scholars, and local databases were systematically searched for studies published up to August 10, 2022, on the prevalence of foot ulcers among diabetic patients in Pakistan. Random-effects meta-analysis was used to generate summary estimates. Subgroup analysis and meta-regression models were used to address the issue of high heterogeneity. Two authors independently identified eligible articles, collected data, and performed a risk of bias analysis. Twelve studies were included in the meta-analysis (14201, range 230-2199, diabetic patients), of which 7 were of "high" quality. The pooled prevalence of diabetic foot ulcers was 12.16% (95% CI: 5.91-20.23%). We found significant between-study heterogeneity (I² = 99.3%; p < 0.001) but no statistical evidence of publication bias (p = 0.8544). Subgroup meta-analysis found significant differences in foot ulcer prevalence by publication year and by the duration of diabetes. An increasing trend was observed during the last two decades, with the prevalence of diabetic foot ulcers being the highest in the latest period from 2011 to 2022 (19.54%) than in the early 2000 s (4.55%). This study suggests that the prevalence of diabetic foot ulcers in Pakistan is relatively high, with significant variation between provinces. Further study is required to identify ways for early detection, prevention, and treatment in the population.

Profile of Diabetic Foot Ulcer Patients at Tertiary Care Hospital in Surabaya, Indonesia

Background: Diabetic Foot Ulcer (DFU) has been associated with a high mortality rate of Diabetes Mellitus (DM) patients. Both behavioral and biological factors cause predisposition to DFU. Purpose: This research describes the profile of hospitalized DFU patients at a tertiary care hospital in Surabaya. Methods: A retrospective descriptive study that analyzed medical records of hospitalized T2DM patients with DFU in Dr. Soetomo General Hospital. Sampled respondents were patients ≥ 21 years old who were hospitalized between 2016–2018. Demographic data, clinical characteristics, medical histories, length of hospital stay, laboratory results, precipitating factors, microorganism culture results, treatment, and outcome were analyzed. Descriptive analysis is presented in the form of narratives, tables, and diagrams. Results: 9.08% of hospitalized Type 2 DM (T2DM) cases were related to foot ulcers. The average patient age was 57.00 ± 9.83 years with no gender predominance. DM was poorly controlled (Mean HbA1C 9.78±2.83%; RBG 251.83 ± 158.15 mg/dL). The majority of patients had sepsis (68.26%) and renal function impairment (62.72%). Ulcers with Wagner grades of 4–5 were frequent (41.31%). The highest percentage of sepsis (80.49%) and the average leukocyte level (22.60±11.95 x109/L) were found in gangrenous feet. Anemia was more predominant and severe in ulcers with higher Wagner grades. Trauma and Escherichia coli were the most common precipitating factors and microorganisms isolated, respectively. Amputation was performed for 82.36% of patients who were admitted to hospital with gangrene. The Lower Extremity Amputation (LEA) and mortality rates were 14.11% and 40.93%, respectively. Conclusion: DFUs were found to have a relatively high prevalence among T2DM patients, and must never be neglected due to the high associated mortality rate.

Psychometric Validation of the Cardiff Wound Impact Schedule Questionnaire in a Spanish Population with Diabetic Foot Ulcer

Diabetic foot ulcers (DFU) negatively affect the quality of life (QoL) of people with diabetes. The Cardiff Wound Impact Schedule (CWIS) questionnaire has been designed to measure the QoL of people with chronic foot wounds. However, no studies have been specifically designed to validate this instrument in a Spanish population. In this prospective study, a total of 141 subjects with DFU were recruited. DFU was determined by performing physical examinations. Medical records were exhaustively reviewed to collect clinical variables. The CWIS was transculturally adapted by a group of experts and a group of patients with DFU. The SF-36 and EQ-5D generic instruments were used as reference tools. The questionnaires were administered at 7 days and 4, 12, and 26 weeks after the baseline assessment by personal interview with each of the study subjects. The psychometric properties of the instrument were assessed using statistical methods. The content validity had an average of 3.63 (90.7% of the maximum score of 4). The internal consistency of the CWIS subscales had a standardized Cronbach’s alpha range from 0.715 to 0.797. The reproducibility was moderate with an intraclass correlation coefficient (ICC) range from 0.606 to 0.868. Significant correlations between CWIS domains and SF-36 and EQ-5D subscales were observed, demonstrating a good criterion validity of the CWIS questionnaire (p < 0.001). However, the construct validity of the CWIS was not validated with a comparative fit index (CFI) of 0.69, a root mean square error of approximation (RMSEA) of 0.09, and a standardized root mean square residual (SRMR) of 0.10. The sensitivity to changes over time was optimal in the three domains (i.e., social life, well-being, and physical symptoms) (p < 0.001). In conclusion, the Spanish version of the CWIS shows acceptable psychometric properties to assess the QoL of subjects with DFU, except for its construct validity.

High Incidence of Adverse Outcomes in Haemodialysis Patients with Diabetes with or without Diabetic Foot Syndrome: A 5-Year Observational Study in Lleida, Spain

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.

Adaptation and Validation of the Diabetic Foot Ulcer Scale-Short Form in Spanish Subjects

Diabetic foot ulcer (DFU) is a chronic complication that negatively affects the quality of life (QoL) of diabetic patients. In Spain, there is no specifically designed and validated instrument to assess the QoL of patients with DFU. Our aim was to adapt the Diabetic Foot Ulcer Scale-Short Form (DFS-SF) questionnaire to a Spanish population and validate it. A prospective, observational design was used. The DFS-SF was administered by personal interview. The validated SF-36 and EQ-5D generic instruments were used as reference tools. The reliability, validity, and sensitivity to changes were assessed using standard statistical methods. A sample of 141 patients with DFU was recruited. The content validity was 3.46 on average (maximum score of 4). The internal consistency of the DFS-SF subscales showed a standardized Cronbach’s α range between 0.720 and 0.948. The DFS-SF domains showed excellent reproducibility measures (intraclass correlation coefficient from 0.77–0.92). The criterion validity was good with significant correlations between each DFS-SF subscale and its corresponding SF-36 and EQ-5D subscales (p < 0.001). However, the questionnaire structure was not validated (comparative fit index = 0.844, root mean square error of approximation = 0.095, and standardized root mean square residual = 0.093). The instrument showed high sensitivity to ulcer changes over time (p < 0.001). The adapted and validated Spanish version of the DFS-SF questionnaire has good psychometric properties and shows good sensitivity to ulcer changes, although the construct validity was not optimal. The adapted questionnaire will be a useful tool specifically to assess the QoL in subjects with diabetic foot ulcers in the clinical and research settings in Spain.

Prevalence and associated factors of foot ulcer among diabetic patients in Ethiopia: a systematic review and meta-analysis

Background

Diabetes and its complications including foot ulcer constitute a global public health challenge attributing to a significant cause of morbidity and mortality. Foot ulcer is one of the long-term complication of diabetes mellitus which lead to infection and amputation of lower extremities. In Ethiopia, findings from few studies were inconsistent and there is a need to systematically pool existing data to determine the magnitude of foot ulcer in diabetics and factors contributing to it.

Methods

We identified articles through electronic databases such as Medline, Hinari, Pub Med, Cochrane library, the Web of Science and Google Scholar. Accordingly, we identified 95 published and one unpublished article. Finally, eleven studies which fullfilled eligibility criteria were included in final systematic review and meta-analysis. Data were extracted using a standardized data extraction checklist and the analyses were conducted using STATA version 14. The Cochrane Q test statistic and I² tests were used to assess heterogeneity.

Results

The overall magnitude of foot ulcer was 12.98% (95%CI: 7.81–18.15) in diabetic patients in Ethiopia. Sub-group analyses revealed highest prevalence in Addis Ababa (19.31% (95%CI: 2.7. 41.37)). Foot ulcer was significantly associated with rural residence (OR = 2.72, 95%, CI: 1.84–4.01)), presence of callus on the feet ((OR = 12.67, 95%, CI: 6.47–24.79)), a body mass index of ≥24.5 ((OR = 2.68, 95%, CI: 1.58–4.56)), poor self- care practice ((OR = 1.47, 95%CI: 1.25–1.73)), type I diabetes mellitus ((OR = 0.42, 95%, CI: 0.22–0.79)), staying with DM for < 10 years ((OR = 0.23, 95%, CI: 0.11–0.50)), and age < 45 years ((OR = 0.44, 95%, CI: 0.21–0.92)).

Conclusion

The prevalence of diabetic foot ulcers in Ethiopia is relatively low, although its trend is increasing from time to time. Socio-demographic factors, body weight, and healthcare practice contribute to the development of diabetic foot ulcers. Appropriate interventions towards patient self-care practice, lifestyle modification and follow-up are wanted to prevent diabetic foot ulcers.

Prevalence, Clinical Presentation, and Factors Associated With Diabetic Foot Ulcer in Two Regional Hospitals in Cameroon

This study aimed to determine the prevalence of diabetic foot ulcer and high risk for ulceration, describe the clinical presentation, and identify factors associated with diabetic foot ulcer in the Southwest regional hospitals of Cameroon. In this cross-sectional study, data were collected using a structured questionnaire administered to consecutive patients with diabetes. Findings from detailed foot examination were recorded. Diabetic foot ulcer was diagnosed according to the International Working Group on Diabetic Foot (IWGDF) definition. Data were analyzed with Stata IC version 12. Of the 203 participants included, 63.1% were females. Age ranged from 26 to 96 years. The median duration of diabetes was 4.0 years (interquartile range 1.0-8.0 years). The prevalence of diabetic foot ulcer was 11.8% (24), of whom 29.2% (7) had high grade (grades 2 to 4), and most of the ulcers 58.3% (14) were located at the plantar region. The prevalence of high risk for ulceration was 21.8% (39). Loss of protective sensation (OR = 3.73, 95% CI = 1.43-9.71; P = .007), and peripheral arterial disease (OR = 3.48, 95% CI = 1.14-10.56; P = .028) were independently associated with diabetic foot. Diabetic foot ulcer is a common complication among patients with diabetes attending these regional hospitals. Loss of protective sensation, and peripheral arterial disease increase the odds of having diabetic foot ulcer, and we suggest them as the main target of interest for prevention.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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