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

The Double Burden: Deciphering Chronic Limb-Threatening Ischemia in End-Stage Renal Disease

BACKGROUND

Chronic limb-threatening ischemia (CLTI) in patients with end-stage renal disease (ESRD) poses significant challenges in clinical management due to its unique pathology and poor treatment outcomes. This review calls for a tailored classification and risk assessment for these patients to guide better revascularization choices with early minor amputation as a first-line strategy in advanced stages.

METHODS

This review consolidates key findings from recent literature on CLTI in ESRD, focusing on disease mechanisms, treatment options, and patient outcomes. It evaluates the literature to clarify the decision-making process for managing CLTI in ESRD.

RESULTS

CLTI in ESRD patients often results in worse clinical outcomes, such as nonhealing wounds, increased limb loss, and higher mortality rates. While the literature reveals ongoing debates regarding the optimal revascularization method, recent retrospective studies and meta-analyses suggest potential benefits of endovascular treatment (EVT) over open bypass surgery (OB) in reducing mortality and wound complications, with comparable amputation-free survival rates.

CONCLUSIONS

The selection of revascularization methods in ESRD patients with CLTI is complex, necessitating individualized strategies. The importance of early detection and timely intervention is critical to decelerate disease progression and improve revascularization outcomes. There is a shift in these treatment strategies toward less invasive endovascular procedures, acknowledging the limitations these patients face with open revascularization surgeries. Considering early minor amputations after revascularization could prevent worse consequences, reflecting a shift in the approach to managing CLTI in ESRD patients.

Prediction of amputation risk of patients with diabetic foot using classification algorithms: A clinical study from a tertiary center

Diabetic foot ulcers can have vital consequences, such as amputation for patients. The primary purpose of this study is to predict the amputation risk of diabetic foot patients using machine-learning classification algorithms. In this research, 407 patients treated with the diagnosis of diabetic foot between January 2009-September 2019 in Istanbul University Faculty of Medicine in the Department of Undersea and Hyperbaric Medicine were retrospectively evaluated. Principal Component Analysis (PCA) was used to identify the key features associated with the amputation risk in diabetic foot patients within the dataset. Thus, various prediction/classification models were created to predict the "overall" risk of diabetic foot patients. Predictive machine-learning models were created using various algorithms. Additionally to optimize the hyperparameters of the Random Forest Algorithm (RF), experimental use of Bayesian Optimization (BO) has been employed. The sub-dimension data set comprising categorical and numerical values was subjected to a feature selection procedure. Among all the algorithms tested under the defined experimental conditions, the BO-optimized "RF" based on the hybrid approach (PCA-RF-BO) and "Logistic Regression" algorithms demonstrated superior performance with 85% and 90% test accuracies, respectively. In conclusion, our findings would serve as an essential benchmark, offering valuable guidance in reducing such hazards.

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.

Surgical amputation for patients with diabetic foot ulcers: A Chinese expert panel consensus treatment guide

BACKGROUND

Diabetic foot disease is a serious complication of diabetes mellitus. Patients with diabetes mellitus have a 25% lifetime risk for developing a foot ulcer, and between 14% and 24% of patients require a major or minor lower limb amputation due to severe gangrene. However, decisions concerning whether to amputate or whether to perform a major or minor lower limb amputation, and how best to determine the amputation plane remain unclear.

METHODS

To consolidate the current literature with expert opinion to make recommendations that will guide surgical amputation for patients with diabetic foot ulcers. A total of 23 experts experienced in surgical treatment of patients with diabetic foot ulcers formed an expert consensus panel, and presented the relevant evidence, discussed clinical experiences, and derived consensus statements on surgical amputation for patients with diabetic foot ulcers. Each statement was discussed and revised until a unanimous consensus was achieved.

RESULTS

A total of 16 recommendations for surgical amputation for patients with diabetic foot ulcers were formulated. The experts believe that determination of the amputation plane should be comprehensively evaluated according to a patient's general health status, the degree of injury, and the severity of lower limb vasculopathy. The Wagner grading system and the severity of diabetic lower extremity artery disease are important criteria when determining the degree of amputation. The severity of both diabetic foot infection and systemic underlying diseases are important factors when considering appropriate treatment. Moreover, consideration should also be given to a patient's socioeconomic status. Given the complexities of treating the diabetic foot, relevant issues in which consensus could not be reached will be discussed and revised in future.

CONCLUSION

This expert consensus could be used to guide doctors in clinical practice, and help patients with diabetic foot ulcers gain access to appropriate amputation treatment.

Surgical Optimization for Charcot Patients

Reconstruction of the Charcot foot and ankle demonstrates significant challenges to the foot and ankle surgeon. At present, there is limited clear consensus on the best approach for preoperative optimization. The primary aim of Charcot reconstructions is to limit the risk of ulceration by providing a stable plantigrade foot allowing ambulation. The focus of this article is the discussion of modifiable risk factors associated with Charcot reconstruction for preoperative optimization.

The value of administering intravenous antibiotics during haemodialysis in the treatment of diabetic foot infections

OBJECTIVE

People with diabetes who are on haemodialysis (HD) are at a high risk of diabetic foot infections (DFI) and related complications. We explored the value of treating DFI with intravenous (IV) antibiotics during HD.

METHOD

This was an observational study of consecutively treated patients with DFIs with IV antibiotics during HD. Data collected included baseline characteristics, IV antibiotics used, details of multidisciplinary interventions and DFI treatment outcome.

RESULTS

A cohort of 11 patients, mean (±standard deviation) age 62.4±12.7 years, had 15 episodes of treatment with IV antibiotics during HD. Of the patients, six (54.5%) were male and nine (81.8%) had type 2 diabetes. The estimated mean glomerular filtration rate (eGFR) was 11.4±3.9ml/minute. All patients had infected foot ulceration, soft tissue infection, six (54.5%) patients had osteomyelitis, and two (18.2%) had wet gangrene. The commonest IV antibiotic used was vancomycin (10/15 episodes, 66.7%). Other IV antibiotics used were daptomycin and meropenem. In three episodes, oral ciprofloxacin was used with IV antibiotics. The mean duration of antibiotic treatment was 9.2±4.9 weeks. Of the episodes, 11 (73.3%) were treated successfully with IV antibiotics alone and two (13.3%) episodes required minor surgical debridement/amputation. Some 10 (90.9%) members of the cohort had peripheral arterial disease and of those, five (50%) underwent angioplasty during IV antibiotic treatment.

CONCLUSION

HD provides a good opportunity for treatment with IV antibiotics in DFI. This mode of administration of IV antibiotics, along with multidisciplinary intervention, is associated with ulcer healing and resolution of infection in over three-quarters of patients with DFI.

DECLARATION OF INTEREST

The authors have no conflicts of interest to declare.

Clinical outcomes among patients with chronic kidney disease hospitalized with diabetic foot disorders: A nationwide retrospective study

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.

The impact of comorbid chronic kidney disease and diabetes on health-related quality-of-life: a 12-year community cohort study

BACKGROUND

Quality-of-life is an essential outcome for clinical care. Both chronic kidney disease (CKD) and diabetes have been associated with poorer quality-of-life. The combined impact of having both diseases is less well understood. As diabetes is the most common cause of CKD, it is imperative that we deepen our understanding of their joint impact.

METHODS

This was a prospective, longitudinal cohort study of community-based Australians aged ≥25 years who participated in the Australian Diabetes, Obesity and Lifestyle study. Quality-of-life was measured by physical component summary (PCS) and mental component summary sub-scores of the Short Form (36) Health Survey. Univariate and multivariate linear mixed effect regressions were performed.

RESULTS

Of the 11 081 participants with quality-of-life measurements at baseline, 1112 had CKD, 1001 had diabetes and of these 271 had both. Of the 1112 with CKD 421 had Stage 1, 314 had Stage 2, 346 had Stage 3 and 31 had Stages 4/5. Adjusted linear mixed effect models showed baseline PCS was lower for those with both CKD and diabetes compared with either disease alone (P < 0.001). Longitudinal analysis demonstrated a more rapid decline in PCS in those with both diseases.

CONCLUSIONS

The combination of CKD and diabetes has a powerful adverse impact on quality-of-life, and participants with both diseases had significantly poorer quality-of-life than those with one condition.

Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition)

In recent years, as living standards have continued to improve, the number of diabetes patients in China, along with the incidence of complications associated with the disease, has been increasing. Among these complications, diabetic foot disease is one of the main causes of disability and death in diabetic patients. Due to the differences in economy, culture, religion and level of medical care available across different regions, preventive and treatment methods and curative results for diabetic foot vary greatly. In multidisciplinary models built around diabetic foot, the timely assessment and diagnosis of wounds and appropriate methods of prevention and treatment with internal and external surgery are key to clinical practice for this pathology. In 2019, under the leadership of the Jiangsu Medical Association and Chinese Diabetes Society, the writing group for the Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition) was established with the participation of scholars from the specialist areas of endocrinology, burn injury, vascular surgery, orthopedics, foot and ankle surgery and cardiology. Drawing lessons from diabetic foot guidelines from other countries, this guide analyses clinical practices for diabetic foot, queries the theoretical basis and grades and gives recommendations based on the characteristics of the pathology in China. This paper begins with assessments and diagnoses of diabetic foot, then describes treatments for diabetic foot in detail, and ends with protections for high-risk feet and the prevention of ulcers. This manuscript covers the disciplines of internal medicine, surgical, nursing and rehabilitation and describes a total of 50 recommendations that we hope will provide procedures and protocols for clinicians dealing with diabetic foot.

Registry number: IPGRP-2020cn124

Mortality after amputation in dialysis patients is high but not modified by diabetes status

Background

Survival among dialysis patients with diabetes mellitus (DM) is inferior to survival of non-diabetic dialysis patients, probably due to the higher prevalence of diabetes-related comorbid conditions. One could hypothesize that these comorbid conditions also contribute to a decreased survival after amputation in diabetic patients compared with non-diabetic patients on dialysis.

Methods

Data were collected from the Netherlands Cooperative Study on the Adequacy of Dialysis, a multicentre, prospective cohort study in which new patients with end-stage renal disease were monitored until transplantation or death. Amputation rates (incident cases) were calculated in patients with and without DM. The primary endpoint was all-cause survival after first amputation during dialysis therapy in diabetic patients compared with non-diabetic dialysis patients with an amputation. This was formally assessed using interaction analysis (Poisson regression).

Results

During follow-up (mean duration 2.9 years), 50 of the 413 diabetic patients had a new amputation (12.1%), compared with 20 of 1553 non-diabetic patients (1.2%). Amputation rates/1000 person-years were 47.9 [95% confidence interval (CI) 36.3–63.2] and 4.1 (95% CI 2.7–6.4), respectively, for diabetic patients and non-diabetic patients. Amputation increased mortality risk more than 4-fold in patients without diabetes [hazard ratio (HR) 4.6 (95% CI 2.8–7.6)] as well as in patients with diabetes [HR 4.6 (95% CI 3.3–6.4)]. No formal interaction between diabetes and amputation was found (P = 0.12).

Conclusions

Amputation in dialysis patients is associated with a 4-fold increased mortality risk; this mortality risk was similar for diabetes and non-diabetes patients. Importantly, the risk for amputation is 10-fold higher in DM compared with non-diabetic dialysis patients.

Diabetic Foot Ulcer as a Cause of Significant Decline in the Renal Function Among South Indian Population With Type 2 Diabetes: Role of TGF-β1 and CCN Family Proteins

In the present study, a total of 428 South Indian subjects were divided into four different groups, consisting of individuals with type 2 diabetes without any other complications (T2DM), T2DM subjects with stage 2 and 3 diabetic kidney disease (CKD), T2DM subjects with grade 2 or 3 diabetic foot ulcer (DFU) and T2DM subjects having both diabetic kidney disease and diabetic foot ulcer (CKDDFU). The study was conducted ambispectively by comparing the changes in renal function among two consecutive periods, i.e., the period prior to the development of grade 2 and 3 diabetic foot ulcer (retrospectively) and after the development of DFU (prospectively). A gradual and uniform reduction of eGFR was observed throughout the study period in the subjects affected with either CKD or DFU alone. Whereas in subjects with both CKD and DFU, there was a sharp decline in the eGFR during the six months prior to the baseline, i.e., the period in which the development of ulcer and its progression to grade 2 or 3 happened. Remarkable elevations in the levels of TGF-β1 and CCN2 (CTGF), as well as a significant reduction in the level of CCN3 (NOV), were observed in the serum of CKDDFU group subjects, compared to the other groups. Increased production of TGF-β1 in response to the inflammatory stimulus from multiple sites in CKDDFU subjects caused a subsequent down-regulation of CCN3, followed by the activation of a large quantity of CCN2.

The Relationship Between Dialysis Patients' Quality of Life and Caregivers' Quality of Life

Patients on dialysis require caregiving and assistance in their daily lives from family members and/or others for hospital visitation and supervised administration. This places a considerable burden on caregivers, which can in turn influence caregivers' quality of life (QOL). We recruited dialysis patients and their caregivers to elucidate how the QOL of patients relates to that of their caregivers'. Patients completed the EuroQol 5-Dimension scale (EQ-5D) and Kidney Disease Quality of Life-Short Form. Caregivers completed the EQ-5D and Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). We calculated utility index values for the EQ-5D, and physical, mental (MCS), and role-social component summary scores for the SF-36. Compared to national norms, the caregivers of dialysis patients tended to have poor physical health-related QOL but normal mental health-related QOL, as also found with patients. The multivariate analysis revealed that ≥ median dialysis period and ≥ average burden of kidney disease were significantly related to caregiver MCS score (odds ratios; 6.79 and 9.89, respectively). Caregivers tended to have lower physical health-related QOL if their patients had high social QOL, and lower mental health-related QOL during the early stage of the patient's dialysis treatment, and when patients experienced low disease-targeted QOL.

The Effect of Quality of Life on Medication Compliance Among Dialysis Patients

Dialysis treatment is known to lead to reduced quality of life (QOL) among patients. This decreased QOL is believed to influence medication compliance, although this effect has not yet been clarified. In this study, we investigated whether decreased QOL due to dialysis treatment does in fact influence medication compliance. Participants were 92 patients who self-managed their medication and were receiving dialysis treatment at Secomedic Hospital or Chiba Central Medical Center. We surveyed their age, sex, dialysis period, and medication management situation, and administered the EQ-5D and Kidney Disease Quality of Life Instrument-Short Form. A multiple logistic regression analysis with medication compliance as the dependent variable and QOL as the independent variable was conducted. The recovery rate and effective response rate were both 100%. The results indicated that patients with good sleep QOL (mean or above) had higher odds of medication compliance (odds ratio, 3.36; 95% confidence interval, 1.26-8.96; P = 0.016). Therefore, improving the quality of sleep of dialysis patients might help to improve their medication compliance.

Gender Differences on SF-36 Patient-Reported Outcomes of Diabetic Foot Disease

The primary aim of this study was to evaluate the impact of gender on health-related quality of life (HRQOL) using a generic (Short Form-36 [SF-36]) and region-specific (Foot and Ankle Ability Measure [FAAM]) health measurement tool among a matched cohort of male and female patients with diabetes-related foot complications. The HRQOL of 240 patients with diabetic foot disease was measured using the SF-36 and the FAAM surveys. A total of 120 male patients were matched with 120 female patients with the same primary diagnosis, age, type, and duration of diabetes and insulin use. The SF-36 physical component summary (PCS) and mental component summary (MCS) scores were calculated using orthogonal and oblique rotation methods. The median age of the respondents was 54 years (interquartile range = 46-61). No differences in patient characteristics were found between genders. Among the SF-36 subscales, women reported significantly worse physical function ( P = .014) and bodily pain ( P = .021) scores with a trending decrease in general health score ( P = .067). Subsequently, women had worse orthogonal ( P = .009) and oblique PCS scores ( P = .036) than men. However, orthogonal ( P = .427) or oblique ( P = .140) MCS scores did not differ between groups. No significant differences in FAAM scores with respect to gender were appreciated. Our findings suggest that in patients with diabetic foot disease, women tend to report lower physical HRQOL compared with men. In efforts to increase compliance, providers should recognize the impact of gender on patients' perceptions of foot-related complications of diabetes. This knowledge may improve outcomes by adapting more individualized and gender-specific approaches to patients.

Scoring Mental Health Quality of Life With the SF-36 in Patients With and Without Diabetes Foot Complications

The aim of this study was to examine if using orthogonal and oblique factor analysis detect changes in health-related quality of life differently in diabetic patients on the Short Form-36 (SF-36) survey. A total of 155 patients had diabetic foot complications (DFC), and 145 patients had no DFCs. The SF-36 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were calculated using scoring coefficients determined by orthogonal and oblique rotation principle component analyses of the subscales. The DFC group had lower orthogonal ( P < .00001) and oblique PCS scores ( P < .00001). However, despite lower Mental Health subscale scores in the patients with DFCs, orthogonal MCS scores ( P = .156) did not differ. In contrast, the oblique MCS scores reflected the difference in the Mental Health subscale ( P = .0005). Orthogonal and oblique PCS scores did not differ significantly. However, orthogonal MCS scores were significantly higher than oblique MCS scores in those with DFCs ( P = .0004) and without DFCs ( P = .005). The shorter, 12-item SF-12 survey demonstrated similar results. Poorer physical function leads to higher orthogonal MCS scores than if determined by oblique scoring coefficients since Physical Function, Bodily Pain, and General Health are weighted more negatively in orthogonal coefficients when calculating the MCS score. Oblique scoring coefficients may address this issue, but further study is necessary to confirm whether oblique MCS scores accurately represent the mental health of patients with diabetic foot disease.

Assessing Health-Related Quality of Life in Patients With Diabetic Foot Disease: Why Is It Important and How Can We Improve? The 2017 Roger E. Pecoraro Award Lecture

Patient-reported outcomes (PROs) have become an important subject in the area of diabetes-related foot complications. Self-reported health-related quality of life (HRQOL) surveys can provide a generic measure of overall health (global) and can be disease specific (i.e., diabetes) or even region specific (i.e., lower-extremity function). Analysis of PRO measures utilizing validated instruments allows health care providers to determine whether medical and surgical treatments are providing patients with the highest level of outcome possible and are actually improving HRQOL. The 36-item Short Form (SF-36), EuroQol five-dimension questionnaire (EQ-5D-5L), and Foot and Ankle Ability Measure (FAAM) are examples of commonly used HRQOL surveys. Low HRQOL has been associated with higher rates of hospital admission and mortality in patients with diabetes. Previous studies have demonstrated that patients with diabetes-related foot disease have low self-reported physical quality of life but do not typically report low mental quality of life. The impact of mental quality of life may be underestimated in these patients using the SF-36. In this article, we will discuss several widely used outcome instruments used to measure patient HRQOL and the impact of diabetic foot disease on HRQOL. As health care providers, we must continue to adjust and modify our treatments to achieve the best patient outcomes and associated high quality of life. Assessing PROs will become increasingly important as health care systems transition from a volume-based reimbursement model to a value-based model.