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

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)

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.

Dialysis Treatment is an Independent Risk Factor for Foot Morbidity

Aim: To determine the prevalence of foot morbidity among patients with ESRD on dialysis. Methods: A prospective, non-experimental, quantitative time series design was employed. Forty-seven participants were recruited in the study. Medical records were reviewed followed by non-invasive foot assessments which included: Neurological, Arterial, Biomechanical, and Dermatological Assessment. Participants were assessed twice during the study. Results: Foot morbidity was found to be high among participants with ESRD on dialysis. 95.74% of participants presented with foot deformities, 76.60% had skin and nail conditions. 15% of participants had a history of ulceration and amputation. Moreover, active ulceration and history of revascularisation were also observed. Findings demonstrated overall poor foot health and footcare behavior within this population with 40.43% of participants having inappropriate footwear. The majority of participants did not check feet regularly, did not attend to podiatry appointments, and were unable to reach their feet for self-care. The Toe Brachial Pressure Index (TBPI), Spectral Doppler Waveform Analysis, and the Quantitative Sensory Testing (QST) were re-measured at each visit. Monophasic continuous doppler waveforms increased while triphasic waveforms decreased during the study period. Protective sensation did not decrease during the study period. The mean TBPI decreased during the study period. The relationship between the TBPI and duration of dialysis was found to be significant. Both DM and dialysis duration were identified as significant predictors of reduction in TBPI. Conclusion: This study demonstrates a high prevalence of foot morbidity among patients with ESRD on dialysis. This study highlighted the importance of expanding practice by introducing a podiatry service within the renal unit to provide foot screening, foot assessments, and foot care education, with the aim to reduce severe foot complications.

Duration of total contact casting for resolution of acute Charcot foot: a retrospective cohort study

BACKGROUND

Charcot neuroarthropathy (Charcot foot) is a highly destructive joint disease of the foot and ankle. If there is delayed diagnosis and treatment, it can lead to gross deformity, instability, recurrent ulceration and/or amputation. Total contact casting (TCC) is a treatment commonly used to immobilise the foot and ankle to prevent trauma, further destruction and preserve the foot structure during the inflammatory phase. At present, there is limited Australian data regarding the duration of TCC treatment for resolution of acute Charcot foot, and whether there are any patient and clinical factors affecting its duration. Therefore, this study aimed to address these deficiencies.

METHODS

This study presents a retrospective analysis of 27 patients with acute Charcot foot attending for TCC treatment at a high-risk foot service (HRFS) in a large metropolitan health network in Melbourne, Australia. Over a three-year period, data were retrospectively collected by reviewing hospital medical records for clinical, demographic, medical imaging and foot examination information. To explore between-group differences, independent samples t-tests, Mann-Whitney U tests, Chi-square tests, and/or Fisher's exact tests were calculated depending on data type. To evaluate associations between recorded variables and duration of TCC treatment, mean differences, odds ratios (OR) and 95% confidence intervals were calculated.

RESULTS

Mean age was 57.9 (SD, 12.6) years, 66.7% were male, 88.9% had diabetes, 96.3% had peripheral neuropathy, and 33.3% had peripheral arterial disease. Charcot misdiagnosis occurred in 63.0% of participants, and signs and symptoms consistent with acute Charcot foot were present for a median of 2.0 (IQR, 1.0 to 6.0) months prior to presenting or being referred to the HRFS. All participants had stage 1 Charcot foot. Of these, the majority were located in the tarsometatarsal joints (44.4%) or midfoot (40.7%) and were triggered by an ulcer or traumatic injury (85.2%). The median TCC duration for resolution of acute Charcot foot was 4.3 (IQR, 2.7 to 7.8) months, with an overall complication rate of 5% per cast. Skin rubbing/irritation (40.7%) and asymmetry pain (22.2%) were the most common TCC complications. Osteoarthritis was significantly associated with a TCC duration of more than 4 months (OR, 6.00). Post TCC treatment, 48.1% returned to footwear with custom foot orthoses, 25.9% used a life-long Charcot Restraint Orthotic Walker, and 22.2% had soft tissue or bone reconstructive surgery. There were no Charcot recurrences, however, contralateral Charcot occurred in 3 (11.1%) participants.

CONCLUSIONS

The median TCC duration for resolution of acute Charcot foot was 4 months, which is shorter or comparable to data reported in the United Kingdom, United States, Europe, and other Asia Pacific countries. Osteoarthritis was significantly associated with a longer TCC duration. The findings from this study may assist clinicians in providing patient education, managing expectations and improving adherence to TCC treatment for acute Charcot neuroarthropathy cases in Australia.

Lower Limb Ulcer Associated with Peritonitis in Patients Undergoing Peritoneal Dialysis

Purpose

Peritoneal dialysis (PD)-related peritonitis and lower limb ulcer are the important complications in patients undergoing PD. Although the association between lower limb ulcer and peritonitis in patients undergoing PD is unclear, based on our clinical experience and the clinical importance of the complications in patients undergoing PD, we hypothesized that lower limb ulcer is associated with peritonitis in patients on PD.

Patients and Methods

In this single center, retrospective cohort study, we studied 87 patients who started undergoing PD at our hospital from April 2015 to March 2020. We compared these 8 patients with lower limb ulcer with the other 79 patients without lower limb ulcer. We compared between the patients in the objection period of this study about peritonitis using Log rank test, and used the unpaired t-test and Fisher’s exact test to compare the clinical factors between the two groups. Moreover, we used univariate and multivariate logistic regression analyses to study the association of PD-related peritonitis with the clinical factors.

Results

The period developed first peritonitis of the patients on PD with lower limb ulcer was significant shorter than those without lower limb ulcer in Log rank test (P = 0.011). The Fisher’s exact test and unpaired t-test showed that the difference in the prevalence of PD-related peritonitis (P = 0.009), peritonitis/patient years (P = 0.036), the BMI (P = 0.007) and icodextrin (P = 0.001) were significant. Lower limb ulcer had significant associations with peritonitis in patients on PD in both univariate [odds ratio (OR) 8.461, 95% confidence interval (CI) 1.854–45.60, P = 0.006] and multivariate [OR 7.169, 95% CI 1.519–39.480, P = 0.013] logistic regression analysis.

Conclusion

In conclusion, lower limb ulcer may be associated with peritonitis in patients undergoing PD. Further large-scale, prospective studies are required to confirm these results.

Infrared dermal thermometry is highly reliable in the assessment of patients with Charcot neuroarthropathy

BACKGROUND

Charcot neuroarthropathy (Charcot foot) is a serious limb-threatening complication most commonly seen in individuals with diabetic peripheral neuropathy. Although dermal thermometry is widely used by clinicians to assist in the diagnosis, monitoring, and management of the disease, there is limited high-quality evidence to support its reliability. Therefore, this study investigated the intra-rater and inter-rater reliability of infrared dermal thermometry in patients with Charcot neuroarthropathy.

METHODS

We collected clinical, demographic, health status, and foot examination information on 32 adults with Charcot neuroarthropathy from a metropolitan high-risk foot service in Melbourne, Australia. Infrared dermal thermometry assessments were conducted by two independent raters at 10 anatomical sites of the Charcot foot using both a (i) touch and (ii) non-touch technique. Intra-rater and inter-rater reliability of the two assessment techniques were evaluated using intra-class correlation coefficients (ICCs), limits of agreement, standard error of measurement, and minimal detectable change statistics.

RESULTS

Mean age was 59.9 (standard deviation [SD], 10.5) years, 68.8% were male, average duration of diabetes was 20.6 (SD, 15.1) years, 71.9% had type 2 diabetes, 93.8% had peripheral neuropathy, 43.8% had peripheral arterial disease, and 50% had previous foot ulceration. Charcot foot most commonly affected the tarsometatarsal joints (38.9%), had a median duration of 2.8 (interquartile range [IQR], 1.3 to 5.9) months, and a large proportion were being treated with total contact casting (69.4%). Overall, there was good to excellent intra-rater and inter-rater relative reliability for the 'touch' technique (ICC, 0.87 to 0.99; ICC, 0.83 to 0.98, respectively), and excellent intra-rater and inter-rater relative reliability for the 'non-touch' technique (ICC, 0.93 to 0.99; ICC, 0.91 to 0.99, respectively). In addition, measurement error was found to be relatively low across the 10 anatomical sites.

CONCLUSIONS

Infrared dermal thermometry can now be used with confidence in clinical and research settings to provide a reliable assessment of skin temperature in patients with Charcot neuroarthropathy, using either a touch or non-touch technique at 10 commonly used testing sites. A non-touch technique, however, was observed to have slightly higher reliability indicating it may be associated with less measurement error than the touch technique.

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

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.

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

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.

Does the Start of Dialysis Initiate a Period of Increased Risk of Ulceration or Amputation?

BACKGROUND

Dialysis therapy is associated with an increased incidence of lower-extremity wounds and amputations. We compared the incidence of foot ulcers and amputations before and after the start of dialysis.

METHODS

We evaluated 150 consecutive diabetic patients receiving dialysis and compared the incidence of foot complications 30 months before and after initiation of hemodialysis. We used claims data for diabetes, ulceration, and dialysis and abstracted medical records to verify diagnoses and dates of ulcers and amputations. We compared initial and cumulative ulcer/amputation incidence to account for multiple events in the same person over time. We used the same formula to determine the incidence rate difference and 95% confidence intervals (CIs) to compare new ulcers and amputations during the study.

RESULTS

There was no significant difference in the incidence of first foot ulcers before (91.7 per 1,000 patient-years; 95% CI, 73.7-112.3 per 1,000 patient-years) and after (82.7; 95% CI, 65.7-102.3) the start of hemodialysis. The incidence of cumulative ulcers was significantly higher before (304.0 per 1,000 patient-years; 95% CI, 270.8-340.2) compared with after (210.7 per 1,000 patient-years; 95% CI, 183.0-240.9) dialysis. There was no difference in the incidence of first amputation before (29.3 per 1,000 patient-years; 95% CI, 1 9.4-41.7 per 1,000 patient-years) and after (37.3 per 1,000 patient-years; 95% CI, 19.4-41.7 per 1,000 patient-years) dialysis or in the cumulative incidence of amputations before (61.3 per 1,000 patient-years; 95% CI, 46.7-8.4 per 1,000 patient-years) and after (58.7 per 1,000 patient-years; 95% CI, 44.5-75.5 per 1,000 patient-years) dialysis.

CONCLUSIONS

There was no increase in the incidence of ulcers or amputations after beginning hemodialysis.

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.