Increased risk of lower-extremity amputation among Caucasian diabetic patients on dialysis

Analysis of the Influence of Diabetic Nephropathy in Patients with Diabetic Foot Osteomyelitis

This study analyzed the influence of diabetic nephropathy on the healing prognosis after conservative surgery in diabetic foot osteomyelitis (DFO). A retrospective observational study was carried out between January 2021 and December 2022 and involved 278 outpatients with a diagnosis of DFO at a specialized diabetic foot unit, including 74 (26.62%) patients with DN (group 2) and 204 (73.38%) patients without DN (group 1). There were 266 (95.70%) ulcers on the forefoot, 8 (2.90%) on the midfoot, and 4 (1.45%) on the hindfoot (p = 0.992). The healing rates were 85.1% (n = 63) for group 2 and 81.3% (n = 165) for group 1 (p = 0.457). When exploring the influence of DN on the risk of delayed ulcer healing, the results did not show a significant effect [12 (6; 28) weeks among patients with DN vs. 12 (6; 21) weeks among patients without DN; p = 0.576]. No significant differences were observed in complications, with one (2.59%) death occurring in group 1 (p = 0.296) and three minor amputations being performed in both groups [two (5.13%) amputations in group 1 vs. one amputation (9.09%) in group 2; p = 0.217]. Bone cultures were performed for a total of 190 patients (133 in group 1 and 57 in group 2). Of these, 176 positive bone cultures were isolated: 71 positive bone cultures (57.7%) were monomicrobial cultures in group 1, with 30 (56.6%) in group 2. There were 52 (42.3%) that had at least two microorganisms in group 1, and 23 (43.4%) in group 2 (p = 0.890). The most frequently prescribed oral antibiotic was amoxicillin/clavulanate (43.89%), followed by levofloxacin (28.4%), and trimethoprim/sulfamethoxazole (14.7%). This study shows that DN does not have a significant influence on the healing prognosis of patients with DFO after conservative surgery.

Risk Factors and Surgical Outcomes of Diabetic Foot in Diabetic Patients at King Fahad University Hospital

Background: Diabetes mellitus affects a large number of the population worldwide. One of the most important complications is diabetic foot ulcers, which are debilitating to the patient and the health care system.

Objectives: To assess the risk factors leading to diabetic foot complications and the surgical outcome of management of patients affected by diabetic foot at King Fahd University Hospital.

Methods: This is a retrospective case series study conducted at King Fahd University Hospital. The study included 52 patients who were admitted from the period 2007 to 2017 with cases of diabetic foot ulcers. The study includes a review of medical charts for diabetic foot patients including demographics, diabetic profile, associated comorbidities, clinical signs, laboratory investigations and surgical outcome.

Results: Our study shows that diabetic foot patients had comorbidities like hypertension at 69.2% and hyperlipidemia at 55.8%. Regarding the association between comorbidities and surgical outcomes, we did not find any significance. Furthermore, we found that patients with gangrene were more likely to undergo amputation. Patients who underwent amputation had hemoglobin A1c (HbA1c) of 10.3 ± 2.4% and random blood sugar (RBS) of 259 ±107 mg/dl, indicating poor diabetic control.

Conclusion: Diabetic foot is the result of poor blood sugar control. Surgical intervention plays an important role in the management of diabetic foot. Depending on the presentation, patients may undergo surgical debridement, revascularization, or amputation. We found that patients who developed gangrene were more likely to undergo amputation.

Diabetic foot disease in subjects with End-stage renal Disease: A nationwide study over 14 years highlighting an emerging threat

AIMS

To disclose prevalence, demographic, foot characteristics as well as management and lower-extremity amputations (LEAs) of subjects with end-stage renal disease (ESRD) on diabetic foot diseases (DFDs).

METHODS

Data were derived from the Taiwan National Health Insurance Research Database between 2004 and 2017. DFDs were defined as ulcers, infections, or severe peripheral arterial diseases (PADs) in patients with type 2 diabetes. Clinical characteristics were analyzed between subjects with and without ESRD.

RESULTS

Subjects with ESRD have increased impacts on the DFD population either from annual prevalence (2.7 % to 10.42 %, P for trend < 0.001), or proportional representation in LEAs (7.91 % to 26.37 %, P < 0.001) over 14 years. The annual trends for major-LEAs rates have decreased in both subjects with and without ESRD (13.67 % to 5.82 % and 3.48 % to 1.47 %, both P < 0.001). Notably, the concomitant increase of endovascular treatments (EVTs) (7.09 % to 29.41 %, P < 0.001) was associated with the decrease of major-LEAs (P for interaction < 0.001) in subjects with ESRD.

CONCLUSIONS

As the annual prevalence of subjects with ESRD has increased 3.9-fold over years, they now account for more than 30% of annual major-LEA of the total DFD population. Interdisciplinary team approach and aggressive EVTs might reduce major-LEAs in these patients.

Kidney transplantation reduces the risk of chronic limb threatening ischemia and amputation among patients with end-stage renal disease on hemodialysis

OBJECTIVE

This study aimed to analyze the risk of chronic limb threatening ischemia (CLTI) or amputation among patients with end-stage renal disease (ESRD) entering a hemodialysis (HD) program and to evaluate the protective effect associated with kidney transplantation (KT).

DESIGN, MATERIAL AND METHODS

Retrospective cohort of all consecutive ESRD patients entering into a HD program at our institution between 2000 and 2010. Collected variables included baseline characteristics (pre-entry in hemodialysis), time on HD program, KT and the composite outcome of chronic limb threatening ischemia or need for any amputation (CLTI/AMP). Patients with previous symptomatic peripheral arterial disease or amputation were excluded.

RESULTS

The study group included 336 patients (mean age 63 years, 66% male). The mean follow up was 6.7 years with an average time on HD of 4.2 years. Ninety two patients (27.4 %) underwent transplantation. CLTI free survival rates were 90.3 % and 82.6 % at 5 and 10 years, respectively. The episodes of CLT involved 28 revascularization procedures (17 endovascular and 11 open surgeries), 18 minor amputations and 20 major amputations. KT was associated with a protective effect over the development of CLTI (HR: 0.065; CI 95% 0.02-0.21) after adjustment for confounding factors. The long-term survival of non-transplanted patients was 45 % and 15 % at 5 and 10 years, respectively and the long-term survival in transplanted patients was 89% and 80% at 5 and 10 years, respectively; but decreased to 47 % at 1 year and 18.2 % at 5 years once CLTI occurred.

CONCLUSION

Patients on HD program show a notorious risk of chronic limb threatening ischemia or amputation over time. Once this complication occurs, patient's survival is markedly reduced. Transplantation confers an independent protective effect over the development of chronic limb threatening ischemia or amputation.

Narrative Review of the Relationship Between CKD and Diabetic Foot Ulcer

Diabetic foot ulcer (DFU) and chronic kidney disease (CKD) are 2 significant complications of diabetes mellitus (DM). Up to 40% of patients with DM are expected to also develop CKD, and 19% to 34% will suffer from DFU during their lifetimes. However, data on the link between podiatric risk and the extent of CKD are scarce. Neuropathy, a key element of the International Working Group on the Diabetic Foot (IWGDF) classification, nevertheless appears to be related to the CKD stage. The incidence of DFU and its poor evolution also appear to be linked to the stage of CKD, with mortality reaching its peak in patients with end-stage renal disease (ESRD). Whatever, the decrease in the rate of diabetic foot amputation observed worldwide, especially for major amputations, is also observed in patients with ESRD. Specific actions taken for patients undergoing dialysis seems to improve the DFU prognosis. CKD and DFU share a number of elements of pathophysiology, the first of which is peripheral arterial disease (PAD). Uremic neuropathy and nutritional status also seem to create a link between the development of the 2 complications. This literature review provides an update on the complex and dynamic relationship between DFU and CKD. It examines the epidemiologic link between CKD and diabetic foot risk, CKD and DFU occurrence, and CKD and DFU prognosis. It focuses on the pathophysiological links between these 2 complications. Finally, it highlights the actions taken to improve management in the ESRD population that have reduced the rate of major amputations in this population by more than half.

Improved outcomes in patients with diabetic foot ulcers despite of differences in baseline characteristics

The incidence of diabetes is increasing worldwide with concomitant raising number of patients with diabetic foot disease. Diabetic foot disease treatment has received more attention in the past decades, culminating in the creation of multidisciplinary outpatient clinics, but at the same time, complexity of patients seems to have increased. The aim of this article is to study differences in patient characteristics and outcomes (ulcer healing and ulcer-free survival days) in patients with a diabetic foot ulcer in two prospective cohorts with 15 years in between. Prospective cohort study of all patients in one diabetic foot centre of expertise in 2003-2004 and 2014-2018. Clinical outcomes were determined after a follow-up period of 12 months. Outcomes were differences in baseline characteristics and comorbidities, and differences in ulcer-related outcomes between both cohorts. We included all consecutive diabetic foot ulcer patients from our centre for the period 2003-2004 (n = 79) and 2014-2018 (n = 271). Age (67.0 ± 14.3 vs. 71.6 ± 11.5, p = 0.003) and prevalence of end-stage renal disease (1.3% vs. 7.7%, p = 0.036) were significantly higher in the more recent population. The more recent population had higher healing rate (53.2% vs. 76.4%, p < 0.001), higher median ulcer-free survival days once an ulcer had healed [173 days (IQR 85.3-295.5) vs. 257.0 (IQR 157.0-318.0), p = 0.026], and fewer minor amputations (20.3% vs. 8.1%, p = 0.002). People with diabetic foot ulcers treated in 2014-2018 were older and more frequently diagnosed with ESRD, compared to this population in 2003-2004, while other characteristics were similar; ulcer-related outcomes were better.

Knowledge and Practice on Diabetic Foot Self-Care and Associated Factors Among Diabetic Patients at Dessie Referral Hospital, Northeast Ethiopia: Mixed Method

INTRODUCTION

Diabetic foot ulcer is a serious and disabling complication of diabetes mellitus that consists of lesions in the deep tissues resulting in lower extremity amputations. The incidence of diabetic foot ulcers has increased due to an increased prevalence of diabetes mellitus. This study assessed the knowledge and practice of diabetic foot self-care among diabetic patients attending Dessie referral hospital.

METHODS

A facility-based explanatory sequential mixed method was used from April 03/2019 to May 09/2019. The quantitative method employed an institutional-based cross-sectional study design using a structured questionnaire. A simple random sampling technique was employed to select the study participants. Descriptive and inferential statistics were made using the statistical package for social sciences version 20. Then, a phenomenological study was employed among key informants and content analysis was performed.

RESULTS

Sixty-eight (19.8%) of patients with diabetes developed complication, among them 97 (28%) had foot ulcer. Nearly two-third (217 (61.3%): 95% CI (57.6-68.3%)) and 134 (39%; 95% CI:34.3-45.1%) of patients with diabetes had good knowledge and practice on diabetic foot self-care, respectively. Diabetic nephropathy ((AOR): 0.03, 95% CI (0.00-0.27)) was associated with knowledge on foot self-care. Practice of foot self-care was associated with female ((AOR: 2.07, 95% CI (1.04-4.12)), age 21-30 ((AOR: 6.42, 95% CI (1.54-26.8)), 31-40 years ((AOR: 7.4, 95% CI (1.42-39.05)), 41-50 years ((AOR: 8.4, 95% CI (1.4-50.6)), single ((AOR: 0.35, 95% CI (0.150-0.81)), living in rural ((AOR: 0.31, 95% CI (0.18-0.545)) and no comorbidity ((AOR: 0.406, 95% CI (0.18-0.88)). Key informants were not compliant, confused and negligent to foot self-care.

CONCLUSION

Nearly two-third and more than one-third of patients with diabetes had good knowledge and practice on diabetic foot self-care, respectively. Patients lack proper knowledge regarding self-care and how it is practiced. Patient education and proper management of diabetic foot ulcers are recommended to reduce, delay, or prevent complications.

Transmetatarsal Amputation Outcomes When Utilized to Address Foot Gangrene and Infection: A Retrospective Chart Review

A transmetatarsal amputation (TMA) is a widely utilized procedure to address foot gangrene and infection. Although a common procedure, so too are the associated complications. The purpose of this review was to evaluate TMA healing and to explore if there were associated variables correlating with healed vs. failed to heal TMA sites. To do so, the Medical Department Orthopaedics Division Electronic Database, West Virginia University, College of Medicine was retrospectively searched to identify all cases of TMAs (CPT code 28805) during the period of January 2011 through June 2019, and those variables that might impact TMA healing. Then both univariate and multivariable logistic regression analyses were performed to investigate the associations between these variables and TMA healing, and sensitivity analyses were also conducted to determine if the results resisted the influence of one unmeasured confounder. There were 39 patients (41 procedures) who would undergo a TMA. The mean average patient age was 53 (range 29-73) years old. The median postoperative follow-up period was 617 (range 199-3632) days. TMA mortality data revealed 0 deaths at 30 days, 2 (5.1%) at 1 year, 8 (20.5%) at 5 years. In our study, 29 (70.7%) of the TMAs would achieve primary healing at a median of 31 (range 16-253) days. When comparing the TMA healed group to the failed to heal group the following independent variables were considered: diabetes mellitus, HgA1c >8%, neuropathy, peripheral arterial disease, chronic kidney disease, active smoking status, previous surgery, and a clean margin metatarsal bone pathology specimen positive for osteomyelitis. Of the aforementioned, only neuropathy (odds ratio [OR] = 0.056, 95% confidence interval [CI] = 0-0.501, p = .0062) and positive bone margin (OR = 0.144, 95% CI = 0.022-0.835, p = .0385) were found to be significant in univariate logistic regression analysis. In multivariable logistic regression analyses where the potential confounders age, gender, and body mass index were accounted for, of the 8 independent variables of interest, only neuropathy (OR = 0.037, 95% CI = 0-0.497, p = .0036) remained significantly associated with the healing status. Neuropathy was present in 17 (58.6%) of the healed TMAs and in 12 (100%) of the failed to heal TMAs. However, the positive bone margin failed to reach statistical significance (OR = 0.079, 95% CI = 0-1.39, p = .1331). Results from another multivariable logistic regression model where a quadratic term for age was added revealed that positive bone specimen correlated with the TMA healing status with significance (OR = 0.051, 95% CI = 0.001- 0.560, p = .0404). A positive clean margin bone specimen was found in 3 (10.3%) of the healed TMAs and in 4 (44.4%) of the failed to heal TMAs. The sensitivity analysis where current ulceration was used as an unmeasured confounder indicated that the results regarding the association between neuropathy or positive bone margin and TMA healing, though inconclusive, resisted the influence of this unmeasured confounder. Hopefully these findings will be a beneficial addition to the current TMA literature and as such, further assist with informed surgical decision making.

Sodium-Glucose Cotransporter 2 Inhibitors and the Risk of Below-Knee Amputation: A Multicenter Observational Study

OBJECTIVE

Reports of amputations associated with sodium-glucose cotransporter 2 (SGLT2) inhibitors have been inconsistent. We aimed to compare the risk of below-knee amputation with SGLT2 inhibitors versus dipeptidyl peptidase 4 (DPP-4) inhibitors among patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

This multicenter observational study used administrative health care databases from seven Canadian provinces and the U.K. Incident SGLT2 inhibitor users were matched to DPP-4 inhibitor users using a prevalent new-user design and time-conditional propensity scores. Cox proportional hazards models were used to estimate site-specific adjusted hazard ratios (HR) and corresponding 95% CIs of incident below-knee amputation for SGLT2 inhibitor versus DPP-4 inhibitor users. Random effects meta-analyses were used to pool the site-specific results.

RESULTS

The study cohort included 207,817 incident SGLT2 inhibitor users matched to 207,817 DPP-4 inhibitor users. During a mean exposed follow-up time of 11 months, the amputation rate was 1.3 per 1,000 person-years among SGLT2 inhibitor users and 1.5 per 1,000 person-years among DPP-4 inhibitor users. The adjusted HR of below-knee amputations associated with SGLT2 inhibitor use compared with DPP-4 inhibitor use was 0.88 (95% CI 0.71-1.09). Similar results were obtained in stratified analyses by specific SGLT2 inhibitor molecule.

CONCLUSIONS

In this large multicenter observational study, there was no association between SGLT2 inhibitor use and incident below-knee amputations among patients with type 2 diabetes compared with DPP-4 inhibitor use. While these findings provide some reassurance, studies with a longer duration of follow-up are needed to assess potential long-term effects.

Cat Rearing: A Potential Risk of Fulminant Sepsis Caused by <b><i>Capnocytophaga canimorsus</i></b> in a Hemodialysis Patient

Capnocytophaga canimorsus is a commensal organism colonized in oral flora of dogs and cats and causes severe sepsis through bite wound in immunocompromised patients. To date, hemodialysis has not been reported as a risk of C. canimorsus infection. A 75-year-old woman with end-stage renal disease secondary to hypertension suddenly developed septic shock. She reared 6 cats in her home, but no bite or scratch wound was found on her body. She was empirically treated with piperacillin-tazobactam and temporally received continuous hemodiafiltration. On the fifth day after sampling, blood culture revealed C. canimorsus as the cause of sepsis. After 4 weeks of antibiotic therapy targeting this organism, she recovered from the sepsis and was discharged on the 109th hospitalization day. Hemodialysis patients may be vulnerable to invasion into the blood stream by C. canimorsus due to the presence of punctures in their skin and the impaired immune function associated with uremia. Physicians should consider this organism as a cause of sepsis in hemodialysis patients who rear dogs or cats even in the absence of apparent bite wounds.

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.

Trends of Nontraumatic Lower-Extremity Amputation in End-Stage Renal Disease and Diabetes: United States, 2000-2015

OBJECTIVE

Nontraumatic lower-extremity amputation (NLEA) is a complication of end-stage renal disease (ESRD) and diabetes. Although recent data show that NLEA rates in the U.S. ESRD population are declining overall, trends in diabetes and diabetes subgroups remain unclear.

RESEARCH DESIGN AND METHODS

We estimated annual rates of NLEA hospitalizations during 2000-2015 among >2 million adults (≥18 years) with ESRD from the U.S. Renal Data System. Age, sex, and race-adjusted NLEA rates were stratified by diabetes status, age, sex, race, and level of amputation (toe, foot, below the knee, and above the knee). Time trends were assessed using Joinpoint regression with annual percent changes (APC) reported.

RESULTS

Among adults with diabetes, NLEA rates declined 43.8% between 2000 and 2013 (from 7.5 to 4.2 per 100 person-years; APC -4.9, P < 0.001) and then stabilized. Among adults without diabetes, rates of total NLEAs declined 25.5% between 2000 and 2013 (from 1.6 to 1.1; APC -3.0, P < 0.001) and then stabilized. These trends appear to be driven by a slowing or stagnation in declines of minor NLEAs (toe and foot) in more recent years, while major NLEAs (above the knee) continue to decline.

CONCLUSIONS

Despite an initial period of decline, this analysis documents a stall in progress in NLEA trends in recent years in a high-risk population with both ESRD and diabetes. Increased attention to preventive foot care in the ESRD population should be considered, particularly for those with diabetes.

Factors affecting lifespan following below-knee amputation in diabetic patients

INTRODUCTION

Untreatable foot problems in diabetics may require lower extremity amputation, which has a high level of patient mortality. This high mortality rate is worse than most malignancies. The present study aimed to identify parameters that can be used to estimate survival in DM patients undergoing below-knee amputations for diabetic foot problems.

MATERIALS AND METHODS

A total of 470 patients (299 males, 171 females) with a mean age of 64.32 years who underwent below-knee amputation for diabetic foot problems between 2004 and 2014 were enrolled in the study. The length of time from the operation to time of death was recorded in days. Patient details were obtained, including age during surgery, BMI, oral antidiabetic and insulin usage, dialysis therapy history, lower extremity endovascular intervention, previous amputation at the same extremity, the need for stump revision surgery during follow-up, and above-knee amputation at the same site. Biochemical test results of pre-operative HbA1c, ESR, and levels of CRP, BUN, and creatinine were also obtained.

RESULTS

A total of 333 patients (70.9%) died and 137 (29.1%) survived post-surgery. Survival rates were 90% in the first 7 days, 84% in the first 30 days, and 64% after the first year. Patient median life expectancy post-surgery was 930 ± 106 days. Hemodialysis treatment (p = 0.001), endovascular intervention (p = 0.04), sex (p = 0.004), age (p = 0.001), BUN level (p = 0.001), and duration of insulin use (p = 0.003) were shown to be effective predictors of mortality.

CONCLUSIONS

Life expectancy is low (<3 years) in DM patients requiring below-knee amputations for untreatable foot problems. Survival could be predicted by duration of insulin use, age, sex, and renal insufficiency.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

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.

Clinical outcomes and quality of life in hemodialysis diabetic patients versus non-diabetics

Background

Diabetes is the leading cause of end stage renal disease (ESRD) worldwide.

Objectives

We compared the clinical outcomes in diabetic patients on hemodialysis (HD) with non-diabetics.

Patients and Methods

Adult maintenance HD patients (N= 532) from 9 HD facilities were enrolled to this prospective cohort study in September 2012. Causes of death, hospitalization, and HD exit were recorded in a median 28 months follow up period.

Results

Forty-one percent of patients were diabetic. Diabetic patients compared to non-diabetics had significantly higher age (62.2 ± 11.2 versus 53.1 ± 16.7 years), lower dialysis duration (median: 23 versus 30 months), more cardiovascular comorbidities (64% versus 28%) , higher C-reactive protein (CRP) levels (median: 3.80 versus 2.25 mg/L), lower serum albumin (3.86 ± 0.35 versus 3.93 ± 0.35 g/dL), lower intact parathyroid hormone (iPTH) (median: 272 versus 374 ρg/mL), higher serum triglyceride (167 ± 91 versus 139 ± 67 mg/dL) and low density lipoprotein (LDL) (82.5 ± 24.5 versus 77.5 ± 23.8 mg/dL), and worse short form health survey (SF36) score (45.7 ± 20.9 versus 52.7 ± 20.5). Annual admission rate was higher in diabetics (median: 0.86 versus 0.43) and diabetic foot involved 16% of their admissions. Transplantation rate was 4 and 9 per 100 patient years in diabetics and non-diabetics, respectively. Death rate was two folds higher in diabetics (24 versus 12 per 100 patient years). Cardiovascular diseases ( ± infections/other causes) comprised 80.5% of death in diabetics and 54.5% in non-diabetics. In Cox regression proportional hazard multivariate analysis, hazard risk of death in diabetics was 1.9 times higher than non-diabetics.

Conclusions

Clinical outcomes and health related quality of life (HRQOL) are much worse in diabetic compared to non-diabetic HD patients mainly due to more frequent of cardiovascular diseases (CVDs).

Incidence and Clinical Significance of Heterotopic Ossification After Partial Ray Resection

Heterotopic bone growth is a common finding after partial foot amputation that can predispose to recurrent wounds, osteomyelitis, and reamputation. Heterotopic ossification is the formation of excessive mature lamellar bone in the soft tissues adjacent to bone that is exacerbated by trauma or surgical intervention. The relevance of heterotopic ossification is dependent on its anatomic location. Its occurrence as a sequela of partial foot amputation can lead to prominence on the plantar aspect of the foot that can predispose the patient to recurrent neuropathic ulceration or preclude appropriate wound healing. Reulceration puts the high-risk patient who has already undergone local amputation at greater risk of recurrent infection and further amputation. The present study aimed to assess the incidence and risk factors for heterotopic ossification to further evaluate its role in partial foot amputation. A retrospective analysis of 72 consecutive patients who had undergone partial metatarsal resection was performed, with 90% of the cohort having peripheral neuropathy and 88% diabetes mellitus. Our findings revealed a heterotopic ossification incidence of 75% diagnosed radiographically. The initial onset of heterotopic ossification was not appreciated >10 weeks postoperatively. Ten patients (18.5%) exhibited heterotopic ossification-associated ulceration. The incidence of heterotopic ossification was 30% less in patients with peripheral vascular disease. These results indicate that heterotopic ossification is a common sequela of partial ray resection in an already high-risk patient population. The perioperative use of pharmacologic or radiation prophylaxis in an attempt to minimize amputation-related morbidity should be considered.

Implications of foot ulceration in hemodialysis patients: a 5-year observational study

Foot ulceration (FU) remains a serious concern for patients worldwide. We analyzed the incidence, risk factors, and outcome of FU in hemodialysis (HD) patients. A retrospective cohort study was conducted for 252 HD patients who were followed up for 5 years. Patients were categorized according to whether they developed FU or not. The FU group (17%) was older and had significantly higher incidence of nephropathy, retinopathy, peripheral (PAD), coronary artery disease (CAD), and diabetes mellitus (DM) as compared to no-FU group. FU group had higher frequency of major amputation (P = 0.001) and HD vascular access (P = 0.01). Patients with combined DM and PAD had a 10-fold increased risk of FU in comparison to those who had DM alone. Presence of PAD was the main independent predictor for development of FU in HD with an adjusted odd ratio (aOR) of 16.0 (95% CI: 4.41-62.18; P = 0.001). After adjusting for age, sex, and CAD, predictors for mortality were PAD (aOR 4.3), FU (aOR 3.6), and DM (aOR 2.6). FU is common in HD patients regardless of DM. However, the presence of PAD is significantly associated with more FU and mortality in HD. HD patients need intensive foot care and warrant progressive modification of vascular risk factors.

High serum C-reactive protein level predicts mortality in patients with stage 3 chronic kidney disease or higher and diabetic foot infections

Background

Diabetic patients are predisposed to foot infections because of vascular insufficiency and peripheral neuropathy. Diabetic foot infection is a common cause of mortality and lower extremity amputations (LEAs) in patients with chronic kidney disease (CKD). We evaluated the risk factors for mortality and LEAs in patients with stage 3 CKD or higher with diabetic foot infections.

Methods

We retrospectively evaluated a cohort of 105 CKD patients with diabetic foot infections between July 1998 and December 2011. We reviewed their demographic characteristics and laboratory parameters to evaluate the risk factors for mortality and amputations at 24 weeks after diagnosis of a diabetic foot infection.

Results

The mortality of the 105 enrolled CKD patients was 21% at 24 weeks after the diagnosis of a diabetic foot infection. Cox proportional regression analyses revealed that age 60 years or older [odds ratio (OR) 3.03, 95% confidence interval (CI) = 1.02-9.02, P = 0.047] and initial serum C-reactive protein (CRP) level ≥ 3 mg/dL (OR 3.97, 95% CI = 1.17-13.43, P = 0.027) were independent risk factors for mortality at 24 weeks. Twenty-four patients (23%) underwent LEAs. On Cox proportional regression analyses, peripheral vascular disease (OR=4.49, 95% CI=1.98–10.17, P=0.01) and cerebrovascular accident (OR 2.42, 95% CI=1.09–5.39, P=0.03) were independently associated with LEAs.

Conclusion

This study showed that age and serum CRP level, were independent risk factors for mortality at 24 weeks in patients with stage 3–5 CKD with diabetic foot infections. Peripheral vascular disease and cerebrovascular accident were significantly associated with LEAs.

Reamputation after minor foot amputation in diabetic patients: risk factors leading to limb loss

The prevalence of lower extremity reamputation in diabetic patients has been well-documented. We sought to determine the risk factors for major lower extremity amputation (LEA) after minor foot amputation in diabetic patients. We studied 163 diabetic patients who had undergone an initial minor foot amputation and then had undergone at least 1 subsequent major or minor LEA. The patients were separated into a minor LEA group (initial minor LEA followed by at least 1 subsequent minor LEA) and a major LEA group (initial minor LEA followed by at least 1 subsequent major LEA). We then studied the possible risk factors for both groups. The possible risk factors analyzed were age, glycemic control, kidney function, previous kidney or kidney-pancreas transplantation, smoking history, and presence and severity of peripheral arterial disease (PAD). No statistical significance was found between the 2 groups for hemoglobin A1c, smoking status, chronic kidney disease, end-stage renal disease requiring dialysis, kidney or kidney-pancreas transplantation, or vascular intervention (peripheral arterial bypass). In the minor group, 22.23% had severe PAD. In the major group, 71.15% had severe PAD. This was statistically significant (p < .001). The average interval to major amputation in those without PAD, mild to moderate PAD, and severe PAD was 1,180.9, 591.0, and 559.6 days, respectively. This demonstrates the importance of assessing the peripheral vascular status in all diabetic patients with minor LEA. Early referral to a vascular surgeon might delay (or prevent) major LEA.

Long-term prognosis of diabetic foot patients and their limbs: amputation and death over the course of a decade

OBJECTIVE

There is a dearth of long-term data regarding patient and limb survival in patients with diabetic foot ulcers (DFUs). The purpose of our study was therefore to prospectively investigate the limb and person survival of DFU patients during a follow-up period of more than 10 years.

RESEARCH DESIGN AND METHODS

Two hundred forty-seven patients with DFUs and without previous major amputation consecutively presenting to a single diabetes center between June 1998 and December 1999 were included in this study and followed up until May 2011. Mean patient age was 68.8 ± 10.9 years, 58.7% were male, and 55.5% had peripheral arterial disease (PAD). Times to first major amputation and to death were analyzed with Kaplan-Meier curves and Cox multiple regression.

RESULTS

A first major amputation occurred in 38 patients (15.4%) during follow-up. All but one of these patients had evidence of PAD at inclusion in the study, and 51.4% had severe PAD [ankle-brachial pressure index ≤0.4]). Age (hazard ratio [HR] per year, 1.05 [95% CI, 1.01-1.10]), being on dialysis (3.51 [1.02-12.07]), and PAD (35.34 [4.81-259.79]) were significant predictors for first major amputation. Cumulative mortalities at years 1, 3, 5, and 10 were 15.4, 33.1, 45.8, and 70.4%, respectively. Significant predictors for death were age (HR per year, 1.08 [95% CI, 1.06-1.10]), male sex ([1.18-2.32]), chronic renal insufficiency (1.83 [1.25-2.66]), dialysis (6.43 [3.14-13.16]), and PAD (1.44 [1.05-1.98]).

CONCLUSIONS

Although long-term limb salvage in this modern series of diabetic foot patients is favorable, long-term survival remains poor, especially among patients with PAD or renal insufficiency.

A retrospective analysis of amputation rates in diabetic patients: can lower extremity amputations be further prevented?

Background

Lower extremity amputations are costly and debilitating complications in patients with diabetes mellitus (DM). Our aim was to investigate changes in the amputation rate in patients with DM at the Karolinska University Hospital in Solna (KS) following the introduction of consensus guidelines for treatment and prevention of diabetic foot complications, and to identify risk groups of lower extremity amputations that should be targeted for preventive treatment.

Methods

150 diabetic and 191 nondiabetic patients were amputated at KS between 2000 and 2006; of these 102 diabetic and 99 nondiabetic patients belonged to the catchment area of KS. 21 diabetic patients who belonged to KS catchment area were amputated at Danderyd University Hospital. All patients' case reports were searched for diagnoses of diabetes, vascular disorders, kidney disorders, and ulcer infections of the foot.

Results

There was a 60% reduction in the rate of amputations performed above the ankle in patients with DM during the study period. Patients with DM who underwent amputations were more commonly affected by foot infections and kidney disorders compared to the nondiabetic control group. Women with DM were 10 years older than the men when amputated, whereas men with DM underwent more multiple amputations and had more foot infections compared to the women. 88% of all diabetes-related amputations were preceded by foot ulcers. Only 30% of the patients had been referred to the multidisciplinary foot team prior to the decision of amputation.

Conclusions

These findings indicate a reduced rate of major amputations in diabetic patients, which suggests an implementation of the consensus guidelines of foot care. We also propose further reduced amputation rates if patients with an increased risk of future amputation (i.e. male sex, kidney disease) are identified and offered preventive treatment early.

The impact of creatinine clearance on the outcome of diabetic foot ulcers in north Indian tertiary care hospital

AIM

Wound healing has been reported to be poor in diabetic patients with impaired kidney functions that usually accompanies retinopathy and neuropathy. The insensitive foot is vulnerable to repeated trauma and development of ulcer precedes 70-80% of non-traumatic lower extremity amputation. The present study was aimed to study the impact of creatinine clearance (CCre) on the outcome of diabetic foot ulcers (DFU).

MATERIALS AND METHODS

Data from 162 DFU patients admitted to Rajiv Gandhi Centre for Diabetes and Endocrinology of J.N. Medical College, Aligarh Muslim University, Aligarh, India, between December 2009 and March 2011 were analyzed. Detailed history and patient's profile, grade of DFU, co-morbidities and complications, laboratory data, microbiological profile and final outcome were collected. CCre was calculated according to MDRD formula.

RESULTS

The study revealed that, DFU healing was worst in patients with decreased CCre than in those who had normal CCre. Other factors associated with poor outcome were, higher grade of ulcer, infection type (subcutaneous and osteomyelitis) and biofilm infection. Amputation rates were also found to be higher in those with poor renal functions.

CONCLUSIONS

The results suggest that CCre is an important factor affecting wound healing in patients with DFUs. The automatic reporting of eGFR each time a serum creatinine concentration is requested will increase the awareness of significant kidney dysfunction in clinical practice especially in DFU patients and appropriate measures will improve the outcome.

The effect of creatinine clearance on the short-term outcome of neuropathic diabetic foot ulcers

Reduced creatinine clearance is related to an increased risk for diabetic foot ulcer development. Wound healing has been reported to be worse in diabetic patients with impaired kidney functions than general diabetic population. This study aimed to investigate the effect of creatinine clearance on the short-term outcome of neuropathic diabetic foot ulcers. Data from 147 neuropathic diabetic foot ulcer episodes were included in this observational study. Patients were admitted to Dokuz Eylul University Hospital between January 2003 and June 2008. Patients were excluded if they had limb ischemia. Diabetic nephropathy was investigated by 24h urinary albumin excretion and serum creatinine levels. Creatinine clearance was calculated according to Cockcroft-Gault formula. Foot ulcers were followed up for 6 months to determine the outcome. Our short-term follow-up revealed that neuropathic diabetic ulcers healed worse in patients with decreased creatinine clearance than in those who had normal creatinine clearance. Amputation rates were also found to be higher. Our results suggest that creatinine clearance is an important factor affecting wound healing in patients with neuropathic diabetic foot ulcers.

Dialysis treatment is an independent risk factor for foot ulceration in patients with diabetes and stage 4 or 5 chronic kidney disease

OBJECTIVE

To determine whether dialysis treatment is an independent risk factor for foot ulceration in patients with diabetes and renal impairment.

RESEARCH DESIGN AND METHODS

We performed a cross-sectional study of consecutive patients with diabetes and stage 4 or 5 chronic kidney disease (CKD) attending clinics in Manchester (U.K.). Patients were classified as either receiving dialysis therapy (dialysis) or not (no dialysis). Foot assessment included diabetic peripheral neuropathy (DPN), peripheral arterial disease (PAD), prior foot ulceration and amputation, and foot self-care. Risk factors for prevalent foot ulceration were assessed by logistic regression.

RESULTS

We studied 326 patients with diabetes and CKD (mean age 64 years; 61% male; 78% type 2 diabetes; 11% prevalent foot ulceration). Compared with no dialysis patients, dialysis patients had a higher prevalence of DPN (79 vs. 65%), PAD (64 vs. 43%), prior amputations (15 vs. 6.4%), prior foot ulceration (32 vs. 20%), and prevalent foot ulceration (21 vs. 5%, all P < 0.05). In univariate analyses, foot ulceration was related to wearing bespoke footwear (odds ratio 5.6 [95% CI 2.5-13]) dialysis treatment (5.1 [2.3-11]), prior foot ulceration (4.8 [2.3-9.8], PAD (2.8 [1.3-6.0], and years of diabetes (1.0 [1.0-1.1], all P < 0.01). In multivariate logistic regression, only dialysis treatment (4.2 [1.7-10], P = 0.002) and prior foot ulceration (3.1 [1.3-7.1], P = 0.008) were associated with prevalent foot ulceration.

CONCLUSIONS

Dialysis treatment was independently associated with foot ulceration. Guidelines should highlight dialysis as an important risk factor for foot ulceration requiring intensive foot care.

Diabetic foot disease in people with advanced nephropathy and those on renal dialysis

Among the spectrum of risk for diabetic foot disease conferred by chronic kidney disease (CKD), end-stage renal disease (ESRD) has emerged as a novel independent risk factor. Apart from the classical triad of neuropathy, infection, and peripheral arterial disease that operate in these individuals, the risk is further compounded by inadequate foot self-care by patients and by dialysis centers not providing onsite foot care, as medical priorities are diverted to the dialysis itself. Consequently, the burden of diabetic foot disease has increased in the CKD and ESRD population as exemplified by high ulceration, amputation, and foot-related mortality rates. Current guidelines on foot care in diabetes should recognize advanced CKD and ESRD/dialysis as a separate risk factor for foot disease to alert professionals and highlight the opportunity for prevention. Recent studies have demonstrated improved foot outcomes when chiropody programs are instituted within dialysis units.

Microcirculatory changes and skeletal muscle oxygenation measured at rest by non-infrared spectroscopy in patients with and without diabetes undergoing haemodialysis

Introduction

Haemodialysis has direct and indirect effects on skin and muscle microcirculatory regulation that are severe enough to worsen tolerance to physical exercise and muscle asthenia in patients undergoing dialysis, thus compromising patients' quality of life and increasing the risk of mortality. In diabetes these circumstances are further complicated, leading to an approximately sixfold increase in the incidence of critical limb ischaemia and amputation. Our aim in this study was to investigate in vivo whether haemodialysis induces major changes in skeletal muscle oxygenation and blood flow, microvascular compliance and tissue metabolic rate in patients with and without diabetes.

Methods

The study included 20 consecutive patients with and without diabetes undergoing haemodialysis at Sant Andrea University Hospital, Rome from March to April 2007. Near-infrared spectroscopy (NIRS) quantitative measurements of tissue haemoglobin concentrations in oxygenated [HbO₂] and deoxygenated forms [HHb] were obtained in the calf once hourly for 4 hours during dialysis. Consecutive venous occlusions allowed one to obtain muscular blood flow (mBF), microvascular compliance and muscle oxygen consumption (mVO₂). The tissue oxygen saturation (StO₂) and content (CtO₂) as well as the microvascular bed volume were derived from the haemoglobin concentration. Nonparametric tests were used to compare data within each group and among the groups and with a group of 22 matched healthy controls.

Results

The total haemoglobin concentration and [HHb] increased significantly during dialysis in patients without and with diabetes. Only in patients with diabetes, dialysis involved a [HbO₂], CtO₂ and increase but left mVO₂ unchanged. Multiple regression StO₂ analysis disclosed a significant direct correlation of StO₂ with HbO₂ and an inverse correlation with mVO₂. Dialysis increased mBF only in diabetic patients. Microvascular compliance decreased rapidly and significantly during the first hour of dialysis in both groups.

Conclusions

Our NIRS findings suggest that haemodialysis in subjects at rest brings about major changes in skeletal muscle oxygenation, blood flow, microvascular compliance and tissue metabolic rate. These changes differ in patients with and without diabetes. In all patients haemodialysis induces changes in tissue haemoglobin concentrations and microvascular compliance, whereas in patients with diabetes it alters tissue blood flow, tissue oxygenation (CtO₂, [HbO₂]) and the metabolic rate (mVO₂). In these patients the mVO₂ is correlated to the blood supply. The effects of haemodialysis on cell damage remain to be clarified. The absence of StO₂ changes is probably linked to an opposite [HbO₂] and mVO₂ pattern.

Implementation of diabetic foot ulcer classification system for research purposes to predict lower extremity amputation

BACKGROUND

Patients with diabetic foot ulcers are at a high risk of having both minor or major lower extremity amputations.

AIM

To identify the extent of risk factors for major and minor amputations in patients with diabetic foot ulcers.

MATERIALS AND METHODS

This prospective study was conducted from 2003 to 2005. Using the guidelines for wound classification developed by the International Consensus of the Diabetic Foot, patients were assessed for ischemia, neuropathy, linear measurement of wound diameters, depth of wound, and infection. In addition, end stage renal failure was added as a criterion to assess the association of all these criteria with both toe and lower extremity amputation.

RESULTS

2,321 patients were studied and their mean age was 55 +/- 12 years. Most (83.5%) of the patients presented with foot ulcers (n = 1394). Plantar ulcers were the most common (42.6%) followed by ulcers of the big toe (39%). Some (28.5%) of the patients had different types of amputations: 10% had major lower extreme amputation (MLEA) with 8.7% amputations being below the knee and minor (toe) amputations accounting for 18.5%. The most commonly amputated (9.9%) toe was the first toe.

CONCLUSION

The guidelines for wound classification proposed by the International Consensus of the Diabetic Foot are reliable predictive factors and can determine the outcome of diabetic foot management. Significant factors associated with MLEA were ischemia, neuropathy, and end-stage renal disease and those associated with toe amputation were neuropathy, depth of wound, and grade of infection.

Haemodialysis is associated with changes in cutaneous microcirculation in diabetes mellitus

AIMS

To examine the cutaneous microcirculation on the dorsum of the foot before, during and after haemodialysis in diabetic and non-diabetic patients.

METHODS

Fourteen age-matched patients (seven diabetic, seven non-diabetic) without active foot ulceration were studied. Cutaneous microcirculation was assessed using a micro-lightguide spectrophotometer to measure venous oxygen saturation and relative blood flow determined at two tissue depths: 2 and 6 mm. Cumulative relative changes of each parameter during haemodialysis were calculated as area under the curve. Differences between and within the groups were calculated by Mann-Whitney U-test and anova following post hoc testing, respectively.

RESULTS

At baseline, relative blood flow at 6 mm tissue depth was significantly greater in diabetic patients (P = 0.048). Thirty minutes after the end of dialysis, relative blood flow at 2 and 6 mm tissue depth was significantly higher in non-diabetic patients (P = 0.048 and P = 0.001). Mean cumulative relative changes in venous oxygen saturation and relative blood flow at 2 mm as well as 6 mm tissue depth were positive for non-diabetic subjects and negative for diabetic patients.

CONCLUSIONS

Haemodialysis is associated with changes in cutaneous microcirculation, which differ between people with and without diabetes. In those without diabetes, we found an increase in blood flow during haemodialysis, whereas blood flow was reduced in diabetic patients. This may be the result of abnormal vasomotor regulation due to distal neuropathy.

Association between renal failure and foot ulcer or lower-extremity amputation in patients with diabetes

OBJECTIVE

The objective of this study was to evaluate the association between foot ulcers (DFU) and lower-extremity amputation (LEA) and chronic kidney disease (CKD) in patients with diabetes. RESARCH DESIGN AND METHODS: This was a retrospective cohort study of individuals enrolled between 2002 and 2006 who were aged > or =35 years, had a history of diabetes, and were cared for in general practice. The physicians participated in The Health Information Network of the U.K.

RESULTS

The presence of DFU or LEA and estimated glomerular filtration rate (eGFR) were evaluated in 90,617 individuals with a median time of observation of 2.4 years. Of these individuals 378 had an LEA and 2,619 had a DFU. CKD (eGFR <60 ml/min per 1.73 m(2)) was noted in 23,350 (26%) individuals in our cohort. For the development of DFU compared with our reference group (group 1 [eGFR > or =60 ml/min per 1.73 m(2)]), the hazard ratio (HR) for group 2 (eGFR > or =30 and <60 ml/min per 1.73 m(2)) was 1.85 (95% CI 1.71-2.01) and for group 3 (eGFR <30 ml/min per 1.73 m(2)) was 3.92 (3.23-4.75) (all P < 0.001). For LEA, the HR for group 2 was 2.08 (1.68-2.58) and for group 3 was 7.71 (5.29-11.26) (all P < 0.001).

CONCLUSIONS

In this observational study, there is a strong association between stage of CKD and DFU or LEA that is probably not just related to the presence of peripheral arterial disease. Individuals with even moderate CKD (eGFR <60 ml/min per 1.73 m(2)) have an increased risk for DFU and LEA.

Prediction of outcome in individuals with diabetic foot ulcers: focus on the differences between individuals with and without peripheral arterial disease. The EURODIALE Study

AIMS/HYPOTHESIS

Outcome data on individuals with diabetic foot ulcers are scarce, especially in those with peripheral arterial disease (PAD). We therefore examined the clinical characteristics that best predict poor outcome in a large population of diabetic foot ulcer patients and examined whether such predictors differ between patients with and without PAD.

METHODS

Analyses were conducted within the EURODIALE Study, a prospective cohort study of 1,088 diabetic foot ulcer patients across 14 centres in Europe. Multiple logistic regression modelling was used to identify independent predictors of outcome (i.e. non-healing of the foot ulcer).

RESULTS

After 1 year of follow-up, 23% of the patients had not healed. Independent baseline predictors of non-healing in the whole study population were older age, male sex, heart failure, the inability to stand or walk without help, end-stage renal disease, larger ulcer size, peripheral neuropathy and PAD. When analyses were performed according to PAD status, infection emerged as a specific predictor of non-healing in PAD patients only.

CONCLUSIONS/INTERPRETATION

Predictors of healing differ between patients with and without PAD, suggesting that diabetic foot ulcers with or without concomitant PAD should be defined as two separate disease states. The observed negative impact of infection on healing that was confined to patients with PAD needs further investigation.

Frequency of risk factors for foot ulceration in individuals with chronic kidney disease

BACKGROUND

Although chronic kidney disease (CKD) has been associated with foot ulceration, the pathological pathway involved remains unclear. This pilot study was designed to investigate the risk factors for foot ulceration in individuals with CKD who do not have diabetes. The aims of this study were to establish the risk status for foot ulceration in individuals with CKD and to identify the particular foot ulcer risk factors most prevalent in this group.

METHODS

One hundred outpatients were recruited from a metropolitan hospital and allocated into one of four groups: (i) control: neither diabetes nor CKD, (ii) diabetes alone, (iii) coexisting CKD and diabetes and (iv) CKD alone. All participants were assessed for past/current foot ulcers, peripheral neuropathy, vascular insufficiency, structural deformity and skin pathology. Comparisons were made between the groups regarding the prevalence of these factors.

RESULTS

Participants with CKD who did not have diabetes displayed no significant differences in risk factor presentation from those with diabetes alone. Of the participants with CKD and no diabetes, 36% had peripheral neuropathy, 20% had vascular insufficiency and 24% had the copresentation of peripheral neuropathy and structural deformity. Overall, participants with both CKD and diabetes had the highest presentation of past/current foot ulcers, peripheral neuropathy and vascular insufficiency, all significantly more frequent in this group than in controls (P < 0.05). Eight of the total 10 participants found to have a past/current foot ulcer were in end-stage kidney failure.

CONCLUSION

Individuals with CKD frequently display risk factors for foot ulceration. Risk factors are more prevalent in individuals who also have diabetes and foot ulcers become more frequent with progression to end-stage kidney failure. Risk assessment and patient awareness strategies should therefore be extended to include all patients with CKD so as to reduce future foot ulcer development.

The diabetic foot in end stage renal disease

Diabetic foot lesions remain a major cause of morbidity in patients with renal failure, especially those on dialysis. Foot complications are encountered at a more than twofold frequency in diabetic patients with end-stage renal disease, and the rate of amputations is 6.5-10 times higher in comparison to the general diabetic population. The causal pathways of the diabetic foot in renal failure are multiple and inter-related. Three major pathologies--neuropathy, ischemia, and infection--are the main contributory factors. Increased awareness of this condition and careful clinical examination are indispensable to avoid serious complications. Appropriate management needs to address all contributory factors. Treatment options include revascularization, off-loading to relieve high-pressure areas, and aggressive control of infection. Equally important is the collaboration between health care providers in a multidisciplinary foot care setting. Moreover, patient education on the measures required to achieve both primary and secondary prevention is of great value. Certainly, technical innovations have made considerable progress possible, but there is a need for further improvement to reduce the number of amputations.

The effect of haemodialysis on transcutaneous oxygen tension in patients with diabetes—a pilot study

BACKGROUND

Established renal failure in diabetes is associated with a high incidence of foot ulcers and gangrene, and these are major causes of morbidity and mortality. It has been suggested that this problem is particularly associated with the onset of renal replacement therapy, and since there is evidence that haemodialysis causes hypoxaemia, we have undertaken a pilot study to determine the effect of haemodialysis on lower limb transcutaneous oxygen tension (TcpO2).

METHODS

TcpO2 was measured on the dorsum of the foot through a single dialysis treatment and over the succeeding 4 h using a transcutaneous monitor (TCM400/3, Radiometer Ltd, Copenhagen, Denmark).

RESULTS

The median age (range) of the 10 (7 male) participants was 73 (58-83) years. The median duration of diabetes was 16.5 (7-30) years and that of dialysis treatment 29 (10-88) months. The median (range) baseline TcpO2 on the dorsum of the foot was 54.5 (51-77) mmHg and 54.0 (24-87) at the end of dialysis. Median TcpO2 at 1, 2 and 4 h after the end of dialysis was 50.0 (33-81), 49.0 (24-78) and 47.0 (20-78) mmHg. Analysis by ANOVA suggested a trend towards a difference between median TcpO2 concentrations at different time points (F(1.752, 15.765) = 3.359, P = 0.066).

CONCLUSIONS

The data identified a trend towards a fall in lower limb TcpO2, and that this fall continued for at least 4 h after the end of treatment. Dialysis-associated lower limb hypoxia may be a factor leading to the increased incidence of critical limb ischaemia in this group and further work is needed to define its cause and implications for clinical care.

Coronary artery disease and peripheral vascular disease in chronic kidney disease: an epidemiological perspective

The enormous burden of CAD and PVD inpatients who have CKD contributes substantially to increased morbidity and mortality. The increased risk of vascular disease observed in CKD patients is likely to be multifactorial, with contributions from traditional and nontraditional cardiovascular factors. Given the overwhelming evidence on the known benefits of cardioprotective medications, their underuse remains puzzling in a population at enormous risk. During the past 5 years, the research community and national interest groups have made significant progress in organizing a concerted approach to improve the management of patients who have CKD and vascular disease. Much work remains to be done. The development of national guidelines in the management of these patients at high risk for future cardiovascular events will be a welcome step. The evaluation of multitargeted interventions for reduction of cardiovascular risk through randomized clinical trials is desperately needed. Finally, the low use of known cardioprotective strategies in this high-risk group is a serious issue and warrants immediate attention at local and national levels.

Incidence of Peripheral Arteriosclerotic Complications of the Lower Extremities in Diabetic Patients With Chronic Renal Failure

Patients with diabetes mellitus are at high risk of arteriosclerotic complications. The same is true for those with chronic renal failure (CRF). The present study evaluated clinical factors on the occurrence of peripheral arterial diseases. The severity of peripheral arterial disease was defined as mild (plaque, calcifications) or severe (70% stenosis, obstructions) based upon ultrasonographical examination. Overall in diabetic patients, mild ultrasonographical findings such as plaque and calcification were observed in 25% (17/69) of predialysis patients and in 18% (7/38) of those on hemodialysis (HD). Severe arteriosclerotic findings such as stenosis and obstruction were seen in 42% (29/69) of predialysis patients and in 50% (19/38) of those on HD. The incidence is identical between predialysis patients and patients on HD, regardless of the severity of peripheral arterial diseases. In an attempt to compare diabetics with non-diabetics, the incidence of mild abnormal findings was found in 22% (24/107) of diabetics and in 30% (11/37) of non-diabetics. Similarly, the percentage of patients with severe arteriosclerotic findings was found in 45% (48/107) in diabetics and 11% (4/37) in non-diabetics. The incidence of the severe type findings in the diabetics is significantly more frequent than that in the non-diabetics (P < 0.01, by the chi(2) test). In non-diabetic predialysis patients, the incidence of mild arteriosclerotic findings was observed in 30% (7/23), and 29% (4/14) of non-diabetic patients on HD. Similarly, the percentage of severe type was 9% (2/23) in non-diabetic predialysis patients, and 14% (2/14) in non-diabetic patients on HD. These data are not only supportive of previous data that diabetes is a risk factor for arteriosclerosis, but also suggestive that, even before the initiation of dialysis, patients with CRF are already susceptible to arteriosclerotic assault of peripheral arterial complications.

Diabetes education and care management significantly improve patient outcomes in the dialysis unit

BACKGROUND

The incidence of diabetes mellitus, particularly type 2, is increasing in the general population. Similarly, the incidence of patients with diabetes mellitus who develop end-stage renal disease has increased concomitantly in the dialysis facility to 44% of patients starting dialysis therapy with diabetes mellitus as their primary diagnosis. The aim of this study is to determine whether intensive education and care management of diabetes could improve glycemic control, alter patient behavior, and reduce complications in the setting of the dialysis unit.

METHODS

Eighty-three patients were allocated to either the control group or study group based on their day of dialysis treatment. All patients were followed up for a year. Patients in the study group underwent a diabetes education program and were followed up by a care manager who provided self-management education, diabetes self-care monitoring/management, motivational coaching, and foot checks.

RESULTS

The control group baseline foot risk category worsened from 2.7 to 3.3 (P < 0.05), whereas it was unchanged in the study group (2.2 to 2.0). There were no amputations in the study group versus five amputations in the control group (P < 0.05). Ten patients in the control group were hospitalized with diabetes- or vascular-related admissions versus one patient in the study group (P < 0.002). Hemoglobin A(1c) levels declined from 6.9 to 6.3 in the study group, whereas results of the control group were unchanged (P < 0.005). Diabetes-related quality-of-life scores increased in the study group from 76 to 86 (P < 0.001 versus the control group). There was a significant improvement in self-management behavior in all six categories evaluated in the study group versus the control group. Dialysis centers were recognized by the American Diabetes Association to provide diabetes education.

CONCLUSION

A program of intensive diabetes education and care management in a dialysis unit is effective in providing significant improvements in patient outcomes, glycemic control, and better quality of life in patients with diabetes mellitus.