Diabetic foot ulcers do not heal as well in ESKD as in the absence of kidney failure, and rates of lower extremity amputation (LEA) are higher. Foot ulcer is the root cause of the majority of LEA in diabetes mellitus, but with early detection, many amputations can be prevented by a comprehensive and multidisciplinary approach. Wound healing encompasses nutrition, smoking cessation, glycemic control, appropriate offloading, compliance with wound care visits and dressing changes, vascular work-up, and intervention as indicated, and antibiotics if needed. While many of these items are outside the scope of the dialysis visit, foot checks, foot care education, nutrition, and smoking cessation should be addressed as part of routine dialysis patient care. In addition, nephrologists who understand wound care principles can give additional support to their patients during the intensive phase of wound care treatments, which often comprises weekly sharp debridement. The evidence shows that integrating care into the dialysis treatment setting improves foot-related outcomes; dialysis team education and vigilance are essential, and nephrologists are uniquely positioned to lead this effort. We know enough to act to improve the outcomes of ESKD patients with foot ulcers.
AbstractDiabetic 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.
