Diabetes, established renal failure and the risk to the lower limb

Abstract

The aim of this article is to review the extent of the association between established renal failure, foot ulcers, gangrene and amputation in diabetes, and to consider the possible mechanisms and clinical implications. In order to do this we used our personal knowledge of the literature, supplemented by searches of Medline and PubMed using appropriate key words. The available literature confirms the close association between established renal failure, peripheral vascular disease, foot ulcers, gangrene and amputation, and indicates that this association is between three and five times greater in diabetes. Once they occur, foot complications are associated with a high mortality. There are multiple possible mechanisms underlying the association, and these include those leading to accelerated peripheral arterial disease, as well as the anaemia and metabolic features of renal failure. There is also evidence that the process of dialysis is itself associated with worsening tissue hypoxia. The results of lower limb revascularisation in established renal failure are poor. We conclude that there is a need for further detailed studies into the factors leading to this association, as well as into the effectiveness of potential interventions. The place of pre-emptive vascular intervention needs to be established. In the meantime, all those responsible for the management of impending and established renal failure in diabetes should remain aware of the possibility of foot disease and should ensure that a structured programme of preventive foot care is implemented.

The Diabetic Foot in End Stage Renal Disease

“…[5,61] Similarly, neuropathy is particularly common, possibly aggravated by a component of uremic neuropathy. [59] Specifically, the co-existence of neuropathy and peripheral arterial disease has been found to be significantly (p = 0.015) more common in patients on dialysis than in the general diabetic population. [39] An increased propensity to infection, largely explicable due to the effect of uremic toxins and/or poor nutrition, is a further potential contributory factor.…”

“…[39] An increased propensity to infection, largely explicable due to the effect of uremic toxins and/or poor nutrition, is a further potential contributory factor. [5,59,60] Hence, it appears that the three cardinal etiologic factors previously discussed to be of vital importance in the pathogenesis of the diabetic renal foot are aggravated in ESRD (see Table 1). …”

“…[43,56,58] Yet foot lesions are, rather, attributable to a combination of both entities. [39,59,60] Certainly, diabetic nephropathy, especially ESRD, is accompanied by an increased prevalence of peripheral arterial disease, [5,6,60] largely associated with longer diabetes duration [5,6,59] but also with a significantly more frequent presence of vascular risk factors. [5,61] Similarly, neuropathy is particularly common, possibly aggravated by a component of uremic neuropathy.…”

“…Uremic autonomic neuropathy may confer further skin fragility, as already mentioned, increasing the likelihood of ulceration. [20,59,60] More importantly, postural hypotension, attributable to both disordered vasomotor regulation due to cardiovascular autonomic neuropathy and to post-dialysis volume constriction, increases the risk of trauma. [60] The latter is facilitated by poor vision owing to diabetic retinopathy.…”

Chronic Kidney Disease and the Foot in Diabetes - Is Inflammation the Missing Link?

“…1) [6]. Hitherto it has been assumed that the emphasis of care in patients at this critical time in their disease pathway shifts towards the requirements of their renal disease [18]; pre-dialysis counselling, formation of vascular access, preparation for transplantation and treatment of anaemia and CKD-mineral bone disorder. Whilst this undoubtedly plays a part, it is also possible that the presence of a chronic foot ulcer accelerates the decline in renal function and may precipitate the requirement for RRT.…”