Dialysis Treatment Is an Independent Risk Factor for Foot Ulceration in Patients With Diabetes and Stage 4 or 5 Chronic Kidney Disease

Abstract

OBJECTIVETo determine whether dialysis treatment is an independent risk factor for foot ulceration in patients with diabetes and renal impairment.RESEARCH DESIGN AND METHODSWe 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.RESULTSWe 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.CONCLUSIONSDialysis treatment was independently associated with foot ulceration. Guidelines should highlight dialysis as an important risk factor for foot ulceration requiring intensive foot care.

Non-traumatic lower limb amputation in patients with end-stage renal failure on dialysis: an Australian perspective

“…This could be true in the case of our study as all the subjects with LLA had concurrent DM which is strongly associated with foot ulceration. 12,25 On the other hand, the strong association between PAD and LLAs in the current study was reported by others 21 where calciphylaxis was thought to be a contributing factor. 15 Other risk factors for LLA identified in this study include peripheral neuropathy and retinopathy as previously reported.…”

“…These studies have also identified that LLAs are a frequent event in patients on hemodialysis therapy (HD) and that this risk is further increased with the presence of concurrent DM. 12,15 Regarding the prevalence of LLAs in ESRF patients, on dialysis that has been recorded has a wide distribution from as low as 1.72% in Japan 16 to as high as 13.4% in Canada, 17 there is no recorded prevalence from the Australian continent even though Australian data suggests high rates of CVD, DM and ESRF amongst the indigenous population. 18,19 Indigenous Australians have been found to have a 38 times higher risk for LLA secondary to DM as compared to their non-indigenous counterparts.…”

“…6,7 Recently, ESRF which is defined as nonreversible kidney injury requiring renal replacement therapy 8,9 has been identified as a risk factor for PAD leading to non-healing foot ulcers and LLA. [10][11][12][13][14] Recent international studies have identified dialysis to be an independent risk factor for foot ulcers. These studies have also identified that LLAs are a frequent event in patients on hemodialysis therapy (HD) and that this risk is further increased with the presence of concurrent DM.…”

Stratification of foot risk predicts the incidence of new foot disease, but do we yet know that the adoption of routine screening reduces it?

“…And yet this review collates the overwhelming evidence from both cross-sectional and prospective studies, to indicate that the level of risk can be predicted, with the likelihood of new ulceration being variously increased by the presence of peripheral neuropathy, peripheral arterial disease, deformity and, in particular, by a history of previous ulceration or amputation. Other factors may be important, too, including visual impairment (with risk of foot trauma), renal dialysis (not referred to in this paper but known to be a powerful risk factor [3]) and HbA 1c . The role of the last of these may relate to its association with the development, or progression, of other complications of diabetes [4].…”

Management of adults with diabetes on the haemodialysis unit: summary of new guidance from the Joint British Diabetes Societies (JBDS) and the Renal Association

“…Dialysis/ renal replacement therapy is strongly and independently associated with foot ulcers. [39][40][41][42] Neuropathy greatly increases the risk of pressurerelated ulcers, and care must be taken to ensure adequate pressure relief on patients' heels in renal dialysis units when they are recumbent for prolonged periods. 43 Podiatry input on dialysis units reduces the frequency and severity of diabetic foot complications: regular podiatry assessment (at least 3-monthly) should be ensured, ideally on dialysis units as this frail, multi-morbid population may have difficulty accessing community podiatry services.…”