Functional Outcome of Quadruple Amputees With End-Stage Renal Disease1

Abstract

A rare but catastrophic complication in end-stage renal disease (ESRD) patients with peripheral vascular disease is amputation of all four limbs secondary to gangrene. We present three patients with ESRD who underwent quadruple amputation. The purpose of this case study is to investigate the functional benefit of inpatient rehabilitation for such amputees. Our large, tertiary acute care hospital admitted 1,469 patients with ESRD during a continuous 63-month period. There were 72 amputation procedures: 57 involving lower limbs, and 15 involving upper limbs. Three patients had all four limbs amputated; these three were subsequently admitted to our acute inpatient rehabilitation center. Their median Functional Independence Measurement (FIM) score on admission was 52 and on discharge was 75. Their median length of stay was 24.5 days, which may be attributed to early postoperative therapy and de-emphasis on prosthetic replacement. At discharge, all three patients were able to perform sliding board transfers and self-propel wheelchairs modified with quad knobs and brake extenders. Each continued hemodialysis three times per week. Two patients were independent with feeding using adaptive equipment, and one required verbal cues. Two patients were able to write using dorsal wrist splints and pencil holders. One patient was able to use a speaker phone and lift lightweight objects with a left below-the-elbow hook-type prosthesis. Our review of these three cases demonstrates that inpatient rehabilitation can improve functional scores in quadruple amputee patients with ESRD. A large multicenter study is warranted to obtain adequate sample size to demonstrate statistical significance.

Rehabilitation in the Renal Population: Barriers to Access

“…The average reported age of renal patients receiving inpatient rehabilitation is 60 or older. 10 Case reports as well as several studies that have compared outcomes of renal patients and nonrenal patients after inpatient rehabilitation stays have shown functional gains in renal patients [11][12][13][14][15][16][17][18] and support the conclusion that renal patients "merit a trial of rehabilitation even though they may have compounding impairments." 19 A frequently noted concern has been the time required for the patient to receive dialysis treatment away from the rehabilitation unit, potentially limiting the amount of rehabilitation therapy that the patient receives or leaving the patient too fatigued to fully benefit from rehabilitation therapy.…”

Geriatric Assessment, Falls and Rehabilitation in Patients Starting or Established on Peritoneal Dialysis

“…Geriatric renal rehabilitation has not been widely incorporated into routine dialysis care and, in many cases, is available only on a case-by-case basis. Published results suggest variable outcomes, as measured by the proportion of patients returning home, with anywhere between 20% to 100% of patients returning to their previous home environment (25)(26)(27)(28)(29)(30)(31)(32). In the largest and most recent report, approximately 70% of patients undergoing rehabilitation while also undergoing chronic HD returned home (Table 1) (32,33).…”

Rehabilitation of the Geriatric Dialysis Patient

“…Patients are Comparable to Nondialysis Patients in Several Respects A meta-analysis of 17 randomized controlled trials of inpatient geriatric rehabilitation programs conducted in 2010 reported improved ADL and IADL function, reduced nursing home admissions, and lower mortality at both discharge and after 1 year in patients undergoing rehabilitation compared with standard care (Figure 3) (44). Although inpatient geriatric rehabilitation programs for hemodialysis patients are still uncommon and not well-studied, single-center data are promising (45)(46)(47)(48)(49)(50)(51)(52)(53).…”