Impact of Chronic Kidney Disease on Survival After Amputation in Individuals With Diabetes

Abstract

OBJECTIVETo identify factors that influence survival after diabetes-related amputations.RESEARCH DESIGN AND METHODSWe abstracted medical records of 1,043 hospitalized subjects with diabetes and a lower-extremity amputation from 1 January to 31 December 1993 in six metropolitan statistical areas in south Texas. We identified mortality in the 10-year period after amputation from death certificate data. Diabetes was verified using World Health Organization criteria. Amputations were identified by ICD-9-CM codes 84.11–84.18 and categorized as foot, below-knee amputation, and above-knee amputation and verified by reviewing medical records. We evaluated three levels of renal function: chronic kidney disease (CKD), hemodialysis, and no renal disease. We defined CKD based on a glomerular filtration rate <60 ml/min and hemodialysis from Current Procedural Terminology (CPT) codes (90921, 90925, 90935, and 90937). We used χ2 for trend and Cox regression analysis to evaluate risk factors for survival after amputation.RESULTSPatients with CKD and dialysis had more below-knee amputations and above-knee amputations than patients with no renal disease (P < 0.01). Survival was significantly higher in patients with no renal impairment (P < 0.01). The Cox regression indicated a 290% increase in hazard for death for dialysis treatment (hazard ratio [HR] 3.9, 95% CI 3.07–5.0) and a 46% increase for CKD (HR 1.46, 95% CI 1.21–1.77). Subjects with an above-knee amputation had a 167% increase in hazard (HR 2.67, 95% CI 2.14–3.34), and below-knee amputation patients had a 67% increase in hazard for death.CONCLUSIONSSurvival after amputation is lower in diabetic patients with CKD, dialysis, and high-level amputations.

The Below-Knee Amputation: To Amputate or Palliate?

“…7 This finding is in agreement with previous studies that have also explained the devastating effects of renal disease. Previous studies report that BKA patients face a 77%-86% 1-year survival rate, a 28%-58% 5-year survival rate, and a 35% 10-year survival rate.…”

“…Unfortunately, all studies describing survival rates following a BKA are confounded by the inconsistent timing of the amputation and the comorbid conditions inherent to this population. [1][2][3][4][5][6][7][8] No study to date has demonstrated a BKA to be an independent variable that decreases survival.…”

Barriers and enablers to proper diabetic foot care amongst community dwellers in an Asian population: a qualitative study

“…Improper prevention of diabetic foot conditions can result in significant morbidity, decreased function and quality of life (9). If the condition is severe enough, the pathology involved may require radical surgical management in the form of amputations (10,11) and can be life threatening (12,13). Proper foot care is an essential component in both the prevention and management of diabetic foot disease.…”

Factores fisiopatológicos y metas terapéuticas perioperatorias que influyen en procedimientos quirúrgicos reconstructivos mediante colgajos en pacientes con Diabetes Mellitus

“…La tasa de mortalidad a los cinco años posterior a una amputación mayor puede alcanzar hasta el 78% 14,20 , y la incidencia de una segunda amputación de la extremidad contralateral se aproxima a la mitad de los casos dentro de dos años siguientes 21 . Por lo anterior, se han realizado esfuerzos en mejorar las técnicas y consideraciones quirúrgicas, dado que es otra de las variables que pueden influir en los resultados, utilizando aquellas que se han asociado a mayores tasas de éxito, como las utilizadas en el estudio realizado por Kallio y colaboradores, con una muestra de 63 pacientes diabéticos con lesiones en pie y realizando un seguimiento a 1,5 y 10 años 22 , en el que se dio cobertura realizando transferencia de colgajos libres con una excelente tasa de supervivencia libre de amputación del 90% a largo plazo, siempre y cuando este indemne la arteria encargada del aporte vascular en dicha zona.…”

“…Existen diversas publicaciones que sustentan la evidencia mostrada anteriormente, en los que se demuestra que el salvamento de la extremidad aumenta la supervivencia de la población diabética; así, un estudio retrospectivo publicado por Lavery y colaboradores utilizando técnicas avanzadas para la reconstrucción de tejidos blandos 20 , mostró que mediante la preservación de la extremidad en pacientes diabéticos, la supervivencia a los ocho años fue de 59%, pese a que pueden requerir mayor número de intervenciones y tiempo de cicatrización.…”