Implementation of routine foot check in patients with diabetes on hemodialysis: associations with outcomes

Abstract

ObjectivePatients with diabetes are at increased risk of foot ulcers, which may result in limb amputations. While regular foot care prevents ulcerations and amputation in those patients with diabetes not on dialysis, evidence is limited in diabetic hemodialysis patients. We investigated the association between the implementation of a routine foot check program in diabetic incident hemodialysis patients, and major lower limb amputations.MethodsIn 1/2008, monthly intradialytic foot checks were implemented as part of standard clinic care in all Fresenius Medical Care North America hemodialysis facilities. Patients with diabetes who initiated hemodialysis between 1/2004 and 12/2007 constituted the preimplementation cohort, and patients starting hemodialysis between 1/2008 and 12/2011 comprised the postimplementation cohort. In addition, we conducted a sensitivity analysis where we excluded patients from the clinics with <10 patients in the postimplementation period and where percent difference in patient with diabetes number between postimplementation and preimplementation period was <20%. We compared lower limb amputation rates employing Poisson regression models with offset of exposure time in these two cohorts.ResultsWe studied 35 513 patients in the preimplementation and 25 779 patients in the postimplementation cohort. In the postimplementation cohort, amputation rate decreased by 17% (p=0.0034). The major lower limb amputation rate was 1.30 per 100 patient years in preimplementation and 1.07 in postimplementation cohort. These beneficial results were corroborated in the multivariate analysis (p=0.0175) and were even more pronounced in the sensitivity analysis (p=0.0083).ConclusionMonthly foot checks are associated with reduction of major lower limb amputations in diabetic incident hemodialysis patients.

Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2019 update)

“…However, a publication from the United States suggested that there was an increase in hospital admissions for a diabetic foot ulcer after Medicare cancelled financial coverage in one US state for preventative treatment given by podiatrists . Two further studies suggested that there was a reduction in amputations following the introduction of integrated foot care that included both ulcer prevention and ulcer treatment …”

Incident diabetic foot ulcers and mortality in hemodialysis patients

“…4 Our group demonstrated that implementation of a monthly foot-check program in dialysis units was associated with a reduction of major lower limb amputations in diabetic hemodialysis (HD) patients. 5 However, that study design did not evaluate a potential mechanism for the association and did not track mortality. Therefore, we further evaluated the association between the development of ulcers, amputation and mortality, in a cohort receiving monthly foot-checks from a subset of facilities in the above-mentioned study with electronic capture of foot examination findings.…”

A perifériás verőérbetegséggel és a cukorbetegséggel összefüggő alsó végtagi amputációk. Epidemiológiai adatok bemutatása és a megelőző stratégia lehetőségeinek elemzése

“…A megfelelő konzervatív kezelés hiánya több mint négyszeres kockázatot jelentett az alsó végtagi major amputáció vonatkozásában [48]. További olyan tényezők, amelyek nem az alsó végtagi revascularisatióval közvetlenül függnek össze és a klinikai tanulmányok alapján az alsó végtagi amputációk megelő-zésében jótékonynak bizonyultak: hemoglobin-A-1c-csökkentés [49], statinterápia [50], optimális gyógysze-res kezelés [48], dohányzás felfüggesztése [51], rendszeres alsó végtagi ellenőrzés [52], dialízisminőség [53], a beteg, illetve az ellátószemélyzet edukációja [54,55], betegút-optimalizálás [56], multidiszciplináris kezelés [57], egészségtudatosság szintjének növelése [55].…”