Trends in Rates of Lower Extremity Amputation Among Patients With End-stage Renal Disease Who Receive Dialysis

Franz, Douglas; Zheng, Yuanchao; Leeper, Nicholas J.; Chandra, Venita; Montez‐Rath, Maria E.; Chang, Tara I.

doi:10.1001/jamainternmed.2018.2436

Cited by 39 publications

(43 citation statements)

References 35 publications

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“…Studies included in this systematic review were very heterogeneous, as it was concluded in previous systematic reviews. Confounders and risk factors for LEAs and DFUs are well known in people with diabetes [70,71]. Few studies presented a strategy of risk classification in management (5/12) that allowed us to split the cohort according to the risk [38,41], but it was not possible for the other articles [54,59,60].…”

Section: Literature Comparison and Findingsmentioning

confidence: 99%

Effect of contact with podiatry in a team approach context on diabetic foot ulcer and lower extremity amputation: systematic review and meta‐analysis

Blanchette

Brousseau-Foley

Cloutier

2020

Journal of Foot and Ankle Research

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Multidisciplinary team (MDT) approach has been shown to reduce diabetic foot ulcerations (DFUs) and lower extremity amputations (LEAs), but there is heterogeneity between team members and interventions. Podiatrists have been suggested as "gatekeepers" for the prevention and management of DFUs. The purpose of our study is to review the effect of podiatric interventions in MDTs on DFUs and LEAs. We conducted a systematic review of available literature. Data's heterogeneity about DFU outcomes made it impossible for us to include it in a meta-analysis, but we identified 12 studies fulfilling inclusion criteria that allowed for them to be included for LEA outcomes. With the exception of one study, all reported favourable outcomes for MDTs that include podiatry. We found statistical significance in favour of an MDT approach including podiatrists for our primary outcome (total LEAs (RR: 0.69, 95% CI 0.54-0.89, I 2 = 64%, P = 0.002)) and major LEAs (RR: 0.45, 95% CI 0.23-0.90, I 2 = 67%, P < 0.02). Our systematic review, with a standard search strategy, is the first to specifically address the relevant role of podiatrists and their interventions in an MDT approach for DFU management. Our observations support the literature that MDTs including podiatrists have a positive effect on patient outcomes but there is insufficient evidence that MDTs with podiatry management can reduce the risk of LEAs. Our study highlights the necessity for intervention descriptions and role definition in team approach in daily practice and in published literature.

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Section: Literature Comparison and Findingsmentioning

confidence: 99%

Effect of contact with podiatry in a team approach context on diabetic foot ulcer and lower extremity amputation: systematic review and meta‐analysis

Blanchette

Brousseau-Foley

Cloutier

2020

Journal of Foot and Ankle Research

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“…This increased risk of lower limb amputation was also observed in some observational studies and pharmacovigilance reports, yet whether it is a class effect or not remains an open question [113]. Of note, patients with ESRD who receive dialysis are at high risk of lower extremity amputation, which is associated with a high mortality rate, and among those people with ESRD, patients with diabetes had amputation rates more than five times as high as patients without diabetes [114].…”

Section: Sglt2 Inhibitorsmentioning

confidence: 72%

Preventing and treating kidney disease in patients with type 2 diabetes

Delanaye

Scheen

2018

Expert Opinion on Pharmacotherapy

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Introduction: Chronic kidney disease (CKD) represents a huge burden in patients with type 2 diabetes (T2DM). This review therefore has the aim of assessing the add-on value of new glucose-lowering agents compared or combined with inhibitors of the renin angiotensin aldosterone system (RAAS) on renal outcomes in T2DM patients. Areas covered: This article first summarizes the results reported with RAAS inhibitors, mainstay of nephroprotection in T2DM with albuminuria. Second, it describes the positive results with glucagon-like peptide-1 receptor agonists (GLP-1RAs) and, even more impressive, sodium-glucose cotransporter type 2 inhibitors (SGLT2is). Third, besides the potential of combined therapies, it briefly considers some new approaches currently in development. Expert opinion: RAAS inhibitors exert renoprotective effects beyond their blood pressure lowering effects while SGLT2is, and possibly GLP-1RAs, exert nephroprotection independently of their glucoselowering activity. These effects were demonstrated not only on surrogate endpoints such as albuminuria and estimated glomerular filtration rate decline, but also on hard endpoints, including progression to end-stage renal disease requiring replacement therapy. The underlying mechanisms are different and potentially complementary on glomerular hemodynamics, arguing for combined therapies. Nevertheless, there is still room for new emerging drugs to tackle CKD in T2DM.

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“…34,38 Recognized barriers to receipt of hospice care in this population include difficulty identifying those who are approaching the end of life, 28,39 limited patient and provider familiarity with palliative and hospice care, [40][41][42] and restrictions on Medicare coverage for concurrent hospice and dialysis services. 36,37,43 It is striking that despite widespread recognition that the presence of peripheral arterial disease and receipt of lower extremity amputation portend an exceedingly poor prognosis in this population, [3][4][5][6][7][8]19,44 Medicare beneficiaries with ESRD who undergo a lower extremity amputation near the end of their life receive more-not less-intensive patterns of care than other patients with ESRD. The significant amount of time that these patients spend in acute and subacute care settings during the last year of life is especially concerning because prior studies show that quality of end-of-life care for those who die in hospitals and nursing homes tends to be rated lower than for those who receive home hospice services.…”

Section: Discussionmentioning

confidence: 99%

Lower Extremity Amputation and Health Care Utilization in the Last Year of Life among Medicare Beneficiaries with ESRD

Butler

Schwarze

Katz

et al. 2019

JASN

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Background Lower extremity amputation is common among patients with ESRD, and often portends a poor prognosis. However, little is known about end-of-life care among patients with ESRD who undergo amputation. Methods We conducted a mortality follow-back study of Medicare beneficiaries with ESRD who died in 2002 through 2014 to analyze patterns of lower extremity amputation in the last year of life compared with a parallel cohort of beneficiaries without ESRD. We also examined the relationship between amputation and end-of-life care among the patients with ESRD. Results Overall, 8% of 754,777 beneficiaries with ESRD underwent at least one lower extremity amputation in their last year of life compared with 1% of 958,412 beneficiaries without ESRD. Adjusted analyses of patients with ESRD showed that those who had undergone lower extremity amputation were substantially more likely than those who had not to have been admitted to-and to have had prolonged stays in-acute and subacute care settings during their final year of life. Amputation was also associated with a greater likelihood of dying in the hospital, dialysis discontinuation before death, and less time receiving hospice services. Conclusions Nearly one in ten patients with ESRD undergoes lower extremity amputation in their last year of life. These patients have prolonged stays in acute and subacute health care settings and appear to have limited access to hospice services. These findings likely signal unmet palliative care needs among seriously ill patients with ESRD who undergo amputation as well as opportunities to improve their care.

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Trends in Rates of Lower Extremity Amputation Among Patients With End-stage Renal Disease Who Receive Dialysis

Cited by 39 publications

References 35 publications

Effect of contact with podiatry in a team approach context on diabetic foot ulcer and lower extremity amputation: systematic review and meta‐analysis

Effect of contact with podiatry in a team approach context on diabetic foot ulcer and lower extremity amputation: systematic review and meta‐analysis

Preventing and treating kidney disease in patients with type 2 diabetes

Lower Extremity Amputation and Health Care Utilization in the Last Year of Life among Medicare Beneficiaries with ESRD

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