Renal failure and foot ulcer or lower extremity amputation in those patients with diabetes

NewsBot · Oct 21, 2021

Micro- and macrovascular complications and risk factors for foot ulceration and amputation in individuals receiving dialysis with and without diabetes
Dea Haagensen Kofod et al
Endocrinol Diabetes Metab. 2021 Oct 17

Introduction: This study examined the prevalence of microvascular and macrovascular complications in people receiving dialysis with and without diabetes and investigated independent risk factors for foot ulcers and lower-extremity amputations.

Methods: We performed a cross-sectional study of 119 individuals with diabetes and 219 individuals without diabetes receiving chronic dialysis during June 2019 at the Department of Nephrology, Rigshospitalet, University of Copenhagen, Denmark. Effects of diabetes and other risk factors were assessed by log-binomial regression. Prevalence data were compared with a historical control group of 38 individuals with diabetes receiving dialysis examined in 2004 in the same department.

Results: We found that persons with diabetes had a twofold higher risk ratio of current (unadjusted risk ratio 2.2 [95% CI 1.1, 4.7]) and previous foot ulcer (2.5 [1.7, 3.7]) and a fourfold higher risk ratio of lower-extremity amputation (4.2 [2.1, 8.6]) in comparison with persons without diabetes (all p < .05). Furthermore, persons with diabetes had a 70% increased risk ratio of myocardial infarction (1.7 [1.0-2.8], p = .041). In multivariable-adjusted analysis, current foot ulcer was independently associated with previous foot ulcer (adjusted risk ratio 4.0 [95% CI 1.8, 8.9]), while lower-extremity amputation was independently associated with diabetes (3.8 [1.8, 8.2]) and male sex (4.1 [1.5, 11.3]) (all p < .01).

Conclusions: Individuals with diabetes receiving dialysis had a higher prevalence of foot ulcer, lower-extremity amputation and myocardial infarction compared to individuals without diabetes. Previous foot ulcer was the most important risk factor for current foot ulcer, while diabetes and male sex were important risk factors for lower-extremity amputation.
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NewsBot · Nov 1, 2021

Risk factors for development of nephropathy in patients with a diabetic Charcot foot
Rasmus Bo Jansen et al
BMC Res Notes. 2021 Oct 30;14(1):403

Objective: Charcot foot is a rare complication to neuropathy and can cause severe foot deformities and ulcerations, which often require prolonged antibiotical treatment. The objective of this retrospective study was to investigate whether this treatment is associated to impaired renal function.

Results: In total, 163 patients were included, of whom 105 (64%) had received β-lactam antibiotics for a mean total duration of 13.0 months. There was a significant increase in the urine albumin/creatinine ratio in the group that received antibiotics (p = 0.017), and the use of antibiotics was associated to a subsequent diagnosis of nephropathy (p = 0.01). Patients treated with antibiotics had a 21.9% risk of developing subsequent nephropathy versus 5.2% for patients not treated with antibiotics. We suggest increased awareness on signs of nephropathy in patients with severe Charcot foot.
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NewsBot · Nov 6, 2021

Incidence and Risk Factors of Diabetic Foot Syndrome in Patients Early After Pancreas or Kidney/Pancreas Transplantation and its Association with Preventive Measures
E. Vrátná, J. Husáková, K. Králová, ...
The International Journal of Lower Extremity Wounds November 1, 2021

Diabetic foot (DF) can develop in diabetic patients after organ transplantation (Tx) due to several factors including peripheral arterial disease (PAD), diabetic neuropathy and inappropriate DF prevention. Aim: To assess the occurrence of DF and associated risk factors in transplant patients. Methods: Fifty-seven diabetic patients were enrolled as part of this prospective study. All patients underwent organ Tx (01/2013-12/2015) and were followed up for minimum of 12 months up to a maximum of 50 months. Over the study period we evaluated DF incidence and identified a number of factors likely to influence DF development, including organ function, presence of late complications, PAD, history of DF, levels of physical activity before and after Tx, patient education and standards of DF prevention. Results: Active DF developed in 31.6% (18/57) of patients after organ Tx within 11 months on average (10.7 ± 8 months). The following factors significantly correlated with DF development: diabetes control (p = .0065), PAD (p<0.0001), transcutaneous oxygen pressure (TcPO2;p = .01), history of DF (p = .0031), deformities (p = .0021) and increased leisure-time physical activity (LTPA) before Tx (p = .037). However, based on logistic stepwise regression analysis, the only factors significantly associated with DF during the post-transplant period were: PAD, deformities and increased LTPA. Education was provided to patients periodically (2.6 ± 2.5 times) during the observation period. Although 94.7% of patients regularly inspected their feet (4.5 ± 2.9 times/week), only 26.3% of transplant patients used appropriate footwear. Conclusions: Incidence of DF was relatively high, affecting almost 1/3 of pancreas and kidney/pancreas recipients. The predominant risk factors were: presence of PAD, foot deformities and higher LTPA before Tx. Therefore, we recommend a programme involving more detailed vascular and physical examinations and more intensive education focusing on physical activity and DF prevention in at-risk patients before transplantation.
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NewsBot · Dec 26, 2021

Narrative Review of the relationship between chronic kidney disease and diabetic foot ulcer
Jean-BaptisteBonnetM.D. & ArianeSultanM.D. Ph.D
Kidney International Reports 21 December 2021

Diabetic foot ulcer (DFU) and chronic kidney disease (CKD) are two significant complications of diabetes mellitus (DM). Up to 40% of patients with DM are expected to also develop CKD, and 19 to 34% will suffer from DFU during their lifetimes. However, data on the link between podiatric risk and the extent of CKD are scarce. Neuropathy, a key element of the IWGDF classification, nevertheless appears to be related to the CKD stage. The incidence of DFU and its poor evolution also appear to be linked to the stage of CKD, with mortality reaching its peak in patients with end-stage renal disease (ESRD).

Whatever, the decrease in the rate of diabetic foot amputation observed worldwide, especially for major amputations, is also observed in patients with ESRD. Specific actions taken for patients undergoing dialysis seems to improve the DFU prognosis.

CKD and DFU share a number of elements of pathophysiology, the first of which is peripheral arterial disease. Uremic neuropathy and nutritional status also seem to create a link between the development of the two complications.

This literature review provides an update on the complex and dynamic relationship between DFU and CKD. It examines the epidemiological link between CKD and diabetic foot risk, CKD and DFU occurrence, and CKD and DFU prognosis. It focuses on the pathophysiological links between these two complications. Finally, it highlights the actions taken to improve management in the ESRD population that have reduced the rate of major amputations in this population by more than half.
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NewsBot · Jan 18, 2022

Dialysis Treatment is an Independent Risk Factor for Foot Morbidity
Nathalie Schembri, Cynthia Formosa
Int J Low Extrem Wounds. 2022 Jan 17

Aim: To determine the prevalence of foot morbidity among patients with ESRD on dialysis. Methods: A prospective, non-experimental, quantitative time series design was employed. Forty-seven participants were recruited in the study. Medical records were reviewed followed by non-invasive foot assessments which included: Neurological, Arterial, Biomechanical, and Dermatological Assessment. Participants were assessed twice during the study. Results: Foot morbidity was found to be high among participants with ESRD on dialysis. 95.74% of participants presented with foot deformities, 76.60% had skin and nail conditions. 15% of participants had a history of ulceration and amputation. Moreover, active ulceration and history of revascularisation were also observed. Findings demonstrated overall poor foot health and footcare behavior within this population with 40.43% of participants having inappropriate footwear. The majority of participants did not check feet regularly, did not attend to podiatry appointments, and were unable to reach their feet for self-care. The Toe Brachial Pressure Index (TBPI), Spectral Doppler Waveform Analysis, and the Quantitative Sensory Testing (QST) were re-measured at each visit. Monophasic continuous doppler waveforms increased while triphasic waveforms decreased during the study period. Protective sensation did not decrease during the study period. The mean TBPI decreased during the study period. The relationship between the TBPI and duration of dialysis was found to be significant. Both DM and dialysis duration were identified as significant predictors of reduction in TBPI. Conclusion: This study demonstrates a high prevalence of foot morbidity among patients with ESRD on dialysis. This study highlighted the importance of expanding practice by introducing a podiatry service within the renal unit to provide foot screening, foot assessments, and foot care education, with the aim to reduce severe foot complications.
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NewsBot · Mar 8, 2022

Narrative Review of the Relationship Between CKD and Diabetic Foot Ulcer
Jean-Baptiste Bonnet, Ariane Sultan
Kidney Int Rep. 2021 Dec 21;7(3):381-388

Diabetic foot ulcer (DFU) and chronic kidney disease (CKD) are 2 significant complications of diabetes mellitus (DM). Up to 40% of patients with DM are expected to also develop CKD, and 19% to 34% will suffer from DFU during their lifetimes. However, data on the link between podiatric risk and the extent of CKD are scarce. Neuropathy, a key element of the International Working Group on the Diabetic Foot (IWGDF) classification, nevertheless appears to be related to the CKD stage. The incidence of DFU and its poor evolution also appear to be linked to the stage of CKD, with mortality reaching its peak in patients with end-stage renal disease (ESRD). Whatever, the decrease in the rate of diabetic foot amputation observed worldwide, especially for major amputations, is also observed in patients with ESRD. Specific actions taken for patients undergoing dialysis seems to improve the DFU prognosis. CKD and DFU share a number of elements of pathophysiology, the first of which is peripheral arterial disease (PAD). Uremic neuropathy and nutritional status also seem to create a link between the development of the 2 complications. This literature review provides an update on the complex and dynamic relationship between DFU and CKD. It examines the epidemiologic link between CKD and diabetic foot risk, CKD and DFU occurrence, and CKD and DFU prognosis. It focuses on the pathophysiological links between these 2 complications. Finally, it highlights the actions taken to improve management in the ESRD population that have reduced the rate of major amputations in this population by more than half.
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NewsBot · Apr 27, 2022

Kidney transplantation reduces the risk of chronic limb threatening ischemia and amputation among patients with end-stage renal disease on hemodialysis
Andres Galarza Tapia, Alina Velescu, Silvia Collado Nieto, ...
Vascular April 22, 2022

Objective
This study aimed to analyze the risk of chronic limb threatening ischemia (CLTI) or amputation among patients with end-stage renal disease (ESRD) entering a hemodialysis (HD) program and to evaluate the protective effect associated with kidney transplantation (KT).

Design, Material and Methods
Retrospective cohort of all consecutive ESRD patients entering into a HD program at our institution between 2000 and 2010. Collected variables included baseline characteristics (pre-entry in hemodialysis), time on HD program, KT and the composite outcome of chronic limb threatening ischemia or need for any amputation (CLTI/AMP). Patients with previous symptomatic peripheral arterial disease or amputation were excluded.

Results
The study group included 336 patients (mean age 63 years, 66% male). The mean follow up was 6.7 years with an average time on HD of 4.2 years. Ninety two patients (27.4 %) underwent transplantation. CLTI free survival rates were 90.3 % and 82.6 % at 5 and 10 years, respectively. The episodes of CLT involved 28 revascularization procedures (17 endovascular and 11 open surgeries), 18 minor amputations and 20 major amputations. KT was associated with a protective effect over the development of CLTI (HR: 0.065; CI 95% 0.02–0.21) after adjustment for confounding factors. The long-term survival of non-transplanted patients was 45 % and 15 % at 5 and 10 years, respectively and the long-term survival in transplanted patients was 89% and 80% at 5 and 10 years, respectively; but decreased to 47 % at 1 year and 18.2 % at 5 years once CLTI occurred.

Conclusion
Patients on HD program show a notorious risk of chronic limb threatening ischemia or amputation over time. Once this complication occurs, patient’s survival is markedly reduced. Transplantation confers an independent protective effect over the development of chronic limb threatening ischemia or amputation.
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NewsBot · Jun 5, 2022

Association between Preventive Podiatric Care and Outcomes of New Diabetic Foot Ulceration among Patients with End Stage Renal Disease
TZE-WOEI TAN; DAVID G. ARMSTRONG; CHYI CHYI CHONG; NICHOLAS J. HAMILTON-COTTER; ONKAR S. KSHIRSAGAR; DAVID G. MARRERO; DENNIS J. COTTER
Diabetes 2022;71(Supplement_1):125-OR

Objective: To assess the association between foot care by podiatric surgeons and outcomes of new diabetic foot ulceration (DFU) among patients with end-stage renal disease (ESRD) .

Methods: We used the 2015 and 2016 claim data from the United States Renal Data System to identify patients (≥ 40 years and on dialysis for ≥ 12 months) with a new diagnosis of DFU. The patients were stratified into intervention or control cohort based on whether they received any foot care by a podiatric surgeon within 12 months before the diagnosis of a new DFU. Patients were followed from the index DFU date until December 31, 2018. The study outcome was amputation-free survival (composite endpoint of mortality and major amputation) . Adjusted comparisons between preventive foot care and its association with outcomes were performed by Cox-regression analysis after propensity score matching for age, gender, race, hospitalizations, and Charlson Comorbidity Index (CCI) .

Results: Among the 51,362 ESRD patients included, 16,156 (31.5%) received podiatric care within 12 months before their index DFU. Compared to the control cohort, the intervention cohort was older, likely to be female (44% vs. 39%) , and more likely to have peripheral artery disease (64.2% vs. 49.5%) . The overall major amputation rate was 9.6% during study follow-up (intervention: 9.3% vs. control: 9.8%) . A Kaplan-Meier estimate indicated that foot care before index DFU was associated with increased amputation-free survival based on the Log Rank test (p<0.0001) . In addition, the multivariable analysis demonstrated that foot care prior to index DFU was associated with a lower risk of death or major amputation in both the unmatched (Hazard ratio [HR] 0.92, 95% Confidence Interval [CI] 0.90, 0.93, p<0.0001) and matched cohorts (HR 0.82, 95% CI 0.79, 0.85, p<0.0001) .

Conclusion: Among patients with end stage renal disease, preventive podiatric care appears to improve amputation-free survival for DFU.
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NewsBot · Jun 8, 2022

Risk factors for foot ulcer recurrence in patients with comorbid diabetic foot osteomyelitis and diabetic nephropathy: A 3-year follow-up study
Li Zhang et al
Int Wound J. 2022 Jun 8

This study aimed to explore the risk factors for foot ulcer recurrence in patients with comorbid diabetic foot osteomyelitis (DFO) and diabetic nephropathy (DN). This is a prospective cohort study. Between May 2018 and May 2021, we selected 120 inpatients with comorbid severe diabetic foot infection (PEDIS Grade 3 or above) and DN for inclusion in our study. All cases were followed up for 36 months. The study outcomes were whether foot ulcer recurred and the time to recurrence. The risk factors of ulcer recurrence were analysed by comparing the data of the three groups. According to the recurrence of foot ulcer, the participants were divided into three groups: Group A (no foot ulcer recurrence, n = 89), Group B (foot ulcer recurrence within 12-36 months, n = 19) and Group C (foot ulcer recurrence within 6-12 months, n = 12). The multivariate Cox regression analysis showed that urine albumin-creatinine ratio (UACR) (HR: 1.008, 95% CI: 1.005-1.011, P < .001) and vibration perception threshold (VPT) (HR: 1.064, 95% CI: 1.032-1.096, P < .001) were identified as independent risk factors. Kaplan-Meier curves showed a significant positive association between UACR or VPT and the risk of foot ulcer recurrence (log rank, all P < .05). Areas under the ROC curves for UACR, VPT and the combination of UACR and VPT were 0.802, 0.799 and 0.842, respectively. The best cut-off values of UACR and VPT were 281.51 mg/g and 25.12 V, respectively. In summary, elevated UACR and VPT were independent risk factors. The best clinical cut-off values of UACR and VPT for prediction of foot ulcer recurrence were 281.51 mg/g and 25.12 V, respectively. Besides, our results suggested that microcirculation disorders rather than macrovascular complications play a major role in the recurrence of foot ulcer in patients with comorbid DFO and DN.
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NewsBot · Aug 15, 2022

THE STATE OF RENAL HEMODYNAMICS IN PATIENTS
WITH SEVERE COMPLICATIONS OF DIABETIC FOOT
SYNDROME (ULCER, GANGRENE, AMPUTATION) IS
ASSOCIATED WITH CHRONIC KIDNEY DISEASE
T.T. Kamalov et al
International Journal of Early Childhood Special Education (INT-JECSE)

Objective: to study the nature of renal hemodynamics in patients with severe complications of
diabetic foot syndrome (ulcer, gangrene, amputation) associated with chronic kidney disease.
Research material.95 patients were examined (prospectively) with type 2 diabetes with SDS with
severe complications in the period 2021-2024 in the Department of Endocrinology, in the
department of diabetic foot. All observed patients were divided into 4 groups:
1 gr. – 25 patients with SDS, complicated by ulcer, gangrene and amputation and combined with
CKD of 4-5 stages on hemodialysis
2 gr. – 25 patients with SDS, complicated by ulcers, gangrene and amputation in combination
with CKD of 4-5 stages without hemodialysis
3 gy – 20 patients with SDS, complicated by gangrene and amputation without CKD.
4 gy – 25 patients with SDS, without severe complications, with the initial stage of CKD.
The control group consisted of 20 healthy individuals.
The research methods are biochemical (bilirubin, direct, indirect, lipid spectrum, ALT, AST,
PTI, coagulogram, blood sugar, glycated hemoglobin, urea, creatinine, GFR, wound pathogens,
procalcitonin, interleukin - 6, vascular endothelial growth factor VEGF-A and instrumental:
ECG, MRI of the feet, dopplerography of the main vessels legs, ultrasound of internal organs,
fundus.
The highest rates of fasting glycemia were observed in patients of group 2, that is, with SDS and
CKD 4-5 ct without hemodialysis. Significantly lower hemoglobin values were also observed in
this group of patients (p<0.001), glycated hemoglobin significantly higher values of urea,
creatinine and GFR (p<0.001).All patients had significantly reduced HDL values (p<0.001) and
total cholesterol (p<0.05).
A study of renal hemodynamics found its violation in groups 1 and 2 of patients.
Conclusion 1) Biochemical parameters were significantly impaired in patients of groups 1 and 2,
that is, with SDS and CKD 4-5 ct on hemodialysis, which indicates the need for further studies in
this group of patients. 2) There were significant differences between the indicators of
dopplerography of the renal arteries in groups 1 and 2 in comparison with the data of the control
group.
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NewsBot · Aug 30, 2022

ACUTE DIABETIC FOOT IN POST KIDNEY TRANSPLANTATION PATIENTS RECEIVING CHRONIC IMMUNOSUPPRESSION - CLINICAL PRESENTATION AND OUTCOMES
Kobi Gorin et al
Diabetes Metab Res Rev. 2022 Aug 29

Aims: Data regarding diabetic foot ulcers (DFU) in patients after solid organ transplantation, particularly kidney transplantation, are limited. Chronic immunosuppression may be associated with impaired wound healing and a higher risk of amputations. In this study we characterized the clinical presentation and outcomes of patients after kidney transplantation admitted to the diabetic foot unit, compared to non-kidney-transplant patients.

Materials and methods: Data on the baseline characteristics, clinical presentation and outcomes of all patients admitted to the diabetic foot unit of a large tertiary center between the years 2014-2019 were collected. The most recent admission of each patient was considered. Primary outcomes were major amputations and one-year mortality rate.

Results: During the study period 537 patients were hospitalized, 18 of them receiving immunosuppressive therapy due to kidney transplantation. Baseline characteristics of the patients were broadly similar, except that smoking was reported by 22.0% of the non-transplant patients and by none of the post-transplant patients (p=0.01). Post-transplant patients tended to be younger (59.4±11.1 vs. 65.3±12.2; p=0.07), were more likely to have type-1 diabetes (16.7% vs. 5.2%; p=0.07) and had lower glucose levels upon admission (9.4±4.3 vs. 12.0±6.4 mmol/L; p=0.07). Overall, 30% of the patients underwent major amputation, in-patient mortality rate was 9.3%, and 1-year mortality rate was 27.2%. Rates were similar in the post-transplant vs. the non-post-transplant patients (p=0.83, 1.00, 0.59 respectively).

Conclusions: Post-transplant patients did not incur worse outcomes in spite of immunosuppressive therapy. Limb salvage efforts should be pursued in these patients similar to the overall population.
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NewsBot · Nov 21, 2022

Biomarkers of Chronic Kidney Disease-Mineral Bone Disorder (CKD-MBD) in the Diabetic Foot: A Medical Record Review
Michael A. Jones et al
November 17, 2022

Highlights
•The diabetic foot is an overlooked target of CKD–MBD syndrome.
•Progressive CKD-MBD in the diabetic foot leads to increased risk for minor foot amputation when 3 biomarkers (i.e. pedal vessel calcification, buckling ratio ≥3.5 in 2nd or 5th metatarsal, and peripheral neuropathy) are present.
•Foot radiography and serum markers may be effective screening tools for CKD-MBD in patients with diabetes mellitus.
•Preliminary findings from this novel investigation may alert clinicians in helping to reduce nontraumatic lower extremity amputation (NLEA) in patients with diabetes mellitus/CKD-MBD.
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Aims
Determine the prevalence and relative risk of having single and combinations of biomarkers of chronic kidney disease-mineral bone disorder (CKD-MBD) syndrome in the diabetic foot from an electronic medical record (EMR) review.
Methods
Review of 152 patients with one foot radiograph and diagnoses of both diabetes mellitus (DM) and chronic kidney disease (CKD) stages 1-5. Presence/absence of peripheral neuropathy (PN), targeted serum markers, and both pedal vessel calcification (PVC) and buckling ratio (BR) of 2nd and 5th metatarsals from radiographs were recorded. Prevalence of single and combinations of foot biomarkers are reported as count and percentage. Risk ratios (RR) with 95% confidence intervals (95% CI) were calculated to assess risk of foot biomarkers in each stage of CKD-MBD.
Results
Prevalence and RR of PVC, PN, and BR ≥ 3.5 biomarkers, both single and in combination, all increase with progression of CKD. The RR increases to 9.6 (95% CI: 3, 26; p<0.001)) when all 3 biomarkers present in stage 5.
Conclusions
PVC, PN, and BR ≥ 3.5 are prognostic biomarkers of CKD–MBD syndrome in the diabetic foot. Recognition of these foot biomarkers may allow earlier interventions to help reduce nontraumatic lower extremity amputation in individuals with diabetic CKD-MBD.
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NewsBot · Nov 22, 2022

Diabetic foot disease in subjects with End-stage renal Disease: A nationwide study over 14 years highlighting an emerging threat
Cheng-Wei Lin et al
Diabetes Res Clin Pract. 2022 Oct 29

Aims: To disclose prevalence, demographic, foot characteristics as well as management and lower-extremity amputations (LEAs) of subjects with end-stage renal disease (ESRD) on diabetic foot diseases (DFDs).

Methods: Data were derived from the Taiwan National Health Insurance Research Database between 2004 and 2017. DFDs were defined as ulcers, infections, or severe peripheral arterial diseases (PADs) in patients with type 2 diabetes. Clinical characteristics were analyzed between subjects with and without ESRD.

Results: Subjects with ESRD have increased impacts on the DFD population either from annual prevalence (2.7 % to 10.42 %, P for trend < 0.001), or proportional representation in LEAs (7.91 % to 26.37 %, P < 0.001) over 14 years. The annual trends for major-LEAs rates have decreased in both subjects with and without ESRD (13.67 % to 5.82 % and 3.48 % to 1.47 %, both P < 0.001). Notably, the concomitant increase of endovascular treatments (EVTs) (7.09 % to 29.41 %, P < 0.001) was associated with the decrease of major-LEAs (P for interaction < 0.001) in subjects with ESRD.

Conclusions: As the annual prevalence of subjects with ESRD has increased 3.9-fold over years, they now account for more than 30% of annual major-LEA of the total DFD population. Interdisciplinary team approach and aggressive EVTs might reduce major-LEAs in these patients.
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NewsBot · Jan 16, 2023

The influence of simultaneous pancreas-kidney transplantation on the evolution of diabetic foot lesions and peripheral arterial disease
S S Monteiro et al
J Endocrinol Invest. 2023 Jan 16

Purpose: Simultaneous pancreas-kidney transplantation (SPKT) remains the best treatment option in patients with type 1 diabetes and chronic kidney failure. There are only a few studies addressing the potential ischemic deterioration of peripheral arterial disease (PAD) due to blood diverting from the iliac artery to the kidney graft. We aimed to evaluate diabetic foot lesions and PAD evolution in SPKT recipients and investigate if they are more frequent in ipsilateral lower limb of kidney graft.

Methods: We developed a retrospective cohort, including patients submitted to SPKT in our tertiary center, between 2000 and 2017. Diabetic foot lesions and PAD frequencies were compared in the period before and after transplantation.

Results: Two hundred and eleven patients were included, 50.2% (n = 106) female, with a median age at transplantation of 35 years (IQR 9). After a median follow-up period of 10 years (IQR 7), patient, kidney, and pancreatic graft survival were 90.5% (n = 191), 83.4% (n = 176), and 74.9% (n = 158), respectively. Before transplant, 2.8% (n = 6) had PAD and 5.3% (n = 11) had history of foot lesions. In post-transplant period, 17.1% (n = 36) patients presented PAD and 25.6% (n = 54) developed diabetic foot ulcers, 47.6% (n = 35) of which in the ipsilateral and 53.3% (n = 40) in the contralateral lower limb of the kidney graft (p = 0.48). Nine patients (4.3%) underwent major lower limb amputation, 3 (30%) ipsilateral and 7 (70%) contralateral to the kidney graft (p = 0.29).

Conclusions: Diabetic foot lesions were not more frequent in the ipsilateral lower limb of the kidney graft, therefore downgrading the 'steal syndrome' role in these patients.
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NewsBot · Jan 17, 2023

Clinical Characteristics and Prognosis of Diabetic Foot Ulcers Patients of Different Renal Function Statuses
Da-Wei Chen et al
Sichuan Da Xue Xue Bao Yi Xue Ban. 2023 Jan;54(1):165-170

Objective: To explore the clinical characteristics and the prognosis of diabetic foot ulcers (DFU) inpatients of different renal function statuses.

Methods: A retrospective analysis of 962 inpatients with DFU was conducted. The patients were divided into three groups according to their renal function statuses, and the clinical characteristics of the three groups were compared to identify differences. In addition, the patients were followed up in outpatient clinics or by telephone and their prognostic status and risk factors for death were analyzed.

Results: Analysis of the clinical characteristics showed that, compared with diabetic patients with normal renal function or mild renal function impairment, diabetic patients with moderate and severe renal function impairment had a longer course of disease ( P<0.001). Patients with foot ulcers of Wagner grade 4 predominates the moderate and severe renal function impairment groups ( P<0.05). Patients in the moderate and severe renal function impairment groups had a relatively higher proportion of comorbidities, including hypertension, coronary heart disease, and peripheral arterial disease ( P<0.05). These patients had relatively lower levels of glycosylated hemoglobin and hemoglobin (all P<0.05) and relatively higher levels of neutrophil ratio and procalcitonin (all P<0.05). Of the two groups, patients in the moderate renal function impairment group were older ( P<0.001) and had lower ankle-brachial index ( P<0.001). The severe renal function impairment group had a higher proportion of patients with foot ulcers of Wagner grades 3 and 5 (all P<0.05). For the purpose of conducting prognostic analysis, 748 patients were followed up in outpatient clinics or by telephone for a median length of 41 months. Among them, 239 died. The all-cause mortality was 31.9%, and the mortality in the three groups was 25.8%, 46.2% ( P<0.001), and 59.4% ( P<0.001), respectively. The survival rate of patients in the moderate and severe renal function impairment groups was significantly lower than those in the normal renal function and mild renal function impairment groups ( P<0.001). Univariate Cox regression analysis showed that age, concomitant coronary heart disease and peripheral arterial disease, degree of renal function impairment, and foot ulcers of Wagner grade 4 and 5 were associated with all-cause deaths. Furthermore, multivariate Cox regression analysis showed that moderate and severe renal function impairment was an independent risk factor for all-cause deaths in DFU patients ( P<0.001).

Conclusions: As renal function impairment worsens, patients with DFU present clinical characteristics of greater complexity, higher risks of cardiovascular events, and higher mortality. It is essential to prevent kidney damage and foot ulcers, to pay attention to the cardiovascular risks of DFU patients with moderate and severe renal function impairment, and to reduce mortality.
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NewsBot · Jan 23, 2023

Clinical Characteristics and Prognosis of Diabetic Foot Ulcers Patients of Different Renal Function Statuses
Da-Wei Chen et al
Sichuan Da Xue Xue Bao Yi Xue Ban. 2023 Jan;54(1):165-170

Objective: To explore the clinical characteristics and the prognosis of diabetic foot ulcers (DFU) inpatients of different renal function statuses.

Methods: A retrospective analysis of 962 inpatients with DFU was conducted. The patients were divided into three groups according to their renal function statuses, and the clinical characteristics of the three groups were compared to identify differences. In addition, the patients were followed up in outpatient clinics or by telephone and their prognostic status and risk factors for death were analyzed.

Results: Analysis of the clinical characteristics showed that, compared with diabetic patients with normal renal function or mild renal function impairment, diabetic patients with moderate and severe renal function impairment had a longer course of disease ( P<0.001). Patients with foot ulcers of Wagner grade 4 predominates the moderate and severe renal function impairment groups ( P<0.05). Patients in the moderate and severe renal function impairment groups had a relatively higher proportion of comorbidities, including hypertension, coronary heart disease, and peripheral arterial disease ( P<0.05). These patients had relatively lower levels of glycosylated hemoglobin and hemoglobin (all P<0.05) and relatively higher levels of neutrophil ratio and procalcitonin (all P<0.05). Of the two groups, patients in the moderate renal function impairment group were older ( P<0.001) and had lower ankle-brachial index ( P<0.001). The severe renal function impairment group had a higher proportion of patients with foot ulcers of Wagner grades 3 and 5 (all P<0.05). For the purpose of conducting prognostic analysis, 748 patients were followed up in outpatient clinics or by telephone for a median length of 41 months. Among them, 239 died. The all-cause mortality was 31.9%, and the mortality in the three groups was 25.8%, 46.2% ( P<0.001), and 59.4% ( P<0.001), respectively. The survival rate of patients in the moderate and severe renal function impairment groups was significantly lower than those in the normal renal function and mild renal function impairment groups ( P<0.001). Univariate Cox regression analysis showed that age, concomitant coronary heart disease and peripheral arterial disease, degree of renal function impairment, and foot ulcers of Wagner grade 4 and 5 were associated with all-cause deaths. Furthermore, multivariate Cox regression analysis showed that moderate and severe renal function impairment was an independent risk factor for all-cause deaths in DFU patients ( P<0.001).

Conclusions: As renal function impairment worsens, patients with DFU present clinical characteristics of greater complexity, higher risks of cardiovascular events, and higher mortality. It is essential to prevent kidney damage and foot ulcers, to pay attention to the cardiovascular risks of DFU patients with moderate and severe renal function impairment, and to reduce mortality.
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NewsBot · Feb 6, 2023

An Analysis of the Prevalence and Risk Factors of Contrast-Associated Acute Kidney Injury in Patients With Diabetic Foot Ulcer
Hüseyin Karaaslan et al
Angiology. 2023 Feb 6

The occurrence of contrast-associated acute kidney injury (CA-AKI) is influenced by both patient-related and contrast-related factors. More specifically, CA-AKI has been linked to renal dysfunction, diabetes mellitus (DM), and atherosclerotic cardiovascular diseases (ASCVD). We hypothesized that the prevalence of CA-AKI was high in patients with diabetic foot ulcers (DFU) because they frequently have several ASCVD risk factors and additional comorbid conditions (including ASCVD). We retrospectively examined the medical records of 208 type 2 diabetic patients who were hospitalized for DFU. These patients were divided into two groups: group 1 included 107 patients who underwent contrast-enhanced computed tomographic angiography (CTA); group 2 (control group) included 101 patients who did not receive contrast media. Following CTA, 13 (12.1%) patients developed CA-AKI in group 1, while 3 (3.0%) patients in group 2 had serum creatinine elevations consistent with AKI (P = 0.013). The following risk factors for CA-AKI were identified: longer history of DM, higher baseline serum creatinine, congestive heart failure, Wagner stage 4 and 5 DFUs, peripheral artery disease, older age, and lower hemoglobin values. CA-AKI is a common complication after CTA in patients with DFU. To reduce the risk of CA-AKI in these patients, associated risk factors and preventive measures should be considered.
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NewsBot · May 1, 2023

Contrast-Associated Acute Kidney Injury: More Frequent Among Patients With Diabetic Foot Ulcers

NewsBot · May 9, 2023

The renal function in patients with severe complications of diabetic foot syndrome with chronic kidney disease
Telman Kamalov & Khamidulla Shokirov
Endocrine Abstracts (2023) 90 EP282

Aim: To study renal function in patients with severe complications of diabetic foot syndrome (ulcer, gangrene, amputation) associated with chronic kidney disease.

Material and Methods: 91 patients with DM 2 were examined. The patients were divided into 4 groups:1 gr. – 25 patients with DFS complicated by ulcer, gangrene and amputation and in combination with CKD 4-5 stages on hemodialysis; 2 gr. – 25 patients with DFS complicated by ulcer, gangrene and amputation in combination with CKD stages 4-5 without hemodialysis; 3 gr - 20 patients with DFS complicated by gangrene and amputation without CKD.;4 gr - 21 patients with DFS, without severe complications, with the initial stage of CKD.

Research methods: Biochemical (bilirubin, direct, indirect, lipid spectrum, ALT, AST, PTI, coagulogram, blood sugar, glycated hemoglobin, urea, creatinine, GFR, wound pathogens, procalcitonin, interleukin-6, vascular endothelial growth factorVEGF-A and instrumental: ECG, MRI of the feet, Dopplerography of the main vessels of the legs, ultrasound of the internal organs, the fundus.

Results: The highest rates of fasting glycemia were observed in patients of group 2, that is, with DFS and CKD 4-5 stages without hemodialysis. Significantly lower hemoglobin values were also observed in this group of patients (P<0.001), glycated hemoglobin significantly higher values of urea, creatinine and GFR (P<0.001). All patients had significantly reduced values of HDL (P<0.001) and total cholesterol (P<0.05).

Conclusion: Biochemical parameters were significantly impaired in patients of group 1, that is, with DFS and CKD 4-5 stages on hemodialysis, which indicates the need for further research in this group of patients.
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NewsBot · May 23, 2023

Renal function is highly associated with podiatric risk in diabetic patients
Jean-Baptiste Bonnet, Ilan Szwarc, Antoine Avignon, Sébastien Jugant, Ariane Sultan
Clinical Kidney Journal, 11 May 2023

Introduction
Chronic kidney disease (CKD) is correlated with the incidence of DFU. Furthermore, the International Working Group on the Diabetic Foot (IWGDF) has proposed a classification of the risk factors for diabetic foot ulcer (DFU). The purpose of this study was to investigate the relationship between the IWGDF risk classification and the GFR level estimated by the CKD-EPI formula.

Methods
We conducted a prospective multicentric study. Patients were recruited from either diabetology or nephrology departments. The secondary objectives were to determine this relationship after excluding people on dialysis and to identify the factors associated with podiatric risk.

Results
Four hundred and eighty-six patients were included, with a mean age of 64.2 years (±15.7) and a mean diabetes duration of 15.7 years (±12.1). Based on the IWGDF classification, 53.5% of the population were in podiatric stage 0, 11.7% in stage 1, 34.8% in stage 2 or 3. The mean GFR level was significantly lower in patients with podiatric risk ≥ 2 (36.8 ± 33.9 ml/min/1.73m2 vs 71.9 ± 35.3 ml/min/1.73m2, P < 0.0001) and a significant association was found between the GFR and the podiatric risk. This association remains significant after the exclusion of the hemodialysis patients. After ROC analysis, a cutoff of 45±11 ml/min/1.73m2 (AUC: 0.76) was found discriminant to define a group of CKD patients at higher risk for podiatric stage ≥ 2.

Conclusion
GFR levels are linked to podiatric stages in diabetes mellitus. Patients with GFR <45 ml/min/1.73m2 and dialysis patients should be carefully managed in collaboration with diabetic foot specialized centers.
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NewsBot · Jun 5, 2023

Medial Arterial Calcification and the Risk of Amputation of Diabetic Foot Ulcer in Patients With Diabetic Kidney Disease
Joon Myeong So et al
J Korean Med Sci. 2023 May 29;38(21):e160.

We assessed the risk factors for major amputation of diabetic foot ulcers (DFUs) in patients with diabetic kidney disease (DKD) stages 3b-5. For DFU assessment, in addition to DFU location and presence of infection, ischemia, and neuropathy, vascular calcification was assessed using the medial arterial calcification (MAC) score. Of 210 patients, 26 (12.4%) underwent major amputations. Only the location and extension of DFU, represented by Texas grade differed between the minor and major amputation groups. However, after adjusting for covariates, ulcer location of mid- or hindfoot (vs. forefoot, odds ratio [OR] = 3.27), Texas grades 2 or 3 (vs. grade 0, OR = 5.78), and severe MAC (vs. no MAC, OR = 4.46) was an independent risk factor for major amputation (all P < 0.05). The current use of antiplatelets was a possible protective factor for major amputations (OR = 0.37, P = 0.055). In conclusion, DFU with severe MAC is associated with major amputation in patients with DKD.
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NewsBot · Jul 13, 2023

Variability of toe pressures during haemodialysis: comparison of people with and without diabetes; a pilot study
Rachel Carle, Peta Tehan, Sarah Stewart, David Semple, Andrew Pilmore & Matthew R. Carroll
Journal of Foot and Ankle Research volume 16, Article number: 42 (2023)

Background
Diabetes, end stage renal disease (ESRD), and peripheral arterial disease (PAD) are associated with a higher risk of diabetes-related lower limb amputation. Timely identification of PAD with toe systolic blood pressure (TSBP) and toe-brachial pressure index (TBPI) is critical in order to implement foot protection strategies to prevent foot complications in people with ESRD. There is limited evidence describing the effect of haemodialysis on TSBP and TBPI. This study aimed to determine the variability of TSBP and TBPI during haemodialysis in people with ESRD, and to determine whether any observed variability differed between people with and without diabetes.

Methods
TSBP and TBPI were taken before dialysis (T1), one hour into dialysis (T2) and in the last 15 min of dialysis (T3) during a single dialysis session. Linear mixed effects models were undertaken to determine the variability in TSBP and TBPI across the three time points and to determine whether this variability differed between people with and without diabetes.

Results
Thirty participants were recruited, including 17 (57%) with diabetes and 13 (43%) with no diabetes. A significant overall reduction in TSBP was observed across all participants (P < 0.001). There was a significant reduction in TSBP between T1 and T2 (P < 0.001) and between T1 and T3 (P < 0.001). There was no significant overall change in TBPI over time (P = 0.62). There was no significant overall difference in TSBP between people with diabetes and people with no diabetes (mean difference [95% CI]: -9.28 [-40.20, 21.64], P = 0.54). There was no significant overall difference in TBPI between people with diabetes and people with no diabetes (mean difference [95% CI]: -0.01 [-0.17, 03.16], P = 0.91).

Conclusion
TSBP and TBPI are an essential part of vascular assessment of the lower limb. TBPI remained stable and TSBP significantly reduced during dialysis. Given the frequency and duration of dialysis, clinicians taking toe pressures to screen for PAD should be aware of this reduction and consider how this may have an impact on wound healing capacity and the development of foot related complications.
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NewsBot · Aug 12, 2023

Intradialytic plantar electrical nerve stimulation to improve mobility and plantar sensation among adults with diabetes undergoing hemodialysis: a randomized double-blind trial
Ram Kinker Mishra et al
J Nephrol. 2023 Jul;36(6):1627-1637

Background: Impaired mobility is a debilitating consequence of hemodialysis. We examined the efficacy of intradialytic-plantar-electrical-nerve-stimulation (iPENS) to promote mobility among diabetes patients undergoing hemodialysis..

Methods: Adults with diabetes undergoing hemodialysis received either 1-h active iPENS, (Intervention-Group) or non-functional iPENS (Control-Group) during routine hemodialysis for 12 weeks (3 sessions/week). Participants and care-providers were blinded. Mobility (assessed using a validated pendant-sensor) and neuropathy (quantified by vibration-perception-threshold test) outcomes were assessed at baseline and 12 weeks.

Results: Among 77 enrolled subjects (56.2 ± 2.6 years old), 39 were randomly assigned to the intervention group, while 38 were assigned to the control group. No study-related adverse events and dropouts were reported in the intervention group. Compared to the control group, significant improvements with medium to large effect sizes were observed in the intervention group at 12 weeks for mobility-performance metrics, including active-behavior, sedentary-behavior, daily step counts, and sit-to-stand duration variability (p < 0.05), Cohen's d effect size (d = 0.63-0.84). The magnitude of improvement in active-behavior was correlated with improvement in the vibration-perception-threshold test in the intervention group (r = - 0.33, p = 0.048). A subgroup with severe-neuropathy (vibration-perception-threshold > 25 V) showed a significant reduction in plantar numbness at 12 weeks compared to baseline (p = 0.03, d = 1.1).

Conclusions: This study supports feasibility, acceptability, and effectiveness of iPENS to improve mobility and potentially reduce plantar numbness in people with diabetes undergoing hemodialysis. Considering that exercise programs are not widely used in hemodialysis clinical practice, iPENS may serve as a practical, alternative solution to reduce hemodialysis-acquired weakness and promote mobility.
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NewsBot · Sep 12, 2023

Analysis of the Influence of Diabetic Nephropathy in Patients with Diabetic Foot Osteomyelitis
Yolanda García-Álvarez et al
J Clin Med. 2023 Aug 26;12(17):5557.

This study analyzed the influence of diabetic nephropathy on the healing prognosis after conservative surgery in diabetic foot osteomyelitis (DFO). A retrospective observational study was carried out between January 2021 and December 2022 and involved 278 outpatients with a diagnosis of DFO at a specialized diabetic foot unit, including 74 (26.62%) patients with DN (group 2) and 204 (73.38%) patients without DN (group 1). There were 266 (95.70%) ulcers on the forefoot, 8 (2.90%) on the midfoot, and 4 (1.45%) on the hindfoot (p = 0.992). The healing rates were 85.1% (n = 63) for group 2 and 81.3% (n = 165) for group 1 (p = 0.457). When exploring the influence of DN on the risk of delayed ulcer healing, the results did not show a significant effect [12 (6; 28) weeks among patients with DN vs. 12 (6; 21) weeks among patients without DN; p = 0.576]. No significant differences were observed in complications, with one (2.59%) death occurring in group 1 (p = 0.296) and three minor amputations being performed in both groups [two (5.13%) amputations in group 1 vs. one amputation (9.09%) in group 2; p = 0.217]. Bone cultures were performed for a total of 190 patients (133 in group 1 and 57 in group 2). Of these, 176 positive bone cultures were isolated: 71 positive bone cultures (57.7%) were monomicrobial cultures in group 1, with 30 (56.6%) in group 2. There were 52 (42.3%) that had at least two microorganisms in group 1, and 23 (43.4%) in group 2 (p = 0.890). The most frequently prescribed oral antibiotic was amoxicillin/clavulanate (43.89%), followed by levofloxacin (28.4%), and trimethoprim/sulfamethoxazole (14.7%). This study shows that DN does not have a significant influence on the healing prognosis of patients with DFO after conservative surgery.
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NewsBot · Sep 12, 2023

Risk Factors for Lower Extremity Amputation in Patients with End-Stage Kidney Disease: A Nationwide Cohort Study
Min Jun Seo et al
J Clin Med. 2023 Aug 30;12(17):5641

Individuals with end-stage kidney disease (ESKD) on dialysis are at a high risk of developing foot ulcerations and undergoing subsequent lower extremity amputation (LEA), which can exert significant impacts on their quality of life and contribute to rising healthcare costs. We aimed to identify risk factors associated with LEA in patients with ESKD to predict LEA progression and eventually prevent it. We used 18 years (2002-2019) of data from the Korean National Health Insurance Service (KNHIS). Data were collected from patients with ESKD who underwent renal replacement therapy (RRT) and had no history of amputation caused by trauma or toxins. The risk factors were compared between patients with or without LEA. We collected data from 220,838 patients newly diagnosed with ESKD, including 6348 in the LEA group and 214,490 in the non-LEA group. The total incidence of LEA was 2.9%. Older age, male gender, lower income, non-metropolitan residence, diabetes mellitus, dialysis treatment (compared to kidney transplantation), microvascular disease, peripheral vascular disease, endovascular procedure, and endovascular operation were associated with an increased risk of LEA. Thus, individuals with ESKD who are at a higher risk for LEA should be closely monitored, and kidney transplantation should be considered as a preventative measure.
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NewsBot · Sep 12, 2023

Sequential treatment for diabetic foot ulcers in dialysis patients: A case report
Jin-Jun Wang et al
World J Diabetes. 2023 Aug 15;14(8):1323-1329

Background: Diabetic foot ulcers (DFUs) are common in patients with diabetes, especially those undergoing hemodialysis. In severe cases, these ulcers can cause damage to the lower extremities and lead to amputation. Traditional treatments such as flap transposition and transfemoral amputation are not always applicable in all cases. Therefore, there is a need for alternative treatment methods.

Case summary: This report describes a 62-year-old female patient who was admitted to the hospital with plantar and heel ulcers on her left foot. The patient had a history of renal failure and was undergoing regular hemodialysis. Digital subtraction angiography showed extensive stenosis and occlusion in the left superficial femoral artery, left peroneal artery and left posterior tibial artery. Following evaluation by a multidisciplinary team, the patient was diagnosed with type 2 DFUs (TEXAS 4D). Traditional treatments were deemed unsuitable, and the patient was treated with endovascular surgery in the affected area, in addition to supportive medical treatment, local debridement, and sequential repair using split-thickness skin and tissue-engineered skin grafts combined with negative pressure treatment. After four months, the wound had completely healed, and the patient was able to walk with a walking aid.

Conclusion: This study demonstrates a new treatment method for DFUs was successful, using angioplasty, skin grafts, and negative pressure.
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NewsBot · Sep 12, 2023

Risk factors of foot ulcers in patients with end-stage renal disease on dialysis: A meta-analysis
Shanshan Yan, Dongfang Yao, Ya Wang, Jian Zhang
04 September 2023

The present study aims to assess the risk factors for foot ulcers in patients undergoing dialysis for end-stage renal disease (ESRD) and to provide evidence-based guidance for prevention and treatment. A systematic search was conducted on PubMed, EMBASE, Cochrane Library, China National Knowledge Infrastructure, Chinese Biomedical Literature Database and Wanfang Data from the database inception until May 2023 to identify relevant studies investigating the risk factors for foot ulcers in dialysis patients with ESRD. Two independent researchers conducted the literature screening and data extraction. The meta-analysis was performed using STATA 17.0 software. Ultimately, six articles comprising 1620 patients were included for analysis. The meta-analysis revealed that male (OR, 1.464; 95% CI: 1.082–1.980, p = 0.013), hypertension (OR, 1.781; 95% CI: 1.293–2.4550, p < 0.001), peripheral artery disease (PAD) (OR, 5.014; 95% CI: 2.514–9.998, p < 0.001), type 1 diabetes mellitus (T1DM) (OR, 2.993; 95% CI: 1.477–6.065, p = 0.002) and type 2 diabetes mellitus (T2DM) (OR, 2.498; 95% CI:1.466–4.256, p = 0.001) were risk factors for foot ulcers in dialysis patients with ESRD. Conversely, the female sex (OR, 0.683; 95% CI: 0.505–0.924, p = 0.013) was a protective factor against foot ulcers. Our analysis revealed that male sex, hypertension, PAD, T1DM and T2DM were risk factors for foot ulcers in patients undergoing dialysis for ESRD. Conversely, the female sex was a protective factor against foot ulcers. Therefore, it is crucial to strengthen health education that targets patients with these risk factors and regularly screen high-risk individuals. Early detection and treatment can help delay disease progression.
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NewsBot · Nov 6, 2023

Renal function is highly associated with podiatric risk in diabetic patients
Jean-Baptiste Bonnet et al
Clin Kidney J. 2023 May 11;16(11):2156-2163

Background: Chronic kidney disease (CKD) is correlated with the incidence of diabetic foot ulcer (DFU). Furthermore, the International Working Group on the Diabetic Foot (IWGDF) has proposed a classification of the risk factors for DFU. The purpose of this study was to investigate the relationship between the IWGDF risk classification and the glomerular filtration rate level estimated by the CKD Epidemiology Collaboration formula (eGFR).

Methods: We conducted a prospective multicentric study. Patients were recruited from either diabetology or nephrology departments. The secondary objectives were to determine this relationship after excluding people on dialysis and to identify the factors associated with podiatric risk.

Results: Four hundred and eighty-six patients were included, with a mean age of 64.2 years (±15.7) and a mean diabetes duration of 15.7 years (±12.1). Based on the IWGDF classification, 53.5% of the population were in podiatric stage 0, 11.7% in stage 1 and 34.8% in stage 2 or 3. The mean eGFR level was significantly lower in patients with podiatric risk ≥2 (36.8 ± 33.9 mL/min/1.73 m2 vs 71.9 ± 35.3 mL/min/1.73 m2, P < .0001) and a significant association was found between the eGFR and the podiatric risk. This association remained significant after the exclusion of the hemodialysis patients. After receiver operating characteristic analysis, a cutoff of 45 ± 11 mL/min/1.73 m2 (area under the curve 0.76) was found discriminant to define a group of CKD patients at higher risk for podiatric stage ≥2.

Conclusion: eGFR levels are linked to podiatric stages in diabetes mellitus. Patients with eGFR <45 mL/min/1.73 m2 and dialysis patients should be carefully managed in collaboration with diabetic foot specialized centers.
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NewsBot · Nov 14, 2023

Evaluation of risk factors for foot ulceration in individuals with chronic kidney disease
Vacide Aşık Özdemir, Nesrin Nural
Wounds. 2023 Oct;35(10):E319-E328.

Introduction: CKD, like DM, is an independent risk factor for the development and course of foot ulcers.

Objective: The authors studied the incidence and risk factors of foot ulceration in patients with CKD and with or without DM and in patients receiving or not receiving HD.

Materials and methods: Patients with or without DM and with renal failure were divided into 4 groups of 40 patients each according to whether or not they were receiving HD. Data were collected using a patient information form, physical examination of the foot, and risk assessment forms.

Results: Lower extremity ulceration was highest in group 3 (HD+DM+) (15% [6 of 40]), that is, in patients with CKD and DM receiving HD (P = .421). Patients in group 3 were at highest risk for foot ulcers (72.5%) compared with other groups (P = .001). Risk factors associated with foot ulceration were advanced stage (ie, stage 4 or 5) CKD, HD treatment, age, BMI, history of lower extremity ulceration and/or amputation, foot deformities, skin and nail pathology, neuropathy, and vascular insufficiency.

Conclusions: Patients with CKD receiving HD are at high risk for foot ulcers, and this risk increases with the presence of DM.
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NewsBot · Nov 21, 2023

Redefining Foot Symptoms in a Kidney-Pancreas-Transplanted Type 1 Diabetic Patient: Challenging the Conventional Charcot Foot Diagnosis
Plator Memaj et al
Am J Case Rep. 2023 Nov 2:24

BACKGROUND Acute Charcot foot can be difficult to diagnose, especially because of other alternate diagnoses that can mimic this condition, particularly stress fracture and acute bone and joint infections, which are 2 conditions that require immediate management. Here, we present the case of a patient who received kidney-pancreas-transplantation for type 1 diabetes mellitus, who consulted for right foot pain after walking. CASE REPORT Our patient was a 47-year-old man who had benefited from a kidney-pancreas transplantation in 2014 for type 1 diabetes and terminal kidney failure and was recently followed for a right foot plantar ulcer that was fully healed. He later presented for right foot pain after walking. Clinical examination showed a red, swollen, and warm foot. Blood test results were unremarkable. Imaging (X-ray/MRI) revealed features compatible with acute Charcot foot. The management consisted of prompt right-foot offloading followed by physiotherapy and adapted orthopedic insoles. CONCLUSIONS This case shows the successful treatment of an active phase of Charcot foot, which avoided the classic transition to chronic Charcot foot with severe osteoarticular destruction. Arguments were developed to rule out other possible diagnoses. The underlying mechanisms of Charcot foot in diabetic patients are related to the neurological and micro-vascular complications induced by poor glycemic control, but the mechanisms are unclear. This case report may help clinicians to better understand and consider another less known and less frequent diagnosis when faced with these clinical features.
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NewsBot · Nov 27, 2023

Prevention and management of foot and lower limb health complications in adults undergoing dialysis: a scoping review
Sarah M. Manewell, Purnima Rao, Keren Haneman, Minjia Zheng, Hady Charaf, Hylton B. Menz, Cathie Sherrington & Serene S. Paul
Journal of Foot and Ankle Research volume 16, Article number: 81 (2023)

Background
Foot and lower limb health complications are common among patients undergoing dialysis; but a summary of prevention and management evidence is not available. The aim of this scoping review was to summarise study characteristics and the nature of results regarding strategies to prevent and manage peripheral arterial disease (PAD), foot ulceration, amputation, associated infection and associated hospital admission in adults undergoing dialysis.

Methods
MEDLINE, Embase, CINAHL and AMED databases were searched for longitudinal experimental and observational studies. Eligible studies included adults undergoing dialysis (≥10 dialysis patients, with separate results or ≥ 75% of the cohort). Any interventions relating to PAD, foot ulceration, amputation, associated infection, and associated hospital admission were included.

Results
The review included 212 studies, of which 199 were observational (94%) and 13 were experimental (6%). Sixteen studies (8%) addressed the prevention of foot and lower limb health complications, 43 (20%) addressed management, and 153 (72%) addressed both. The main intervention type in each study was surgery (n = 159, 75%), care from one or more health professionals (n = 13, 6%), screening by a health professional (n = 10, 5%), medication (n = 9, 4%) and rehabilitation (n = 5, 2%). No studies were identified where exercise, offloading or education were the main intervention. Results for PAD were reported in 137 (65%) studies, foot ulceration in 54 (25%), amputation in 171 (81%), infection in 7 (3%), and admission in 26 studies (12%). Results for more than one foot or lower limb outcome were reported in 141 studies (67%), with each study reporting on average two outcomes. Results varied and spanned positive, negative, and neutral outcomes following intervention.

Conclusions
Identified studies frequently aimed to both prevent and manage foot and lower limb health complications. A variety of interventions were identified and studies often reported results for more than one foot or lower limb health outcome. Findings from this review can be used to guide future research, with a goal to support improved patient outcomes.
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NewsBot · Nov 27, 2023

Renal function as risk factor for diabetic foot ulcers: A meta-analysis
Long Jin , Wenwen Xu
Int Wound J. 2023 Nov 22

The meta-analysis aimed to assess renal function (RF) as a risk factor for diabetic foot ulcers (DFUs). Using dichotomous or contentious random or fixed effect models, the outcomes of this meta-analysis were examined, and the odds Ratio (OR) and the mean difference (MD) with 95% confidence intervals (CIs) were computed. 16 examinations from 2004 to 2023 were enrolled for the present meta-analysis, including 808 914 individuals with diabetes mellitus (DM). DFU had significantly higher chronic renal failure (OR, 3.17; 95% CI, 1.97-5.09, p < 0.001), higher serum Creatinine (MD, 29.30; 95% CI, 9.68-48.92, p = 0.003), and a low estimated glomerular filtration rate (MD, -15.31; 95% CI, -19.36 to -11.26, p < 0.001) compared to non-DFU patients with DM. The examined data revealed that DFU had significantly higher chronic renal failure, higher serum Creatinine, and a low estimated glomerular filtration rate compared to non-DFU patients with DM. Yet, attention should be paid to its values since some comparisons had a low number of selected studies.
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NewsBot · Mar 2, 2024

Foot and Ankle Care by Podiatrists and Amputations in Patients With Diabetes and Kidney Failure
Tze-Woei Tan et al
JAMA Netw Open. 2024 Mar 4;7(3):e240801

Importance: Patients with kidney failure have an increased risk of diabetes-related foot complications. The benefit of regular foot and ankle care in this at-risk population is unknown.

Objective: To investigate foot and ankle care by podiatrists and the outcomes of diabetic foot ulcers (DFUs) in patients with kidney failure.

Design, setting, and participants: This retrospective cohort study included Medicare beneficiaries with type 2 diabetes receiving dialysis who had a new DFU diagnosis. The analysis of the calendar year 2016 to 2019 data from the United States Renal Data System was performed on June 15, 2023, with subsequent updates on December 11, 2023.

Exposures: Foot and ankle care by podiatrists during 3 months prior to DFU diagnosis.

Main outcomes and measures: The outcomes were a composite of death and/or major amputation, as well as major amputation alone. Kaplan-Meier analysis was used to estimate 2 to 3 years of amputation-free survival. Foot and ankle care by podiatrists and the composite outcome was examined using inverse probability-weighted Cox regression, while competing risk regression models were used for the analysis of amputation alone.

Results: Among the 14 935 adult patients with kidney failure and a new DFU (mean [SD] age, 59.3 [12.7] years; 35.4% aged ≥65 years; 8284 men [55.4%]; Asian, 2.7%; Black/African American, 35.0%; Hispanic, 17.7%; White, 58.5%), 18.4% (n = 2736) received care by podiatrists in the 3 months before index DFU diagnosis. These patients were older, more likely to be male, and have more comorbidities than those without prior podiatrist visits. Over a mean (SD) 13.5 (12.0)-month follow-up, 70% of those with podiatric care experienced death and/or major amputation, compared with 74% in the nonpodiatric group. Survival probabilities at 36 months were 26.3% vs 22.8% (P < .001, unadjusted Kaplan-Meier survival analysis). In multivariate regression analysis, foot and ankle care was associated with an 11% lower likelihood of death and/or amputation (hazard ratio [HR], 0.89 95% CI, 0.84-0.93) and a 9% lower likelihood of major amputation (above or below knee) (HR, 0.91; 95% CI, 0.84-0.99) than those who did not.

Conclusions and relevance: The findings of this study suggest that patients with kidney failure at risk for DFUs who receive foot and ankle care from podiatrists may be associated with a reduced likelihood of diabetes-related amputations.
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Renal failure and foot ulcer or lower extremity amputation in those patients with diabetes

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