Is Limb Salvage Practical In Patients With Diabetes And Renal Failure?
Although the patient with diabetes and renal failure presents serious challenges to the limb salvage team, there is evidence and argument to support aggressive treatment and attempted limb salvage in a multidisciplinary clinical environment. An abundance of medical literature discusses the separate wound care challenges posed by diabetes and renal failure. Less work has been done, however, to identify proper treatment and salvage techniques for patients who suffer from both maladies. While many do opt for primary amputation in the patient with diabetes, renal failure and a problem wound, a growing number of wound care experts directly challenge this approach. The argument that limb salvage is feasible in this patient population is highly controversial among the medical community.1 Renal failure often sets up patients for disastrous effects in the lower extremity, particularly in the foot. Complications of the foot are also of heightened concern for those with diabetes as this diagnosis is known to be the most common reason for hospitalization in this subgroup.2 It is well documented that patients who suffer from a combination of diabetes and renal failure are at greatest risk for limb problems and amputation. Age is also a key contributor to major lower limb amputations in this patient population.3 Ischemia is the most serious result of renal failure that leads to the eventual breakdown of a healthy foot.4 Peripheral arterial disease is the most prevalent condition linked with limb ischemia in renal failure patients. This unfortunate complication itself increases the risk of amputation 13 percent annually.5,6 Not only is ischemia a major cause of death in all patients with end-stage renal disease (ESRD), it is also a significant factor in the outcome of limb salvage attempts and a main cause of high operative mortality for these patients.7,8 One study found that ESRD patients have a limb salvage success rate almost 20 percent lower than patients without renal failure.9 Dialysis or renal transplant patients, in particular, have a higher risk of limb amputation after revascularization procedures than patients with lesser degrees of renal failure.1,10 Accordingly, revascularization to correct vasculopathy of ESRD patients can be a very risky treatment option.11 Since the establishment of stable arterial sufficiency is a crucial precursor to successful limb salvage, patients with renal failure face considerable odds in wound healing.
Understanding The Risk Factors In The Diabetic Population
One common diabetic foot risk classification system places individuals into five different categories: normal, high risk, ulcerated, infected and the most critical stage, necrotic.9 Several studies have reported that 70 to 86 percent of amputations in patients with diabetes were preceded by ulceration.12 Labeled as a “pivotal event” in diabetic foot care, ulceration is a concerning milestone in the degeneration of a healthy limb.13 Callus and neuropathy are two serious factors that can lead to ulceration. Education about footwear and control of blood glucose, lipids and blood pressure are crucial ingredients in fighting diabetic foot disease.2,14 Once the diabetic foot progresses to the ulceration stage, it can be difficult to avoid infection. Unlike those with renal failure, patients suffering from diabetes alone often exhibit positive results after undergoing revascularization, even when infection or tissue loss complicates the case.15 However, patients suffering from both diabetes mellitus and ESRD have low survival rates after revascularization (65 percent after one year and 45 percent after two years).4 Nevertheless, when the patient can maintain arterial sufficiency, an aggressive treatment plan should involve timely and frequent debridements to sustain viable tissue in order for foot ulcers to heal. One study confirms that the longer debridement is delayed, the further up the leg amputation will occur.16 As a result of medical complications in the patient with diabetes and renal failure, the risk of amputation increases with the degree of ulceration and the extent of arterial disease.
A Closer Look At Revascularization And Amputation In Patients With Diabetes And ESRD
As diabetes and renal failure both significantly impede recovery of a diseased foot, many providers support primary amputation for these patients. It is no secret that the combination of these conditions greatly complicates limb salvage. One study found: “The chronic renal failure patient with diabetes has a lower limb amputation rate 10 times greater than the diabetic population at large.”17 The literature clearly suggests that the implications of ESRD are more dire than those of diabetes mellitus when it comes to the life expectancy and amputation status of these patients. In support of this assertion, one study of ESRD patients reports that no differences were found between patients with diabetes and those patients without diabetes in regard to “ … the number of revascularization operations performed, the level of major amputation or overall survival.”18 Some specialists argue that limb salvage rates are too dismal to avoid primary amputation in patients with ESRD.8 One study affirms that 75.9 percent of major lower extremity amputations are the cause of critical ischemia, the main consequence of renal failure, while only 17.2 percent were caused by diabetic infection.2 Physicians argue that the failure to heal trumps arterial sufficiency in decisions to amputate in this population.19 Accordingly, some maintain that primary amputation is necessary for the patient with ESRD regardless of whether a patent bypass is achieved.9 As a result, the amputation rate has been as high as 37 percent even after vascular surgeons have achieved revascularization.20 Many physicians argue that the presence of gangrene (especially in the midfoot) and extensive infection are indications that warrant primary amputation.1,6,18,19 Nevertheless, if revascularization is performed as early as ischemic disease is detected, the literature predicts better results for the patient with ESRD.18,19
Can Multidisciplinary Clinics Facilitate Limb Salvage For These Patients?
This is where the multidisciplinary wound care clinic comes into play. Despite the discouraging opinion in the aforementioned literature, early action is the key to success in caring for patients with an at-risk limb. Early debridements, timely revascularization, control of blood glucose levels and care of ulceration when it first emerges are all steps that increase the probability that one may salvage the limbs of patients with diabetes and renal failure.14 Despite the decreased survival rates of this patient group, limb salvage through aggressive and timely treatment is justified.4,20 As major amputation results in greatly reduced life expectancy, there is much to gain in saving these patients’ limbs.14 The multidisciplinary foot clinic combines podiatry, endocrinology, plastic surgery, vascular surgery and wound care practices to create a comprehensive center for successful limb salvage in the patient with diabetes and renal failure. Treatments also include footwear education, antibiotics, frequent debridements, meticulous dressing changes and soft tissue adjunctive procedures that have improved limb salvage rates for this patient population.20,21 One study concludes: “The multidisciplinary diabetic foot clinic model provides an ideal setting for early intervention, treatment and assistance with preventive strategies.”17 The patient with diabetes and renal failure will never fare as well as patients who do not suffer from either disease. Nevertheless, multidisciplinary care focused on timely control and prevention of the advancement of foot disease should replace primary amputation for the properly selected patient with diabetes and renal failure. Ms. Kaylor is a Research Intern at Georgetown University Hospital in Washington, DC. Dr. Steinberg (pictured at right) is an Assistant Professor in the Department of Plastic Surgery at the Georgetown University School of Medicine in Washington, D.C. For further reading, see “Treating Lower Extremity Wounds In The Face Of Systemic Disease” in the January 2006 issue of Podiatry Today or check out the archives at www.podiatrytoday.com.
References:
1. Sanchez LA, Goldsmith J, Rivers SP, Panetta TF, Wengerter KR, Veith FJ. Limb salvage surgery in end stage renal disease: is it worthwhile? J Cardiovasc Surg (Torino). 1992 May-Jun;33(3):344-8.
2. Lawrence A. Foot care education in renal patients with diabetes. EDTNA ERCA J. 2004 Jul-Sep;30(3):153-6. Review.
3. Lim TS, Finlayson A, Thorpe JM, Sieunarine K, Mwipatayi BP, Brady A, Abbas M, Angel D. Outcomes of a contemporary amputation series. ANZ J Surg. 2006 May;76(5):300-5.
4. Georgopoulos S, Filis K, Vourliotakis G, Bakoyannis C, Papapetrou A, Klonaris C, Papalambros E, Bastounis E. Lower extremity bypass procedures in diabetic patients with end-stage renal disease: is it worthwhile? Nephron Clin Pract. 2005;99(2):c37-41. Epub 2004 Dec 21.
5. O'Hare A, Johansen K. Lower-extremity peripheral arterial disease among patients with end-stage renal disease. J Am Soc Nephrol. 2001 Dec;12(12):2838-47. Review.
6. Boufi M, Ghaffari P, Allaire E, Fessi H, Ronco P, Vayssairat M. Foot gangrene in patients with end-stage renal disease: a case control study. Angiology. 2006 May-Jun;57(3):355-61.
7. Koch M, Trapp R, Kulas W, Grabensee B. Critical limb ischaemia as a main cause of death in patients with end-stage renal disease: a single-centre study. Nephrol Dial Transplant. 2004 Oct;19(10):2547-52. Epub 2004 Jul 20.
8. Simsir SA, Cabellon A, Kohlman-Trigoboff D, Smith BM. Factors influencing limb salvage and survival after amputation and revascularization in patients with end-stage renal disease. Am J Surg. 1995 Aug;170(2):113-7.
9. Edwards JM, Taylor LM Jr, Porter JM. Limb salvage in end-stage renal disease (ESRD). Comparison of modern results in patients with and without ESRD. Arch Surg. 1988 Sep;123(9):1164-8.
10. O’Hare AM, Sidawy AN, Feinglass J, Merine KM, Daley J, Khuri S, Henderson WG, Johansen KL. Influence of renal insufficiency on limb loss and mortality after initial lower extremity surgical revascularization. J Vasc Surg. 2004 Apr;39(4):709-16.
11. Reddan DN, Marcus RJ, Owen WF Jr, Szczech LA, Landwehr DM. Long-term outcomes of revascularization for peripheral vascular disease in end-stage renal disease patients. Am J Kidney Dis. 2001 Jul;38(1):57-63.
12. Larsson J, Apelqvist J, Agardh CD, Stenstrom A. Decreasing incidence of major amputation in diabetic patients: a consequence of a multidisciplinary foot care team approach? Diabet Med. 1995 Sep;12(9):770-6.
13. Edmonds M. Diabetic Foot Ulcers: Practical Treatment Recommendations. Drugs. 2006;66(7):913-929.
14. Miyajima S, Shirai A, Yamamoto S, Okada N, Matsushita T. Risk factors for major limb amputations in diabetic foot gangrene patients. Diabetes Res Clin Pract. 2006 Mar;71(3):272-9. Epub 2005 Aug 31.
15. Stone PA, Back MR, Armstrong PA, Flaherty SK, Keeling WB, Johnson BL, Shames ML, Bandyk DF. Midfoot amputations expand limb salvage rates for diabetic foot infections. Ann Vasc Surg. 2005 Nov;19(6):805-11.
16. Faglia E, Clerici G, Caminiti M, Quarantiello A, Gino M, Morabito A. The role of early surgical debridement and revascularization in patients with diabetes and deep foot space abscess: retrospective review of 106 patients with diabetes. J Foot Ankle Surg. 2006 Jul-Aug;45(4):220-6.
17. Deery HG 2nd, Sangeorzan JA. Saving the diabetic foot with special reference to the patient with chronic renal failure. Infect Dis Clin North Am. 2001 Sep;15(3):953-81. Review.
18. Korzets A, Ori Y, Rathaus M, Plotnik N, Baytner S, Gafter U, Isakov E. Lower extremity amputations in chronically dialysed patients: a 10 year study. Isr Med Assoc J. 2003 Jul;5(7):501-5.
19. Johnson BL, Glickman MH, Bandyk DF, Esses GE. Failure of foot salvage in patients with end-stage renal disease after surgical revascularization. J Vasc Surg. 1995 Sep;22(3):280-5; discussion 285-6.
20. Attinger CE, Ducic I, Neville RF, Abbruzzese MR, Gomes M, Sidawy AN. The relative roles of aggressive wound care versus revascularization in salvage of the threatened lower extremity in the renal failure diabetic patient. Plast Reconstr Surg. 2002 Apr 1;109(4):1281-90; discussion 1291-2.
21. El Sakka K, Fassiadis N, Gambhir RP, Halawa M, Zayed H, Doxford M, Greensitt C, Edmonds M, Rashid H. An integrated care pathway to save the critically ischaemic diabetic foot. Int J Clin Pract. 2006 Jun;60(6):667-9.
