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Presentation and Management of the Renal Ischaemic Foot

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Limb Salvage of the Diabetic Foot

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Abstract

Diabetic patients in renal failure present a major problem in terms of foot care. Neuropathy and arterial disease are present with extensive vascular calcification and this is associated with substantial risks for both morbidity and death. The classical lesion is dry digital necrosis. It may be precipitated by trauma and can spread to involve the mid foot and hind foot. The presence of neuropathy and peripheral arterial disease in the background of renal failure leads to increased susceptibility to infection. However, the overall outlook of the diabetic renal foot can be improved by understanding the vulnerability of the diabetic patient in renal failure and by setting up services to provide preventative care, to rapidly treat ulceration and infection and to perform early revascularisation. Rapid treatment of tissue loss is crucial and patients should have prompt access to expert care to treat wounds and prevent extensive necrosis. Early referral for revascularization, before development of extensive tissue ischaemia and infection is important. After initial concerns, there has been an increasingly progressive approach to revascularisation in patients with renal failure admittedly in the background of high mortality. Open and endovascular therapies have complementary roles in diabetic patients with renal failure. It is also vital to treat infections aggressively, especially post-operative infections, and limit the extent of any necrosis which may compromise the integrity of the foot and lead to amputation despite a successful bypass. Interdisciplinary treatment to co-ordinate these modalities of care is vital for the diabetic patient in renal failure.

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References

  1. Ndip A, Lavery LA, Boulton AJ. Diabetic foot disease in people with advanced nephropathy and those on renal dialysis. Curr Diab Rep. 2010;10:283–90.

    Article  Google Scholar 

  2. Hill MN, Feldman HI, Hilton SC, Holechek MJ, Ylitalo M, Benedict GW. Risk of foot complications in long-term diabetic patients with and without ESRD: a preliminary study. ANNA J. 1996;23:381–8.

    CAS  PubMed  Google Scholar 

  3. Valabhji J. Foot problems in patients with diabetes and chronic kidney disease. J Ren Care. 2012;38(Suppl 1):99–108. https://doi.org/10.1111/j.1755–6686.2012.00284.x.

    Article  PubMed  Google Scholar 

  4. Zeymer U, Parhofer KG, Pittrow D, Binz C, Schwertfeger M, Limbourg T, et al. Risk factor profile, management and prognosis of patients with peripheral arterial disease with or without coronary artery disease: results of the prospective German REACH registry cohort. Clin Res Cardiol. 2009;98:249–56.

    Article  Google Scholar 

  5. Locking-Cusolito H, Harwood L, Wilson B, Burgess K, Elliot M, Gallo K, et al. Prevalence of risk factors predisposing to foot problems in patients on hemodialysis. Nephrol Nurs J. 2005;32(4):373–84.

    PubMed  Google Scholar 

  6. Kato S, Chmielewski M, Honda H, Pecoits-Filho R, Matsuo S, Yuzawa Y, et al. Aspects of Immune Dysfunction in End-stage Renal Disease. Clin J Am Soc Nephrol. 2008;3(5):1526–33. https://doi.org/10.2215/CJN.00950208.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Otte J, Van Netten JJ, Woittiez AJ. The association of chronic kidney disease and dialysis treatment with foot ulceration and major amputation. J Vasc Surg. 2015;62(2):406–11. https://doi.org/10.1016/j.jvs.2015.02.051. Epub 2015 May 1

    Article  PubMed  Google Scholar 

  8. Kaminski MR, Raspovic A, McMahon LP, Strippoli GFM, Palmer SC, Ruospo M, et al. Risk factors for foot ulceration and lower extremity amputation in adults with end-stage renal disease on dialysis: a systematic review and meta-analysis. Nephrol Dial Transplant. 2015;30:1747–66.

    Article  Google Scholar 

  9. Meloni M, Giurato L, Izzo V, Stefanini M, Pampana E, Gandini R, et al. Long term outcomes of diabetic haemodialysis patients with critical limb ischemia and foot ulcer. Diabetes Res Clin Pract. 2016;116:117–22.

    Article  Google Scholar 

  10. Kaminski MR, Raspovic A, McMahon LP, Lambert KA, Erbas B, Mount PF, et al. Factors associated with foot ulceration and amputation in adults on dialysis: a cross-sectional observational study. BMC Nephrol. 2017;18:293. https://doi.org/10.1186/s12882-017-0711-6.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Gilhotra RA, Rodrigues BT, Vangaveti VN, Kan G, Porter D, Sangla KS, et al. Non-traumatic lower limb amputation in patients with end-stage renal failure on dialysis: an Australian perspective. Ren Fail. 2016;38(7):1036–43. https://doi.org/10.1080/0886022X.2016.1193872. Epub 2016 Jun

    Article  CAS  PubMed  Google Scholar 

  12. Morbach S, Quante C, Ochs HR, Gaschler F, Pallast JM, Knevels U. Increased risk of lower-extremity amputation among Caucasian diabetic patients on dialysis. Diabetes Care. 2001;24:1689–90. https://doi.org/10.2337/diacare.24.9.16898.

    Article  CAS  PubMed  Google Scholar 

  13. Game FL, Chipchase SY, Hubbard R, Burden RP, Jeffcoate WJ. Temporal association between the incidence of foot ulceration and the start of dialysis in diabetes mellitus. Nephrol Dial Transplant. 2006;21:3207–10.

    Article  Google Scholar 

  14. Hinchliffe RJ, Kirk B, Bhattacharjee D, Roe S, Jeffcoate W, Game F. The effect of haemodialysis on transcutaneous oxygen tension in patients with diabetes—a pilot study. Nephrol Dial Transplant. 2006;21:1981–3.

    Article  Google Scholar 

  15. Beckert S, Sundermann K, Wolf S, Königsrainer A, Coerper S. Haemodialysis is associated with changes in cutaneous microcirculation in diabetes mellitus. Diabet Med. 2009;26(1):89–92.

    Article  CAS  Google Scholar 

  16. McGrath NM, Curran BA. Recent commencement of dialysis is a risk factor for lower-extremity amputation in a high risk diabetic population. Diabetes Care. 2000;23:432–3.

    Article  CAS  Google Scholar 

  17. Griffiths GD, Wieman TJ. The influence of renal function on diabetic foot ulceration. Diabetes Care. 2012;35(10):2021–7.

    Article  Google Scholar 

  18. Margolis DJ, Hofstad O, Feldman HI. Association between renal failure and foot ulcer or lower-extremity amputation in patients with diabetes. Diabetes Care. 2008;31(7):1331–6. https://doi.org/10.2337/dc07–2244PMCID. PMC2453658

    Article  PubMed  PubMed Central  Google Scholar 

  19. Papanas N, Liakopoulos V, Maltezos E, Stefanidis I. The diabetic foot in end stage renal disease. Ren Fail. 2007;29:519–28.

    Article  CAS  Google Scholar 

  20. Ndip A, Lavery LA, Lafontaine J, Rutter MK, Vardhan A, Vileikyte L, et al. High levels of foot ulceration and amputation risk in a multiracial cohort of diabetic patients on dialysis therapy. Diabetes Care. 2010;33:878–80.

    Article  Google Scholar 

  21. Volaco A, Chantelau E, Richter B, Luther B. Outcome of critical foot ischaemia in longstanding diabetic patients: a retrospective cohort study in a specialised tertiary care centre. Vasa. 2004;33:36–41.

    Article  CAS  Google Scholar 

  22. Lavery LA, Hunt NA, Ndip A, Lavery DC, Van Houtum W, Boulton AJ. Impact of chronic kidney disease on survival after amputation in individuals with diabetes. Diabetes Care. 2010;33(11):2365–9.

    Google Scholar 

  23. Richbourg MJ. Preventing amputations in patients with end stage renal disease: whatever happened to foot care? ANNA J. 1998;25:13–20.

    CAS  PubMed  Google Scholar 

  24. Lawrence A. Foot care education in renal patients with diabetes. EDTNA ERCA J. 2004;30:153–6.

    Article  CAS  Google Scholar 

  25. Foster AVM, Snowden S, Grenfell A, Watkins PJ, Edmonds ME. Reduction of gangrene and amputations in diabetic renal transplant patients: the role of a special foot clinic. Diabet Med. 1995;12:632–5.

    Article  CAS  Google Scholar 

  26. Lipscombe J, Jassal SV, Bailey S, Bargman JM, Vas S, Oreopoulos DG. Chiropody may prevent amputations in diabetic patients on peritoneal dialysis. Perit Dial Int. 2003;23:255–9.

    PubMed  Google Scholar 

  27. Lepäntalo M, Fiengo L, Biancari F. Peripheral arterial disease in diabetic patients with renal insufficiency: a review. Diabetes Metab Res Rev. 2012;28(Suppl 1):40–5. https://doi.org/10.1002/dmrr.2233.

  28. Maithel SK, Pomposelli FB, Williams M, Sheahan MG, Scovell SD, Campbell DR, et al. Creatinine clearance but not serum creatinine alone predicts long-term postoperative survival after lower extremity revascularization. Am J Nephrol. 2006;26:612–20.

    Google Scholar 

  29. Ortmann J, Gahl B, Diehm N, Dick F, Traupe T, Baumgartner I. Survival benefits of revascularization in patients with critical limb ischemia and renal insufficiency. J Vasc Surg. 2012;56:737–45.

    Google Scholar 

  30. 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;123(9):1164–8.

    Google Scholar 

  31. Johnson BL, Glickman MH, Bandyk DF, Esses GE. Failure of foot salvage in patients end-stage renal disease after surgical revascularization. J Vasc Surg. 1995;22:280–6.

    Article  CAS  Google Scholar 

  32. Peltonen S, Biancari F, Lindgren L, Mäkisalo H, Honkanen E, Lepäntalo M. Outcome of infrainguinal bypass surgery for critical leg ischaemia in patients with chronic renal failure. Eur J Vasc Endovasc Surg. 1998;15:122–7.

    Article  CAS  Google Scholar 

  33. Biancari F, Kantonen I, Mätzke S, Albäck A, Roth WD, Edgren J, et al. Infrainguinal endovascular and bypass surgery for critical leg ischemia in patients on long-term dialysis. Ann Vasc Surg. 2002;16(2):210–4. Epub 2002 Feb 20

    Article  Google Scholar 

  34. Harrington EB, Harrington ME, Schanzer H, Haimov M. End-stage renal disease—is infrainguinal limb revascularization justified? J Vasc Surg. 1990;12(6):691–5. discussion 695–6

    Article  CAS  Google Scholar 

  35. Ramdev P, Rayan SS, Sheahan M, Hamdan AD, Logerfo FW, Akbari CM, et al. A decade experience with infrainguinal revascularization in a dialysis-dependent patient population. J Vasc Surg. 2002;36(5):969–74.

    Article  Google Scholar 

  36. Leers SA, Reifsnyder T, Delmonte R, Caron M. Realistic expectations for pedal bypass grafts in patients with end-stage renal disease. J Vasc Surg. 1998;28(6):976–80.

    Article  CAS  Google Scholar 

  37. Lumsden AB, Besman A, Jaffe M, MacDonald MJ, Allen RC. Infrainguinal revascularization in end-stage renal disease. Ann Vasc Surg. 1994;8(1):107–12.

    Article  CAS  Google Scholar 

  38. Carrell TW, Jenkins MP, Wolfe JH, Cheshire NJ. Critical limb ischemia in the dialysis-dependent patient: infrainguinal vein bypass is justified. J Vasc Endovascular Surg. 2006;40:362–6.

    Article  Google Scholar 

  39. Wölfle K, Schaal J, Rittler S, Bruijnen H, Loeprecht H. Infrainguinal bypass grafting in patients with end-stage renal disease and critical limb ischaemia: is it worthwhile? Zentralbl Chir. 2003;128(9):709–14.

    Article  Google Scholar 

  40. Korn P, Hoenig SJ, Skillman JJ, Kent KC. Is lower extremity revascularization worthwhile in patients with end-stage renal disease? Surgery. 2000;128(3):472–9.

    Article  CAS  Google Scholar 

  41. Sigala F, Georgopoulos S, Langer S, Baunach C, Papalambros E, Sigalas K, et al. Outcome of infrainguinal revascularization for critical limb ischemia in diabetics with end stage renal disease. Vasa. 2006;35(1):15–20.

    Article  CAS  Google Scholar 

  42. Yamamoto S, Hosaka A, Okamoto H, Shigematsu K, Miyata T, Watanabe T. Efficacy of revascularization for critical limb ischemia in patients with end-stage renal disease. Eur J Vasc Endovasc Surg. 2014;48(3):316–24. https://doi.org/10.1016/j.ejvs.2014.05.019. Epub 2014 Jun 26

    Article  CAS  PubMed  Google Scholar 

  43. Albers M, Romiti M, Bragança Pereira CA, Fonseca RL, da Silva Júnior M. A meta-analysis of infrainguinal arterial reconstruction in patients with end-stage renal disease. Eur J Vasc Endovasc Surg. 2001;22(4):294–300.

    Article  CAS  Google Scholar 

  44. Patel VI, Mukhopadhyay S, Guest JM, Conrad MF, Watkins MT, Kwolek CJ, et al. Impact of severe chronic kidney disease on outcomes of infrainguinal peripheral arterial intervention. Endovascular J Vasc Surg. 2014;59(2):368–75. https://doi.org/10.1016/j.jvs.2013.09.006. Epub 2013 Oct 28

    Article  PubMed  Google Scholar 

  45. Silverberg D, Yalon T, Rimon U, Reinitz ER, Yakubovitch D, Schneiderman J, et al. Endovascular treatment of lower extremity ischemia in chronic renal failure patients on dialysis: early and intermediate term results. Isr Med Assoc J. 2013;15(12):734–8.

    PubMed  Google Scholar 

  46. Rabellino M, Aragón-Sánchez J, González G, Zander T, Baldi S, Garcia-Nielsen L, et al. Is endovascular revascularisation worthwhile in diabetic patients with critical limb ischemia who also have end-stage renal disease? Diabetes Res Clin Pract. 2010;90(3):e79–81. https://doi.org/10.1016/j.diabres.2010.09.021. Epub 2010 Oct 27

    Article  PubMed  Google Scholar 

  47. Graziani L, Silvestro A, Bertone V, Manara E, Alicandri A, Parrinello G, et al. Percutaneous transluminal angioplasty is feasible and effective in patients on chronic dialysis with severe peripheral artery disease. Nephrol Dial Transplant. 2007;22:1144–9. Epub 2007 Jan 31.

    Article  Google Scholar 

  48. Aulivola B, Gargiulo M, Bessoni M, Rumolo A, Stella A. Infrapopliteal angioplasty for limb salvage in the setting of renal failure: do results justify its use? Ann Vasc Surg. 2005;19(6):762–8.

    Article  Google Scholar 

  49. Gandini R, Merolla S, Scaggiante J, Meloni M, Giurato L, Uccioli L, et al. Endovascular distal plantar vein arterialization in dialysis patients with no-option critical limb ischemia and posterior tibial artery occlusion: a technique for limb salvage in a challenging patient subset. J Endovasc Ther. 2018;25(1):127–32. https://doi.org/10.1177/1526602817750211. Epub 2017 Dec 21

    Article  PubMed  Google Scholar 

  50. Kum S, Tan YK, Schreve MA, Ferraresi R, Varcoe RL, Schmidt A, et al. Midterm outcomes from a pilot study of percutaneous deep vein. Arterialization for the treatment of no-option critical limb ischemia. J Endovasc Ther. 2017;1:1526602817719283. https://doi.org/10.1177/1526602817719283.

    Article  Google Scholar 

  51. Meyer A, Lang W, Borowski M, Torsello G, Bisdas T, CRITISCH collaborators. Critsch registry. In-hospital outcomes in patients with critical limb ischemia and end-stage renal disease after revascularization. J Vasc Surg. 2016;63(4):966–73. https://doi.org/10.1016/j.jvs.2015.10.009. Epub 2016 Feb 1

    Article  PubMed  Google Scholar 

  52. Jaar BG, Astor BC, Berns JS, Powe NR. Predictors of amputation and survival following lower extremity revascularization in hemodialysis patients. Kidney Int. 2004;65(2):613–20.

    Article  Google Scholar 

  53. Biancari F, Arvela E, Korhonen M, Söderström M, Halmesmäki K, Albäck A. PTA and bypass End-stage renal disease and critical limb ischemia: a deadly combination? Scand J Surg. 2012;101(2):138–43.

    Article  CAS  Google Scholar 

  54. Fallon JM, Goodney PP, Stone DH, Patel VI, Nolan BW, Kalish JA, et al. Outcomes of lower extremity revascularization among the hemodialysis-dependent. J Vasc Surg. 2015;62(5):1183–91. https://doi.org/10.1016/j.jvs.2015.06.203. Epub 2015 Aug 5

    Article  PubMed  PubMed Central  Google Scholar 

  55. Younes HK, Davies MG, Peden EK. End-stage renal disease and limb salvage. Methodist Debakey Cardiovasc J. 2013;9(2):108–11.

    Article  Google Scholar 

  56. Garimella PS, Hirsch AT. Peripheral artery disease and chronic kidney disease: clinical synergy to improve outcomes. Adv Chronic Kidney Dis. 2014;21(6):460–71. https://doi.org/10.1053/j.ackd.2014.07.005. Epub 2014 Oct 24

    Article  PubMed  PubMed Central  Google Scholar 

  57. Baigent C, Landray MJ, Reith C, Emberson J, Wheeler DC, Tomson C, et al. The effects of lowering LDL cholesterol with simvastatin plus ezetimibe in patients with chronic kidney disease (Study of Heart and Renal Protection): a randomised placebo-controlled trial. Lancet. 2011;377(9784):2181–92. https://doi.org/10.1016/S0140–6736(11)60739–3.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  58. Fellström BC, Jardine AG, Schmieder RE, Holdaas H, Bannister K, Beutler J, et al. Rosuvastatin and cardiovascular events in patients undergoing hemodialysis an assessment of survival and cardiovascular events (AURORA) trial. N Engl J Med. 2009;360(14):1395–407. https://doi.org/10.1056/NEJMoa0810177. Epub 2009 Mar 3

    Article  CAS  PubMed  Google Scholar 

  59. Lepäntalo M, Fiengo L, Biancari F. Peripheral arterial disease in diabetic patients with renal insufficiency: a review. Diabetes Metab Res Rev. 2012;28(Suppl 1):40–5. https://doi.org/10.1002/dmrr.2233.

    Article  PubMed  Google Scholar 

  60. 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;123(9):1164–8.

    Article  CAS  Google Scholar 

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Authors and Affiliations

  1. Department of Vascular Surgery, King’s College Hospital NHS Foundation Trust, London, UK

    Hani Slim

  2. Diabetic Foot Clinic, King’s College Hospital NHS Foundation Trust, London, UK

    Joanne Casey, Jennifer Tremlett & Michael E. Edmonds

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  1. Hani Slim
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  2. Joanne Casey
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  3. Jennifer Tremlett
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  4. Michael E. Edmonds
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Correspondence to Michael E. Edmonds .

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  1. King’s College Hospital, London, UK

    Michael E. Edmonds

  2. School of Medicine, Yale University, New Haven, CT, USA

    Bauer E. Sumpio

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Slim, H., Casey, J., Tremlett, J., Edmonds, M.E. (2019). Presentation and Management of the Renal Ischaemic Foot. In: Edmonds, M., Sumpio, B. (eds) Limb Salvage of the Diabetic Foot. Springer, Cham. https://doi.org/10.1007/978-3-319-17918-6_27

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