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