Is Limb Salvage Practical In Patients With Diabetes And Renal Failure?
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