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Limb Preservation With Concomitant Renal Failure: More Common, Complex And Costly Than Ever Before

Recently, Sigi, Rumenapf and Morbach along with their colleagues in Germany published some important data on end-stage renal disease (ESRD) and critical limb ischemia (CLI).1 Each of these conditions are associated with high rates of mortality and morbidity. In this study, 77 inpatients on hemodialysis with 91 threatened limbs had wound, ischemia and foot infection (WIfI) clinical stages of 3 or 4. Researchers assessed these patients for in-hospital treatment of peripheral arterial disease, limb salvage and overall survival.

After a composite endpoint analysis, the one-year major amputation-free survival rate was 65 percent.1 Patients with WIfI stage 4 had more than double the risk of death or major amputation in comparison with the rest of the population. However, revascularization did appear to have an impact in this population of patients with WIfI stage 4. 

After 12 years of follow-up, patients with WIfI stage 4 had significantly lower major amputation-free survival but there was no significant difference in overall survival than the cohort of patients with WIfI stage 3.1

As one climbs from overall WIfI stage 3 to 4, we have consistently seen similar jumps in morbidity from study to study. Severe chronic kidney disease makes this even more true WIfI staging really helps us answer “can we work to preserve this limb?” Subsequent assessments of a patient’s overall functional capacity (which likely takes into account the patient’s renal status) might help us answer the question: “Should we work to preserve this limb?”

This study just reinforces the utility of the WIfI classification when evaluating expectations for treatment plans and outcomes.

Dr. Armstrong is a Professor of Surgery at the Keck School of Medicine at the University of Southern California. He is the Director of the Southwestern Academic Limb Salvage Alliance (SALSA). 

Editor’s Note: This blog originally appeared at It is adapted with permission from the author.


  1. Sigi M, Noe T, Rümenapf G, et al. Outcomes of severe limb ischemia with tissue loss and impact of revascularization in haemodialysis patients with wound, ischemia and foot infection (WIfI) stage 3 or 4. Vasa. 2019. Accessed October 9, 2019.
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