Tuesday, May 5, 2009

Putting your best foot forward

Diabetes Watch
Focusing on preventive foot care in hemodialysis patients
by: Zahid Ahmad, MD
Nephronline.com - Article May 2009

With changes in overall care, mortality in the dialysis patient population has improved. But comorbid conditions have limited the impact. One such area that remains under the radar for patients with diabetes and end-stage renal disease is morbidity and mortality related to peripheral vascular disease and foot care.

For the most part, at this stage, foot care attracts attention only after a problem has already arisen. There are no screening protocols in dialysis centers to identify the problem earlier on. As a result, preventive strategies to reduce morbidity and mortality related to this issue remains unaddressed. The magnitude of this problem is unrealized until you add to the equation that the majority of hemodialysis patients are diabetics as well. Currently, there is a high-risk of lower extremity amputations in hemodialysis patients.

Early risk factors for diabetic foot complications may be disregarded, and this may lead to amputation-a failure for both the patient and physician. Diabetic foot complications, including amputation, add significantly to the morbidity and mortality of the patient with diabetes and CKD. However, of all the long-term complications of diabetes, foot complications may be the most preventable.

And diabetic foot examinations reduce the risk of amputation. For two decades, the United States Department of Health and Human Services (DHHS) has used health promotion and disease prevention objectives to improve the health of the American people. The overall goal for diabetes in Healthy People 2010 is, "Through prevention programs, reduce the disease and economic burden of diabetes and improve the quality of life for all persons who have or are at risk for diabetes." A specific objective contained within this goal targets a 55% reduction in the rate of lower extremity amputations in persons with diabetes. This would amount to 1.8 lower extremity amputations per 1,000 patients with diabetes per year, down from 4.1 per 1,000 patients that occurred in 1997, according to DHHS. Several clinical studies in the nondialysis diabetic population have shown that coordinated programs to screen for high-risk feet and to provide regular foot care decreased lower extremity amputation rates. In a controlled study, 45 hemodialysis patients were assigned to intensive education and care management that included preventive foot care, and 38 HD patients were assigned to usual care. Over the 12-month follow-up period, there were no amputations in the study group while there were five lower extremity amputations and two finger amputations in the control group.

The American Diabetes Association says that "all individuals with diabetes should receive a thorough foot examination at least once yearly to identify high-risk foot conditions." The ADA goes on to recommend more frequent evaluation for people with one or more risk factors and a visual foot inspection at every visit with a health care professional for diabetic patients with neuropathy.

Preventive foot care for hemodialysis patients is lost in efforts and time spent to provide care in other much politicized areas of care. But ignoring prevention in this area leads to significant morbidity and mortality. There are no randomized controlled trials of intensive education and care management versus usual care of feet in diabetic dialysis patients. Nonetheless, diabetic dialysis patients are likely to benefit from examination of the foot as part of the routine dialysis care. Given the fact that prevention can be easily done in a hemodialysis center by nursing staff, there is little reason not to introduce it. Three times a week contact between hemodialysis nurses and patient is a potential opportunity to assess risks, educate, and provide early intervention for foot issues in the dialysis population. Simple measures such as routine foot screening and education for this high risk population can prevent ulcer-initiating events and detect small ulcers when they may heal with proper intervention. Preventive strategies should include protocol- based strategy for referral to a specialist. Computerized networks should allow this to happen seamlessly and effortlessly to the benefit of all involved in hemodialysis care. In this regard, all involved in medical care of hemodialysis patients can no longer afford to ignore the importance of preventive care of hemodialysis patients.."

Dr. Ahmad is assistant professor of medicine at University of Oklahoma, specializing in interventional nephrology in the Section of Nephrology & Hypertension.

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