Preventing amputations in patients with diabetes and chronic kidney disease

Foot lesions are the single most frequently mismanaged problem of patients with diabetes mellitus and chronic kidney disease (CKD). Foot problems are often viewed as a minor problem, yet frequently impact patient survival (Schomig, Ritz, Standl, & Allenberg, 2000). Recommendations for improving the survival of patients with diabetes and CKD include improvement in the foot care and education of both patients and nephrology health care providers regarding diabetic foot complications (Ritz, Koch, Fliser, & Schwenger, 1999).

Over 40% of patients in United States starting chronic dialysis count diabetes mellitus as the primary cause of renal failure, making it the number one cause of CKD (Berman, 2001). Patients with diabetes and chronic renal disease frequently present with a combination of the devastations of diabetes including: nephropathy, retinopathy, and vasculopathy. Diabetic foot complications, including amputation, add significantly to the morbidity and mortality of the patient with diabetes and CKD. The main focus of the care of this patient has been on the target organs of the heart and kidneys. Therefore, early risk factors for diabetic foot complications may be disregarded, and this may lead to amputation--a failure for both the patient and clinician. However, of all the long-term complications of diabetes, foot complications may be the most preventable.

In the United States, diabetes is the cause of 50% of nontraumatic lower extremity amputations and is increasing annually (Levin, 2002). The cost of treating patients with diabetes is astronomical both financially and in terms of quality of life. The loss of a lower extremity or even part of a lower extremity greatly impacts quality of life. Depression is common after amputation. Leisure activities as well as employment status are altered. The mortality rate after amputation in patients with diabetes is 11%-41% at 1 year, 20%-50% at 3 years, and 39%-68% at 5 years (Fritschi, 2001).

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