Hemodialysis foot ulcer risk not confined to diabetes

By Lynda Williams

Hemodialysis patients with and without diabetes are at risk for foot ulceration, say UK researchers who believe preventive resources must be directed towards both patient groups.

"Current CKD [chronic kidney disease] guidelines and recommendations fail to recognise the association between haemodialysis and the development of foot ulceration," say Stephen Riley (University Hospital of Wales, Cardiff) and co-workers.

"We suggest that further work on strategies to monitor and prevent FP [foot pathology] in this high-risk population is needed to minimise morbidity and mortality associated with foot ulceration."

Overall, 79% of both the 24 patients with diabetes and the 33 patients without diabetes attending a satellite hemodialysis unit had structural FP, such as claw toes, hallux valgus, prominent metatarsal heads, corns, callosities and nail pathologies.

Peripheral neuropathy, diagnosed using a 10 g filament or vibration perception, was present in 32% of patients, including 50% of those without diabetes and 18% of nondiabetes patients.

Peripheral arterial disease (PAD) was diagnosed at the dorsalis pedis and posterior tibial arteries using handheld Doppler ultrasound in 45% of diabetes and 30% of nondiabetes patients. Furthermore, the Edinburgh Claudication Questionnaire demonstrated symptomatic vascular insufficiency in 41% of diabetes and 75% of nondiabetes patients.

Recognizing that FP, peripheral neuropathy, and PAD are risk factors for foot ulceration, the team notes that 49% of the group had two or more factors and a high risk for lower limb-threatening complications.

Just 12% of patients, including two diabetes and five nondiabetes patients, had feet with no risk factors, say Riley et al in the International Wound Journal.

The researchers say their results are consistent with findings suggesting that peripheral neuropathy may be associated with progression of CKD secondary to uremia, and that patients with renal disease have a two-fold risk for PAD due to both traditional arterial and renal-specific risk factors.

They add that smoking is strongly associated with both these foot ulcer risk factors, noting that 12 of the 18 patients with peripheral neuropathy, and 15 of the 21 patients with PAD were former or current smokers.

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