Predictors of major lower limb amputation in type 2 diabetic patients referred for hospital care with diabetic foot syndrome

Nawaf J Shatnawi, Nabil A Al-Zoubi, Hassan M Hawamdeh, Yousef S Khader, Khaled Garaibeh, Hussein A Heis, Nawaf J Shatnawi, Nabil A Al-Zoubi, Hassan M Hawamdeh, Yousef S Khader, Khaled Garaibeh, Hussein A Heis

Abstract

Purpose: This study was conducted to determine the risk factors of major lower extremity amputations in type 2 diabetic patients referred for hospital care with diabetic foot syndrome.

Patients and methods: This retrospective study involved 225 type 2 diabetic patients referred for management of diabetic foot syndrome at King Abdullah University Hospital in the period between January 2014 and December 2015. A structured customized diabetic foot data collection form with diabetic foot characteristics chart was used for documentation of relevant information, which checks for age, sex, body mass index, smoking, duration of diabetes, diabetic control therapy, associated hypertension, cardiac diseases, stroke, chronic renal impairment, renal replacement therapy (hem-dialysis), and history of diabetes-related complication in both feet prior to the study period. The predictors for major lower limb amputations were compared between groups using chi-square test, and binary logistic regression was used to determine the factors associated with major amputation.

Results: Twenty-seven limbs underwent major amputations with an overall rate of major amputation of 11.6%. The following predictors were found to be associated with the higher incidence of major lower limb amputations: duration of diabetes ≥15 years, HbA1c ≥8%, patients on insulin, with hypertension, cardiac diseases, chronic renal impairment, stroke, having gangrene, higher number of components, higher Wagner classification, and ischemia. However, the rate did not differ significantly between men and women.

Conclusion: Presentation with gangrenous tissue and poor glycemic control are the important risks and significant predictive factors for type 2 diabetes-related major lower limb amputations.

Keywords: amputations; diabetes mellitus; diabetic foot complication; gangrene.

Conflict of interest statement

Disclosure The authors report no conflicts of interest in this work.

References

    1. Frykberg RG, Zqonis T, Armstrong DG, et al. American College of Foot and Ankle Surgeons Diabetic foot disorders: a clinical practice guideline (2006 revision) J Foot Ankle Surg. 2006;45(5 Suppl):S1–S66.
    1. Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation: basis for prevention. Diabetes Care. 1990;13(5):513–521.
    1. Jeffloate WJ, Macfarlane RM, Fletcher EM. The description and classification of diabetic foot lesions. Lancet. 2005;366:1719–1724.
    1. Singh N, Armestrong DG, Lipsky BA. Foot ulcer in patients with diabetes. JAMA. 2005;293(2):217–228.
    1. Reiber GE, Vileikyte L, Boyko EJ, et al. Causal pathways for incident lower extremity ulcers in patients with diabetes from two settings. Diabet Care. 1999;22(1):157–162.
    1. Jude EB, Boulton AJM. End stage complication of diabetic neuropathy. Diabet Rev. 1999;7:395–410.
    1. Lipsky BA, Berendt AR, Cornia PB, et al. Infectious Diseases Society of America 2012 Infectious disease society of Americas clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2012;54(12):e132–e173.
    1. Nather A, Bee CS, Huak CY, et al. Epidemiology of diabetic foot problems and predictive factors for limb loss. J Diabetes Complications. 2008;22(2):77–82.
    1. Moxey PW, Gogalniceanu P, Hinchliffe RJ, et al. Lower extremity amputations – a review of global variability in incidence. Diabet Med. 2011;28(10):1144–1153.
    1. Jeffcoate WJ, Van Hountum WH. Amputation as a marker of the quality of foot care in diabetes. Diabetologia. 2004;47(12):2051–2058.
    1. van Hauttum P, Schaper N, Prompers L, et al. Differences in minor amputation rate in diabetic foot disease throughout Europe are in part explained by differences in disease severity at presentation. Diabet Med. 2011;28(2):199–205.
    1. Pscherer S, Dippel FW, Lauterbach S, Kostev K. Amputation rate and risk factors in type 2 patients with diabetic foot syndrome under real-life conditions in Germany. Prim Care Diabetes. 2012;6(3):241–246.
    1. Pemayun TG, Naibaho RM, Novitasari D, Amin N, Minuljo TT. Risk factors for lower extremity amputation in patients with diabetic foot ulcers: a hospital-based case control study. Diabet Foot Ankle. 2015;6:29629.
    1. Davis WA, Norman PE, Bruce DG, Davis TM. Predictors, consequences and costs of diabetes-related lower extremity amputation complicating type 2 diabetes: the Fremantle Diabetes Study. Diabetologia. 2006;49(11):2634–2641.
    1. Wukich DK, Armstrong DG, Attinger CE, et al. Inpatient management of diabetic foot disorders: a clinical guide. Diabetes Care. 2013;36(9):2862–2871.
    1. Ajlouni K, Kader YS, Batieh A, Ajlouni H, El-Khateeb M. An increase in the prevalence of diabetes in Jordan over 10 years. J Diabetes Complications. 2008;22(5):317–324.
    1. Jbour AS, Jarrah NS, Radideh AM, et al. Prevalence and predictors of diabetic foot syndrome in type 2 diabetes mellitus in Jordan. Saudi Med J. 2003;24(7):761–764.
    1. Wagner FW., Jr The dysvascular foot: a system for diagnosis and treatment. Foot Ankle. 1981;2(2):64–122.
    1. Rutherford RB, Baker JD, Ernst C, et al. Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg. 1997;26(3):517–538.
    1. Alvarsson A, Sandgren B, Wendel C, Alvarsson M, Brismar K. A retrospective analysis of amputation rates in diabetic patients: can lower extremity amputation be farther prevented? Cardiovasc Diabetol. 2012;11:18.
    1. Bakker K, Apelqvist J, Lipsky BA, Van Netten JJ, International Working Group on Diabetic Foot The 2015 IWGDF guidance documents on prevention and management of foot problems in diabetes: development of an evidence-based global consensus. Diabetes Metab Res Rev. 2016;32(Suppl 1):S2–S6.
    1. McNeely MJ, Boyko EJ, Ahroni JH, et al. The independent contributions of diabetic neuropathy and vasculopathy in foot ulceration. How great are the risks? Diabetes Care. 1995;18(2):216–219.
    1. Pompers L, Schapper N, Apelqvist J, et al. Prediction of outcome in individuals with diabetic foot ulcers: focus on the differences between individuals with and without peripheral arterial disease. The (EURO-FIALE) study. Diabetologia. 2008;51(5):747–755.
    1. Thewjitcharoen Y, Krittiyawong S, Porramatikul S, et al. Outcomes of hospitalized diabetic foot patients in a multi-disciplinary team setting: Thailand’s experience. J Clin Transl Endocrinol. 2014;1(4):187–191.
    1. Oyibo SO, Jude EB, Voyatzoglou D, Boulton AJM. Clinical characteristics of patients with diabetic foot problems: changing patterns of foot ulcer presentation. Pract Diabet Int. 2002;19(1):10–12.
    1. Adler AI, Boyko EJ, Ahroni JH, Smith DG. Lower-extremity amputation in diabetes. The independent effect of peripheral vascular disease, sensory neuropathy and foot ulcer. Diabet Care. 1999;22(7):1029–1035.
    1. Van Houtum WH, Lavery LA. Outcomes associated with diabetes related amputations in The Netherlands and in the state of California, USA. J Intern Med. 1996;240(4):227–231.
    1. Armstrong DG, Larvery LA, Harkless LB. Validation of a diabetic wound classification system. The contribution of depth, infection and ischemia to risk of amputation. Diabetes Care. 1998;21(5):855–859.
    1. Shajaiefard A, Khorgami Z, Larijani B. Independent risk factors for amputation in diabetic foot. Int J diabetes Dev Ctries. 2008;28(2):32–37.
    1. Burn C, Siersma V, Guassora AD, Holstein P, de Fine Olivarius N. History of amputations and foot ulcers in patients newly diagnosed with type 2 diabetes mellitus and observed for 19 years: the role of age gender and comorbidities. Diabet Med. 2013;30(8):964–972.
    1. Lee JS, Lu M, Lee VS, Russel D, Bahr C, Lee ET. Lower extremity amputation: incidence, risk factors and mortality in the Oklahoma Indian Diabetes Study. Diabetes. 1993;42(6):876–882.
    1. Abbott CA, Carrington AL, Ashe H, et al. North-West Diabetes Foot Care Study The North-West Diabetes Foot Care Study: incidence of, and risk factors for new diabetic foot ulceration in a community-based patient cohort. Diabet Med. 2002;19(5):377–384.
    1. Forsythe RO, Brownrigg J, Hinchliffe RJ. Peripheral arterial disease and revascularization of diabetic foot. Diabetes Obes Metab. 2015;17(5):435–444.
    1. Gross JL, de Azevedo MJ, Silveiro SP, Canani LH, Caramori ML, Zelmanovitz T. Diabetic nephropathy: diagnosis, prevention, and treatment. Diabetes Care. 2005;28(1):164–176.
    1. Aggers PW, Gohdes D, Pugh J. Nontraumatic lower extremity amputations in the Medicare end-stage renal disease population. Kidney Int. 1999;56(4):1524–1533.
    1. Margolis DJ, Hofstad O, Feldman HI. Association between renal failure and foot ulcer or lower-extremity amputation in patients with diabetes. Diabetes Care. 2008;31(7):1331–1336.
    1. Zhou ZY, Liu YK, Chen HL, Yang HL, Liu F. HbA1c and lower extremity amputation risk in patients with diabetes: a meta-analysis. Int J Low Extrem Wounds. 2015;14(2):168–177.
    1. Adler AI, Erqou S, Lima TA, Robinson AH. Association between glycated hemoglobin and the risk of lower extremity amputation in patients with diabetes mellitus review and meta-analysis. Diabetologia. 2010;53(5):840–849.
    1. Rai NK, Suryabhan, Ansari M, Kumar M, Shukla VK, Tripathi K. Effect of glycemic control on apoptosis in diabetic wounds. Int J Low Extrem Wounds. 2015;14(2):168–177.
    1. Klein R. Hyperglycemia and microvascular and macrovascular disease in diabetes. Diabetes Care. 1995;18(2):258–268.

Source: PubMed

Sponsors et collaborateurs

Les conditions médicales

Interventions en matière de drogue

3
S'abonner