SLR - May 2019 - Greg Nero

Impact of Heart Failure and Dialysis in the Prognosis of Diabetic Patients with Ischemic Foot Ulcers

Reference: Meloni, Izzo, Giurato, Cervelli, Gandini, Uccioli. Impact of Heart Failure and Dialysis in the Prognosis of Diabetic Patients with Ischemic Foot Ulcers. Journal of Clinical & Translational Endocrinology, Volume 11 (2018): 31–35.

Scientific Literature Review

Reviewed By: Greg Nero, DPM
Residency Program:  Health Alliance Hospital, Kingston, NY

Podiatric Relevance: Chronic complications from diabetes can affect other organs, such as the kidneys and heart. Impairment of renal and cardiac function can deeply influence the outcomes of diabetic foot ulcer (DFU) treatment. The role of these comorbidities in the prognosis of patients with ischemic DFUs is usually underestimated. With the prevalence of diabetes on the rise, it is essential to analyze the impact of comorbidities on wound healing to establish prognosis in select patients and to strive toward successful wound care management. The aim of this study is to evaluate the impact of heart failure and hemodialysis on the outcomes of patients with diabetes and ischemic foot ulcers treated by conventional limb salvage treatment.

Methods: A total of 136 patients living with diabetes and ischemic foot ulcers (stages C and D of Texas Wound Classification) were included in this study. All patients underwent a set limb salvage protocol, including routine ulcer debridement, antibiotic therapy, offloading and peripheral revascularization. According to the presence of heart failure (HF) or dialysis (D), patients were divided into four subgroups: Group 1 (66 patients) without HF and without D defined as ischemic foot (IF); Group 2 (26 patients) with HF and without D defined as heart ischemic foot (HIF); Group 3 (24 patients) without HF and with D defined as renal ischemic foot (R-IF); and Group 4 (20 patients) with HF and with dialysis defined as heart-renal foot (HRIF). After one year follow-up, patients would be stratified as survival with limb salvage, survival with major amputation or death.

Results: One hundred three (75.7 percent) of patients survived with limb salvage, 10 (7.4 percent) survived with major amputation and 23 (16.9 percent) died. Survival with limb salvage was highest in Group 1 (92.4 percent) and lowest in Group 4 (35 percent). Group 3 (8.3 percent) and Group 2 (7.7 percent) had the highest rates of survival with major amputation, respectively. Group 4 had that highest mortality rate (55 percent) with Group 2 following (30.8 percent).

Conclusions: The study shows that both dialysis and heart failure can have negative effects on wound healing independently of each other while also having a compound effect when present together. It would have been interesting to include information on their debridement/offloading techniques for their limb salvage protocol. Another important factor the study could have included was wound location and its effect on prognosis. Lastly, results on the revascularization procedures would have been helpful to distinguish patients based on levels of ischemia.  

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