SLR - April 2021 - Brian T. Haven
Reference: Pérez Pico AM, Dorado P, Santiesteban MÁ, Mingorance-Alvarez E, García-Bernalt Funes V, Mayordomo R. Prevalence of Foot Disorders According to Chronic Kidney Disease Stage. J Ren Care. 2021 Mar;47(1):17-26. doi: 10.1111/jorc.12342. Epub 2020 Jul 30. PMID: 33216453.
Level of Evidence: II
Scientific Literature Review
Reviewed By: Brian T. Haven, DPM
Residency Program: Carl T. Hayden VA Medical Center – Phoenix, AZ
Podiatric Relevance: A podiatric surgeon treats the entire patient and not just the feet. The majority of patients seen in a clinical or surgical setting will have some subset of comorbidities that can and should influence medical management. By and large, most concerns are focused on the diabetic population; however, chronic kidney disease (CKD) can lead to extensive morbidity and mortality. There are five stages of CKD that is stratified according to the glomerular filtration rate (GFR). As the disease process progresses, there is also increased burden on the health care system. Foot ulcer pathology worsens with the severity of CKD. Therefore, stratifying foot disorders according to the stages of chronic kidney disease allows for earlier detection, treatment, and medical management in this high-risk population.
Methods: Two hundred nine Caucasian people (109 women and 100 men) with an average age of 71.7 years participated in this voluntary observational cross-sectional study at a hospital in Spain. Inclusion criteria was anyone over 18 who had not seen a podiatrist within seven days. The subjects CKD was staged based on their serum creatinine value with the upper bound >90 (G1) and the lower eGFR <15 (G5). A podiatrist, blind to the patient’s eGFR, examined the patient’s feet for pathology related to dermatopathies, keratopathies, onychopathies and toe deformities. Results were stratified and analyzed by the Fisher’s exact test for statistical significance with a p <0.05.
Results: Ninety-seven point six percent of subjects had at least one dermatopathy and most commonly this was either skin changes or a vascular change. Keratopathies were seen in 66 percent of patients with hyperkeratosis far more prevalent than helomas. Onychopathies was almost universal at 98.5 percent of all patients, and most had more than one. Ninety-seven point one percent of patients had toe deformities with hallux valgus being most prevalent at 71.7 percent. Comparing between stages of CKD showed that G4 and G5 had the most pronounced dermatopathies, while keratopathies were more found in the initial stages of CKD. Onychopathies were more seen in the middle to late stage of the disease while toe deformities were irrespective of CKD.
Conclusions: Patients with CKD are at greater risk for morbidity and mortality. The multifocal affects seen in the lower extremity are a microcosm of the whole patient. The inability to filter waste could lead to xerosis, as was seen at every stage, to worsening circulatory function, atrophic skin, ulcerations, and spontaneous hematomas in end stage. As patients progress downward and their activity deteriorates, they may have less callus formation due to decreased activity levels. However, their friable skin, increased cardiac burden and need for frequent hemodialysis greatly increase their risk for morbidity, as well as their burden on the healthcare system. The authors concluded that those at end stage renal disease should be seen monthly for routine foot checks to dissuade severe debilitating morbidity. This is twice as frequent as the current recommendation for diabetic foot risk assessment. The risk only intensifies in patients with both diabetes and CKD.