Title: The Prognosis of Patients On Hemodialysis with Foot Lesions

SLR-January 2014- Douglas Appel

Reference: The Prognosis of Patients on Hemodialysis with Foot Lesions. Y. Orimoto, T. Ohta, H. Ishibashi, Isugimoto, H. Iwata, T. Yamada, M. Tadakoshi, N. Hida. Journal of Vascular Surgery. 2013 November: 58(5);1291-299

Scientific Literature Review

Reviewed By: Douglas Appel, DPM

Residency Program: Morristown Memorial Hospital

Podiatric Relevance: The authors were attempting to determine the prognosis of patients with foot lesions on hemodialysis and how to best manage these patients. As foot and ankle specialists, we deal with ulcerations of the lower extremity in patients that are frequently on hemodialysis and who present with other comorbidities.
 

Methods: This was a retrospective case serieswith data that was collected in a retrospectively maintained database for 319 lower limbs with foot lesions in 234 hemodialysis patients treated in auniversity hospital. Variables influencing survival and limb salvage were compared using log-rank tests and Cox regression analysis. All wounds were retrospectively classified using the University of Texas Diabetic Wound Classification; excluding wounds classified as grade 0 or stage A. Non-invasive vascular testing was performed to classify wounds and to determine the need for intervention. Limbs that did not fit criteria fore vascularization and were not healthy were included in the Critical LimbIschemia (CLI) Group. Variable groups for comparison were as follows: sex, smoking habit, hypertension, hyperlipidemia, diabetes, history of cardiovascular disease, heart failure, CVD and malignancy, diseased limb, CLI, CTR, ischemic changes on ECG, arterial reconstruction and major amputation.

Results: Seventy-three  percent (171) patients died during follow up. Age at admission, age on commencing hemodialysis, CTR>50 percent, ischemic changes of ECG, and major amputation independently increased risk of death (hazards ratios (HR) of 1.04, 1.02, 1.44, 1.46, 1.32, respectively). However, hyperlipidemia and a higher level of hemoglobin and albumin independently decreased the risk of death (HRs, 0.54, 0.91, and 0.680, respectively). Peripheral Arterial Disease (PAD) was found to be one of the most important determinants of overall survival in patients on HD. Survival rates of HD patients without PAD were 94 percent  at one year and 73 percent at five years compared to patients with PAD on HD with survival rates at one year 90 percent and at five years of 59 percent. However, survival rates of patients on HD with foot lesions were especially poor being 65 percent at one year and 23 percent at five years.
 

Conclusion: Patients with foot lesions and on HD have a worse prognosis than patients with liver, lung, esophagus, stomach, kidney, prostate, or breast cancer when compared individually. In fact, it has the second lowest survival rates only second to pancreatic cancer. Patients who underwent revascularization had better survival rates andhigher limb salvage rates. I find that this article defines the need for podiatrists to recognize PAD early and refer the patient for revascularization and the need to treat ulcerations of the foot in patients on HD more aggressively.