SLR - September 2013 - Sarah Rincker
Reference: Yuki Orimoto, Takashi Ohta, Hiroyuki Ishibashi, Ikua Sugimoto, Hirohide Iwata, Tetsuya Yamada, Masao Tadakoshi, and Noriyuki Hida. The prognosis of patients on hemodialysis with foot lesions. J Vasc Surg. 2013 Jun 27.
Scientific Literature Review
Reviewed By: Sarah Rincker, DPM
Residency Program: Grant Medical Center, Columbus, Ohio
Podiatric Relevance: Hemodialysis patients with foot lesions present a major problem for the foot and ankle surgeon. They often have lesions that require surgery and are not only plagued with the complications associated with chronic renal failure, but many studies have also shown a high incidence of PAD in this patient cohort. This paper seeks to describe the probability of limb salvage, and hypothesizes management in this group of patients.
Methods: A retrospective data collection was accomplished including 319 lower limbs in 234 hemodialysis patients being treated in a university hospital between 1980 and 2011. Variables that influenced survival and limb salvage were compared.
Results: Two hundred and thirty four patients (72 percent men) with a mean age of 65.4 years upon admission and 84 percent with diabetes were included in analysis. The mean duration of hemodialysis was 6.8 years. During the follow-up period, 73 percent of patients had died (n=171). One-, three-, five-, and seven-year survival rates were found to be 65.2 percent, 35.5 percent, 23.4 percent, and 12.8 percent respectively. Age upon admission and EKG ischemic changes independently increased the risk of death (hazard ratio of 1.02 and 1.48). Hyperlipidemia independently decreased the risk of death (hazard ration of 0.56). Critical limb ischemia was present in 77 percent of legs (n=247). Arterial reconstruction was done in 88 limbs (28 percent) and 119 limbs (37 percent) required major amputation. The one-, three-, five-, and seven-year limb salvage rates were 8.9 percent, 57.2 percent, 53.8 percent, and 51.7 percent respectively. It was found that patent arterial reconstruction and albumin independently decreased the risk of major amputation (hazard ratios 0.265 and 0.392).
Conclusions: Patient with foot lesions that are hemodialysis-dependent have a relatively very poor prognosis and a result in a high rate of mortality and amputation. Optimizing blood flow and appropriate albumin levels were found to decrease major risk of amputation. This makes prompt assessment of the severity of their systemic conditions including these and cardiac ischemia very important to the foot and ankle surgeon.