The Importance of Podiatric Care in Patients With Diabetes and End-Stage Renal Disease

Diabetic foot complications continue to plague patients at an alarming rate. Recent data estimate 1.6 million people each year in the United States and 18.6 million worldwide will develop a foot ulcer.¹ It is well known that diabetic foot ulcers are a causative factor in 80% of amputations performed.¹ It has been established that the 5-year mortality rates of people with diabetic foot ulcers, lower extremity minor amputations, and major amputations (30.5, 46.2, and 56.5% respectively) are comparable to cancer. Furthermore, it appears that these diabetic foot complications are an independent marker for premature death.²

Pecoraro and colleagues’ pivotal work in 1990 that identified causal pathways to diabetic limb amputation is still relevant today.³ The researchers found 7 contributing factors (typically in combination) leading to amputation. These factors include ischemia, infection, neuropathy, faulty wound healing, minor trauma, cutaneous ulceration, and gangrene. Researchers surmised that one could prevent amputation by preventing or treating the portion of the causal pathway early.³ Today, we routinely address these causal pathways. This includes lower extremity arterial vascular interventions for ischemia and gangrene, infection control with surgery and antibiotics, advanced wound healing modalities for ulcers and slow to heal wounds, and education and diabetic shoes and inserts to prevent minor trauma.

Research also shows that we should also consider advanced kidney disease as another independent risk factor leading to diabetic ulcers and amputations.^4,5 This is especially true in patients with end-stage renal disease (ESRD) requiring dialysis.^4,5 The correlation is complex and multifactorial, including behavioral, nutritional, and medical issues. Research reveals that many dialysis patients do not perform preventative measures such as inspecting their feet daily, avoiding barefoot walking, wearing well-fitting shoes, and regularly attending foot care clinics.⁴ Authors hypothesize that dialysis could be a factor, especially since a large number of dialysis patients experience depression and struggle with engaging in self-care.⁴ Being on hemodialysis creates a nutritional deficit. This is particularly true for protein and essential vitamins and minerals, such as zinc, which are vital for wound healing. Appropriate diet and supplementation are critical for treating patients with foot ulcers.^6,7 Many dialysis patients have concomitant vascular and cardiac disease, which impacts healing potential. Anemia is also common in ESRD patients, which will deleteriously affect the oxygen and nutrient delivery to the wound site.⁶

A Closer Look at Amputation and ESRD

The outlook for amputation is striking in patients with diabetes and ESRD. In general, patients with diabetes and ESRD are 10 times more likely to have some level of lower extremity amputation than a patient with diabetes, but without ESRD.⁸ Hospital mortality in patients with diabetes and ESRD undergoing minor (partial foot) and major (below-knee and above-knee) limb amputations is higher than those without renal disease.⁹ A study in south Texas found that patients with diabetes and ESRD have more major amputations and a 3-times greater 10-year mortality rate than those patients without kidney disease.¹⁰ Studies recommend focusing on preventative foot care in this high-risk diabetic population and aggressive treatment to heal diabetic foot ulcers to prevent major amputations.^5,8,9,11

It is therefore imperative that podiatrists be involved in all aspects of foot care in the patient with diabetes and ESRD. This includes wound care and surgical intervention, but the importance of regular, quarterly surveillance foot care cannot be overstated. These visits allow the practitioner to perform a focused foot exam to look for interval changes such as new ulcers, deformity, or advancing vascular disease and start appropriate treatment. Considering many foot complications start as minor issues such as skin trauma caused by patient self-care of toenails and calluses, it is important for health care practitioners to provide nail and callus care. Many foot complications also start from poor fitting footwear and therefore shoe and brace inspection should be performed and prescription for new shoes, inserts, and braces provided as necessary These visits are a great time to provide patient education for appropriate foot check practices and the need to communicate complications in a timely manner.

Insights on Kidney Transplants in Patients With ESRD

The importance of podiatric care for ESRD patients became apparent to me just before matriculating to podiatry school in Des Moines, Iowa in the late 1990s. During my senior year of college my older brother, Jason, went into renal failure. Unfortunately, his kidneys did not recover and at the age of 27 he became faced with the harsh reality of hemodialysis to stay alive. He was encouraged my pursuits at podiatry school, as he saw many patients with diabetes in his dialysis unit with foot dressings in place for ulcers and many with one or both legs amputated. He thought I might be able to help. I took this to heart and learned a great deal about end-stage renal disease and the diabetic foot while performing a required podiatry school project and my commitment continues today.

The treatment for end-stage renal disease to avoid life-threatening uremia is renal replacement therapy with hemodialysis or peritoneal dialysis and kidney transplant with either a live or deceased donor. Interestingly, in the United States, before the Social Security Amendments of 1972 extended Medicare coverage to people with ESRD, diabetes was a contraindication to treatment for dialysis or transplant.8 In 1978, there were 15,327 people receiving dialysis.⁸ Since that time, the number of people undergoing treatment with dialysis and transplants has dramatically increased, with diabetes now being the most common cause for advanced renal failure requiring treatment.⁸ In 2000 in the United States, the incidence of new patients requiring dialysis was 92,493 and the prevalence of patients on dialysis was 282,483. In 2020, the incidence of new patients requiring dialysis jumped to 130,522 and the prevalence almost doubled to 562,074.¹²

If a patient is eligible and willing, kidney transplant is the best available treatment option for ESRD. While there is risk with the transplant procedure and postoperative care, a successful transplant can reduce patient mortality, improve quality of life, and reduce the yearly cost of treatment.^13,14 In the United States in 2000, there were 13,361 kidney transplants and in 2023 this increased to 27,332.¹⁵ Currently, there are 92,000 people awaiting a kidney transplant in the US.¹⁶

The process for obtaining a kidney transplant is extensive. It starts with a referral to a transplant center for an initial cursory screening. If a patient is a likely candidate, they then schedule a meeting with the center. Each center has its own protocols, but typically the members of the transplant team perform a thorough workup, including the surgeons, nephrologist, nurse coordinator, social worker, financial coordinator, and dietician. Centers will typically encourage family and support network involvement in the workup process. The workup includes a thorough history and physical exam, a psychological exam, compatibility tests (blood typing, tissue typing, crossmatching), blood chemistry, chest X-ray, echocardiogram, electrocardiogram, cardiac stress test, cancer screening, colonoscopy, gynecological or prostate exam, and dental evaluation.¹⁷ If the patient receives clearance for transplant, the next step is placement on the deceased donor waiting list or moving forward with a willing live donor.

My brother was very grateful to be on dialysis to stay alive, but 2 years of dialysis had started to wear on him. He was spending 5 hours, 3 times per week tethered to his hemodialysis center, which was equivalent to 1,560 hours, or 65 days, or 9 weeks, or 2 months. The worst for him, however, was the limited fluid intake, typically to 1 to 2 liters between dialysis sessions. He said it was like being in a state of perpetual thirst. So, my brother and I went through an extensive kidney transplant workup and between my first and second year of medical school I donated my kidney to him.

Why DFU Treatment Is Important for ESRD Patients

Not all patients with ESRD are candidates for kidney transplants. There are specific contraindications for a kidney transplant, such as recurring infections not able to be treated effectively, cancer, severe heart disease, and other medical conditions preventing a safe surgery.¹⁸ Even though foot ulcers are common in those with diabetes and ESRD, there does not appear to be specific protocols to address this within transplant centers. Over the years, I have found that—regardless the size of a foot ulcer or whether or not infection is present—patients are often removed from the transplant list until the foot ulcer is resolved.

Thus, it is paramount that we treat foot ulcers in an expeditious manner for these patients. This requires podiatrists to work in a multidisciplinary team, making sure there is adequate arterial inflow, infection management, and optimization of any underlying medical conditions. Once this has been established, one should apply orthoplastic techniques to address the soft tissue deficits and correct any underlying musculoskeletal abnormalities with the goal of achieving a fully healed, plantigrade, functional foot.¹⁹

It is well known this diabetic patient cohort carries especially challenging medical and surgical circumstances. Anecdotally, I have experienced that in comparison to patients with diabetes without end-stage renal disease, patients with diabetes and ESRD heal much slower, can require more surgeries, and can suffer more complications. During the treatment process, expect to take steps forward and then at times backwards. Understanding this dynamic and educating the patients and their families is vital to maintaining a positive treatment regimen and realistic healing timeframe. This knowledge is also the key for a practitioner to remain passionate about treating these patients over the long run.

Final Thoughts

The most satisfying day in clinic by far is when I inform hemodialysis patients that their foot ulcers are healed, and they can now move forward with the kidney transplant process. This is a truly positive, life-changing moment for the patients and their families.

As of writing this article, my brother is 24 years, 8 months, and 20 days out from his kidney transplant. During this time, his transplant has saved him 19,350 hours, or 806 days, or 115 weeks, or 28 months, or 2.4 years enduring hemodialysis.

The challenges one may face in treating patients with diabetes and ESRD, I hope, will not dissuade many podiatrists from using their unique talents to positively change the life of a potential future kidney transplant recipient.

Dr. Pehde is an Assistant Clinical Professor of Podiatric Medicine and Surgery in the Department of Orthopaedics, Division of Podiatry at UT Health San Antonio. He serves as the Director of the Amputation Prevention and Research Fellowship and is the Lee J. Sanders Endowed Professor of Lower Extremity Amputation Prevention.

References

1.     Armstrong DG, Tan TW, Boulton AJM, Bus SA. Diabetic foot ulcers: a review. JAMA. 2023 Jul 3;330(1):62-75.
2.     Armstrong DG, Swerdlow MA, Armstrong AA, Conte MS, Padula WV, Bus SA. Five year mortality and direct costs of care for people with diabetic foot complications are comparable to cancer. J Foot Ankle Res. 2020 Mar 24;13(1):16.
3.     Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation. Basis for prevention. Diabetes Care. 1990 May;13(5):513-21.
4.     Ndip A, Rutter MK, Vileikyte L, et al. Dialysis treatment is an independent risk factor for foot ulceration in patients with diabetes and stage 4 or 5 chronic kidney disease. Diabetes Care. 2010 Aug;33(8):1811-6.
5.     Griffiths GD, Wieman TJ. The influence of renal function on diabetic foot ulceration. Arch Surg. 1990 Dec;125(12):1567-9
6.     Ramond S. Promoting wound healing in dialysis patients through nutrition. Clinical Care. Posted January 31, 2019.
7.     Maroz N, Simman R. Wound healing in patients with impaired kidney function. J Am Coll Clin Wound Spec. 2014 Jun 8;5(1):2-7.
8.     Eggers PW, Gohdes D, Pugh J. Nontraumatic lower extremity amputations in the Medicare end-stage renal disease population. Kidney Int. 1999 Oct;56(4):1524-33.
9.     Dossa CD, Shepard AD, Amos AM, et al. Results of lower extremity amputations in patients with end-stage renal disease. J Vasc Surg. 1994 Jul;20(1):14-9.
10.     Lavery LA, Hunt NA, Ndip A, Lavery DC, Van Houtum W, Boulton AJ. Impact of chronic kidney disease on survival after amputation in individuals with diabetes. Diabetes Care. 2010 Nov;33(11):2365-9.
11.     Tan TW, Caldwell B, Zhang Y, Kshirsagar O, Cotter DJ, Brewer TW. Foot and ankle care by podiatrists and amputations in patients with diabetes and kidney failure. JAMA Network Open. 2024 Mar 4;7(3):e240801.
12.     National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Accessed March 31, 2024.
13.     Kaballo MA, Canney M, O’Kelly P, Williams Y, O’Seaghdha CM, Conlon PJ. A comparative analysis of survival of patients on dialysis and after kidney transplantation. Clin Kidney J. 2018 Jun;11(3):389-393.
14.     Axelrod DA, Schnitzler MA, Xiao H, Irish W, Tuttle-Newhall E, Chang SH, Kasiske BL, Alhamad T, Lentine KL. An economic assessment of contemporary kidney transplant practice. Am J Transplant. 2018 May;18(5):1168-1176.
15.     US Department of Health and Human Services. Organ Procurement and Transplantation Network. Accessed March 31, 2024.
16.     American Kidney Fund. Site Accessed March 31, 2024.
17.     National Kidney Foundation. Accessed March 31, 2024.
18.     Johns Hopkins Medicine. Accessed March 31, 2024.
19.     Pehde CE, Bennett J, Kingston M. Orthoplastic approach for surgical treatment of diabetic foot ulcers. Clin Podiatr Med Surg. 2020 Apr;37(2):215-230. doi: 10.1016/j.cpm.2019.12.001.
20.     Miri S, Hosseini SJ, Takasi P, et al. Effects of breathing exercise techniques on the pain and anxiety of burn patients: A systematic review and meta-analysis. Int Wound J. 2023;20(6):2360-2375. doi:10.1111/iwj.14057
21.     Farzan R, Firooz M, Ghorbani Vajargah P, et al. Effects of aromatherapy with Rosa damascene and lavender on pain and anxiety of burn patients: A systematic review and meta-analysis. Int Wound J. 2023;20(6):2459-2472. doi:10.1111/iwj.14093
22.     Gardner SE, Blodgett NP, Hillis SL, et al. HI-TENS reduces moderate-to-severe pain associated with most wound care procedures: a pilot study. Biol Res Nurs. 2014;16(3):310-319. doi:10.1177/1099800413498639
23.     Price PE, Fagervik-Morton H, Mudge EJ, et al. Dressing-related pain in patients with chronic wounds: an international patient perspective. Int Wound J. 2008;5(2):159-171. doi:10.1111/j.1742-481X.2008.00471.x
24.     Admassie BM, Ferede YA, Tegegne BA, Lema GF, Admass B A. Wound-related procedural pain management in a resource limited setting: Systematic review. Int J Surgery Open. 2022; 47:100549.