Preventive Foot Care in Hemodialysis Patients

Patients with diabetes and chronic renal disease frequently present with a combination of the devastations of diabetes including: nephropathy, retinopathy and vasculopathy. The main focus of the care of these patients has been on the target organs like heart and kidneys. Therefore, early risk factors for diabetic foot complications may be disregarded, and this may lead to amputation—a failure for both the patient and physician. Diabetic foot complications, including amputation, add significantly to the morbidity and mortality of the patient with diabetes and CKD. However, of all the long-term complications of diabetes, foot complications may be the most preventable. In the United States, diabetes is the cause of 50 percent of nontraumatic lower extremity amputations and is increasing annually (Levin, 2002). The prevalence of lower extremity amputation for patients with diabetes and CKD is much greater than those without CKD. The rate of lower limb amputation for the population at large increased during a recent four-year period from 4.8 to 6.2/100 persons. During the same time frame, this rate of lower extremity amputation rose from 11.8 to 13.8/100 among persons with CKD attributed to diabetic nephropathy. The rate for patients with diabetes and CKD was 10 times greater than the diabetic population at large (Eggers, Gohdes, & Pugh et al., 1999). The cost of treating patients with diabetes is astronomical both financially and in terms of quality of life. The loss of a lower extremity or even part of a lower extremity greatly impacts quality of life. Depression after amputation is common. Leisure activities as well as employment status are altered. The mortality rate after amputation in patients with diabetes is 11 percent to 4 percent at one year, 20 percent to 50 percent at three years, and 39 percent to 68 percent at five years (Fritschi, 2001). The impact of disorganized foot care on overall morbidity and mortality in hemodialysis patients therefore can no longer be ignored. One could always argue the benefit of putting resources into such an endeavor.