Preventive Foot Care in Hemodialysis Patients

Reducing Amputation Risk

Do diabetic foot examinations reduce the risk of amputation? For two decades, the United States Department of Health and Human Services (HHS) has used health promotion and disease prevention objectives to improve the health of the American people. The overall goal for diabetes in the Healthy People 2010 objective is, “Through prevention programs, reduce the disease and economic burden of diabetes and improve the quality of life for all persons who have or are at risk for diabetes” (HHS, 2000). A specific objective contained within this goal targets a 55 percent reduction in the rate of lower extremity amputations in persons with diabetes. This would amount to 1.8 lower extremity amputations per 1,000 patients with diabetes per year, down from 4.1 per 1,000 patients that occurred in 1997 (HHS, 2000). Several clinical studies in the nondialysis diabetic population have shown that coordinated programs to screen for high-risk feet and to provide regular foot care decreased lower extremity amputation rates. In a controlled study, 45 hemodialysis patients were assigned to intensive education and care management that included preventive foot care and 38 HD patients were assigned to usual care. Over the 12-month follow-up period, there were no amputations in the study group while there were five lower extremity amputations and two finger amputations in the control group. Mortality was unaffected over the short time of the study, but the morbidity benefit was obvious. Benefit from aggressive preventive care is therefore very likely if not proven through prospective randomized controlled trials.

Nobody would disagree that regular foot care is standard care for every diabetic, and diabetic patients on dialysis are no exception to this standard of care. The American Diabetic Association recommends, “All individuals with diabetes should receive a thorough foot examination at least once yearly to identify high-risk foot conditions.” The ADA goes on to recommend more frequent evaluation for people with one or more risk factors and a visual foot inspection at every visit with a healthcare professional for diabetic patients with neuropathy. “Examination of the foot is an obvious, fundamental step to identifying certain foot risk factors that can be modified, thus reducing the risk of ulceration and amputation” (Mayfield, Reiber et al. 1998). Foot lesions are the single most frequently mismanaged problem of patients with diabetes mellitus and chronic kidney disease (CKD). Recommendations for improving the survival of patients with diabetes and CKD include improvement in the foot care and education of both patients and nephrology healthcare providers regarding diabetic foot complications (Ritz, Koch et al. 1999).