• 1

    Lavery LA. Lavery DC. Hunt NA. et al: Amputations and foot-related hospitalisations disproportionately affect dialysis patients. Int Wound J 12: 523, 2015.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 2

    Ndip A. Lavery LA. Boulton AJ. Diabetic foot disease in people with advanced nephropathy and those on renal dialysis. Curr Diab Rep 10: 283, 2010.

  • 3

    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 33: 1811, 2010.

    • Crossref
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 4

    Margolis DJ. Hofstad O. Feldman HI. Association between renal failure and foot ulcer or lower-extremity amputation in patients with diabetes. Diabetes Care 31: 1331, 2008.

    • Crossref
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 5

    Game FL. Chipchase SY. Hubbard R. et al: Temporal association between the incidence of foot ulceration and the start of dialysis in diabetes mellitus. Nephrol Dial Transplant 21: 3207, 2006.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Lavery LA. Peters EJ. Armstrong DG. et al: Risk factors for developing osteomyelitis in patients with diabetic foot wounds. Diabetes Res Clin Pract 83: 347, 2009.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 7

    Sahai H. Khurshid A. Statistics in Epidemiology: Methods, Techniques, and Applications, p 321, CRC Press Inc, Boca Raton, FL, 1996.

  • 8

    Lavery LA. Peters EJ. Williams JR. et al: Reevaluating the way we classify the diabetic foot: restructuring the diabetic foot risk classification system of the International Working Group on the Diabetic Foot. Diabetes Care 31: 154, 2008.

    • Crossref
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 9

    Peters EJ. Lavery LA. International Working Group on the Diabetic Foot: Effectiveness of the diabetic foot risk classification system of the International Working Group on the Diabetic Foot. Diabetes Care 24: 1442, 2001.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10

    Lavery LA. Hunt NA. Lafontaine J. et al: Diabetic foot prevention: a neglected opportunity in high-risk patients. Diabetes Care 33: 1460, 2010.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 11

    Ndip A. Lavery LA. Lafontaine J. et al: High levels of foot ulceration and amputation risk in a multiracial cohort of diabetic patients on dialysis therapy. Diabetes Care 33: 878, 2010.

    • Crossref
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 12

    Lavery LA. Armstrong DG. Wunderlich RP. et al: Diabetic foot syndrome: evaluating the prevalence and incidence of foot pathology in Mexican Americans and non-Hispanic whites from a diabetes disease management cohort. Diabetes Care 26: 1435, 2003.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Hinchliffe RJ. Kirk B. Bhattacharjee D. et al: The effect of haemodialysis on transcutaneous oxygen tension in patients with diabetes: a pilot study. Nephrol Dial Transplant 21: 1981, 2006.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Lavery LA. Armstrong DG. Temperature monitoring to assess, predict, and prevent diabetic foot complications. Curr Diab Rep 7: 416, 2007.

  • 15

    Lavery LA. Higgins KR. Lanctot DR. et al: Home monitoring of foot skin temperatures to prevent ulceration. Diabetes Care 27: 2642, 2004.

  • 16

    Kaminski MR. Raspovic A. McMahon LP. et al: Risk factors for foot ulceration in adults with end-stage renal disease on dialysis: study protocol for a prospective observational cohort study. J Foot Ankle Res 8: 53, 2015.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 17

    Kaminski MR. Raspovic A. McMahon LP. et al: Risk factors for foot ulceration in adults with end-stage renal disease on dialysis: a systematic review and meta-analysis. Nephrol Dial Transplant 30: 1747, 2015.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation

Does the Start of Dialysis Initiate a Period of Increased Risk of Ulceration or Amputation?

Lawrence A. Lavery Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX.

Search for other papers by Lawrence A. Lavery in
Current site
Google Scholar
PubMed
Close
 DPM
,
David C. Lavery Aurora Statistical Consultants, Aurora, CO.

Search for other papers by David C. Lavery in
Current site
Google Scholar
PubMed
Close
 MS
,
Nathan A. Hunt Orthopedic and Spine Center of the Rockies, Fort Collins, CO.

Search for other papers by Nathan A. Hunt in
Current site
Google Scholar
PubMed
Close
 DPM
,
Javier La Fontaine Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX.

Search for other papers by Javier La Fontaine in
Current site
Google Scholar
PubMed
Close
 DPM
, and
Ryan D. Lavery Texas Tech University, Dallas, TX.

Search for other papers by Ryan D. Lavery in
Current site
Google Scholar
PubMed
Close
Restricted access

Background:

Dialysis therapy is associated with an increased incidence of lower-extremity wounds and amputations. We compared the incidence of foot ulcers and amputations before and after the start of dialysis.

Methods:

We evaluated 150 consecutive diabetic patients receiving dialysis and compared the incidence of foot complications 30 months before and after initiation of hemodialysis. We used claims data for diabetes, ulceration, and dialysis and abstracted medical records to verify diagnoses and dates of ulcers and amputations. We compared initial and cumulative ulcer/amputation incidence to account for multiple events in the same person over time. We used the same formula to determine the incidence rate difference and 95% confidence intervals (CIs) to compare new ulcers and amputations during the study.

Results:

There was no significant difference in the incidence of first foot ulcers before (91.7 per 1,000 patient-years; 95% CI, 73.7–112.3 per 1,000 patient-years) and after (82.7; 95% CI, 65.7–102.3) the start of hemodialysis. The incidence of cumulative ulcers was significantly higher before (304.0 per 1,000 patient-years; 95% CI, 270.8–340.2) compared with after (210.7 per 1,000 patient-years; 95% CI, 183.0–240.9) dialysis. There was no difference in the incidence of first amputation before (29.3 per 1,000 patient-years; 95% CI, 1 9.4–41.7 per 1,000 patient-years) and after (37.3 per 1,000 patient-years; 95% CI, 19.4–41.7 per 1,000 patient-years) dialysis or in the cumulative incidence of amputations before (61.3 per 1,000 patient-years; 95% CI, 46.7–8.4 per 1,000 patient-years) and after (58.7 per 1,000 patient-years; 95% CI, 44.5–75.5 per 1,000 patient-years) dialysis.

Conclusions:

There was no increase in the incidence of ulcers or amputations after beginning hemodialysis.

Corresponding author: Lawrence A. Lavery, DPM, Department of Plastic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390. (E-mail: larry.lavery@utsouthwestern.edu)