The Effect of Hemodialysis on Diabetic Foot Complications

Introduction: People with diabetes undergoing hemodialysis are ten times more likely to undergo lower extremity amputation than people with diabetes alone. Regular podiatric care is shown to have protective benefits against adverse outcomes in people with diabetes. Despite this, little is known regarding the effect of preventative care with podiatric medicine in the setting of patients on hemodialysis. This study evaluated the effect of preventative podiatric care on risk of amputation in people with chronic kidney disease.Methods:A retrospective review was conducted of consecutive patients from Jan 2016- March 2020 managed by podiatric physicians at a tertiary academic hospital with chronic kidney disease stage 3a or worse. Patients were followed for no less than 2 years and evaluated for adverse outcomes such as new index foot ulcer, re-ulceration, amputation, and date of hemodialysis initiation.Results:82 patients were identified: 49 individuals had chronic kidney disease but had not commenced hemodialysis, while 33 individuals having had been on dialysis. 17 of the chronic kidney disease without dialysis underwent a lower extremity amputation (35%), and nineteen of the chronic kidney disease with dialysis patients underwent an amputation (58%). Of the 33 patients undergoing hemodialysis, 13 had established with podiatry before starting dialysis of which seven underwent an amputation, all of which were minor amputations (transmetatarsal or distal). Of the remaining 20 whom did not establish with podiatry before dialysis, eight underwent amputation, of which five were major lower extremity amputations. There was 2.5x odds ratio of amputation for patients undergoing hemodialysis compared to individuals with CKD not undergoing hemodialysis (p 0.05).  The timing of podiatric care, whether before or after starting dialysis, did not impact the rate of overall amputations, but even in this small cohort, there was an apparent 11 fold increase in major lower extremity amputations in patients who did not establish with podiatry prior to initiating HD (p~0.1). Discussion: People on hemodialysis with diabetes were at an increased risk of amputation compared to those with chronic kidney disease alone. Timeline to establish care with a podiatrist did not decrease rate of overall amputations but may be protective against major lower extremity amputation in this patient population.   References:1. Umanath et al. American Journal of Kidney Disease. 2018. 2. Rajagopalan et al. Circulation. 2006 3. Raskin et al. Neurology and General Medicine. 1995 4. Krishnan et al. Muscle and Nerve. 2007. 5. Margolis et al. Diabetes Care. 2008 6. McGrath et al. Diabetes Care. 2000 7. Eggers et al. Kidney International. 1999 8. Franz et al. JAMA Internal Medicine. 2018.