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© 2004 by the American Diabetes Association, Inc.
Pathophysiology/Complications |
Diabetes Is the Strongest Risk Factor for Lower-Extremity Amputation in New Hemodialysis Patients
1 Rollins School of Public Health, Emory University, Atlanta, Georgia
2 Centers for Medicare & Medicaid Services, Center for Beneficiary Choices, Baltimore, Maryland
3 National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
4 Department of Nephrology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
Address correspondence and reprint requests to William McClellan, MD, MPH, Georgia Medical Care Foundation, 1455 Lincoln Parkway, Suite 800, Atlanta, Georgia 30329. E-mail: bmcclellan{at}gmcf.org
OBJECTIVE—End-stage renal disease (ESRD) patients, especially those with diabetes, have an increased risk of nontraumatic lower-extremity amputation (LEA). The present study aims to examine the association of demographic and clinical variables with the risk of hospitalization for LEA among incident hemodialysis patients.
RESEARCH DESIGN AND METHODS—The study population consisted of incident hemodialysis patients from the study years 1996–1999 of the ESRD Core Indicator/Clinical Performance Measures (CPM) Project. Cox proportional hazard modeling was used to identify factors associated with LEA.
RESULTS—Four percent (116 of 3,272) of noncensored incident patients had an LEA during the 12-month follow-up period. Factors associated with LEA included diabetes as the cause of ESRD or preexisting comorbidity (hazard ratio 6.4, 95% CI 3.4–12.0), cardiovascular comorbidity (1.8, 1.2–2.8), hemodialysis inadequacy (urea reduction ratio [URR] <58.5% (1.9, 1.1–3.3), and lower serum albumin level (1.6, 1.1–2.3). Among patients with diabetes, hemodialysis inadequacy and cardiovascular comorbidity were risk factors for LEA (2.6, 1.4–4.8, and 1.7, 1.1–2.6, respectively).
CONCLUSIONS—These data suggest that diabetes is a potent risk factor for LEA in new hemodialysis patients. In ESRD patients with diabetes, a multipronged approach may reduce the rate of LEA. Potentially beneficial strategies include adherence to hemodialysis adequacy guidelines, aggressive treatment of cardiovascular comorbidities, and the utilization of LEA prevention strategies recommended for the general population of patients with diabetes.
Abbreviations: BCG, bromcresol green • BCP, bromcresol purple • CMS, Centers for Medicare & Medicaid Services • CPM, Clinical Performance Measures • ESRD, end-stage renal disease • LEA, lower-extremity amputation • SAF, Standard Analytical File • URR, urea reduction ratio • USRDS, U.S. Renal Data System
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