Wednesday, October 14, 2009

Amputation and diabetes: How to protect your feet

Foot care is especially important if you have diabetes. Diabetes can impair blood flow to your feet and cause nerve damage. Without proper attention and care, a small injury can develop into an open sore (ulcer) that can be difficult to treat. Sometimes amputation is necessary if an infection severely damages the tissue and bone.

The good news is that with proper diabetes management and careful foot care, amputation may be preventable. Here's what you need to know about the link between amputation and diabetes — and how to keep your feet healthy.
Why does diabetes pose a risk of amputation?

Diabetes can cause two potentially dangerous threats to your feet.

* Nerve damage (diabetic neuropathy). When the network of nerves in your feet is damaged the sensation of pain in your feet is reduced. Because of this, you can develop a blister or cut your foot without realizing it.
* Reduced blood flow. Diabetes can also narrow your arteries, reducing blood flow to your feet. With less blood to nourish tissues in your feet, it's harder for sores to heal. An unnoticed cut or sore hidden beneath your socks and shoes can quickly develop into a larger problem.

Left untreated, a minor foot injury could become a serious infection — even leading to tissue death (gangrene). Severe damage might require toe, foot or even leg amputation.

~ ~

The diabetic foot: amputations are preventable

People with diabetes are at risk of nerve damage (neuropathy) and problems with the blood supply to their feet (ischaemia). Both neuropathy and ischaemia can lead to foot ulcers and slow-healing wounds which, if they get infected, may result in amputation.

In 2000 the International Diabetes Federation endorsed the International Working on the Diabetic Foot as a Consultative Section on the Diabetic Foot. Together the organizations established goals for the future of diabetic foot care worldwide.


* to inform people of the extent of diabetic foot problems worldwide
* to raise awareness of the diabetic foot among those at risk and those in a position to take action
* to persuade healthcare decision makers that action is both possible and affordable
* to warn healthcare decision makers of the consequences of not taking action
* to inform people with diabetes of the measures they can take to prevent foot complications

Diabetes is a serious chronic disease. In 2003 the global prevalence of diabetes was estimated at 194 million. This figure is predicted to reach 333 million by 2025 as a consequence of longer life expectancy, sedentary lifestyle and changing dietary patterns. This rise is likely to bring a proportional increase in the numbers of people with diabetes complications, including problems of the foot.

Most amputations begin with a foot ulcer

Diabetic foot ulcers as a result of neuropathy or ischaemia are common. In developed countries, up to five per cent of people with diabetes have foot ulcers, and one in every six people with diabetes will have an ulcer during their lifetime. Foot problems are the most common cause of admission to hospital for people with diabetes. In developing countries, foot problems related to diabetes are thought to be even more common. Without action, global amputations rates will continue to rise.

Every 30 seconds a leg is lost to diabetes somewhere in the world

Extensive epidemiological surveys have indicated that between 40% and 70% of all lower extremity amputations are related to diabetes. This means that every 30 seconds a lower limb is lost to diabetes. The vast majority (85%) of all diabetes-related amputations are preceded by foot ulcers.

For most people who have lost a leg, life will never return to normal. Amputation may involve life-long dependence upon the help of others, inability to work and much misery. Aggressive management of the diabetic foot can prevent amputations in most cases. Even when amputation takes place, the remaining leg and the person’s life can be saved by good follow-up care from a multidisciplinary foot team.

In developed countries diabetic foot care accounts for up to 20% of total healthcare resources available for diabetes. In developing countries, it has been estimated that foot problems may account for as much as 40% of the resources available. In western countries, the economic cost of a diabetic foot ulcer is thought to be between US$7,000 and US$10,000. Where healing is complicated and amputation required, this cost may increase to as much as US$65,000 per person.

Up to 85% of amputations can be prevented

In most cases, however, diabetic foot ulcers and amputations can be prevented. Researchers have established that between 49% and 85% of all amputations can be prevented. It is imperative, therefore, that healthcare professionals, policymakers and diabetes representative organizations undertake concerted action to ensure that diabetic foot care is structured as effectively as local resources will allow. This will facilitate improvements in foot care for people with diabetes throughout the world and bring about a reduction in diabetic-foot-related morbidity and mortality.

Significant reductions in amputations can be achieved by well-organized diabetic foot care teams, good diabetes control and well-informed self care

There is strong evidence to indicate that foot care is best delivered when it is provided by a multidisciplinary team. This should closely involve the person with diabetes and his or her family, along with healthcare professionals from different specialties. Ideally the team will include a physician, a nurse, a specialist educator, a podiatrist, a surgeon, an orthotist (shoemaker) and an administrator. The podiatrist is a key member of the multidisciplinary diabetic foot team. At present there is a lack of trained podiatrists working in diabetic foot care. Mandatory minimal skills and equipment for those offering a podiatry service should be controlled to ensure that people with diabetes are not put at increased risk by unregulated, unqualified and poorly equipped practitioners.

IDF’s position is that management in the prevention and treatment of diabetic foot problems includes the following:

* Annual inspection of the foot
* Identification of the foot at risk
* Education of people with diabetes and healthcare professionals
* Appropriate foot wear
* Rapid treatment of all foot problems

Only through a multidisciplinary approach addressing the diversity of possible foot problems in people with diabetes can the desired reduction in amputation rates be achieved.


It is now time to take appropriate action to ensure that people with diabetes everywhere receive the quality of care that they deserve. It is hoped that global awareness of diabetes and its complications will be raised and that the necessary attention will be paid to the need for improved foot care for people with diabetes throughout the world.

IDF recommends that every individual with diabetes receive the best possible foot care. At the organizational level, diabetic foot care should be structured in such a way as to optimize treatment and prevention possibilities. For this to be feasible all parties involved (i.e. healthcare providers, policymakers and patient organizations) should recognize the need for combined action.

~ International Diabetes Federation ~

Prevalence of risk factors predisposing to foot problems in patients on hemodialysis

The prevalence of peripheral arterial occlusive disease (PAOD) in the general public is estimated at 3.5% to 23% (O'Hare & Johansen, 2001). Among individuals with diabetes, the prevalence of PAOD is four to seven times greater than in those without diabetes (Armstrong, Lavery, & Harkless, 1998). The most common cause of chronic renal failure is diabetes, accounting for 44.3% of new end stage renal disease (ESRD) patients annually in the United States (U.S.) and 33% of new ESRD patients in Canada (U.S. Renal Data Systems [USRDS], 2003).

Annually more than 125,000 people in the U.S. undergo lower extremity amputations (Armstrong et al., 1998). Of these, between 50% and 80% are attributable to diabetes (Lavery et al., 1996; Spollett, 1998). There is some evidence to suggest that the prevalence of foot problems among patients with diabetes who also have ESRD is even greater than in patients with diabetes without ESRD (Eggers, Gohdes, & Pugh, 1999; Hill et al., 1996; Rith-Najariah & Gohdes, 2000). Thus, the potential burden of illness in a dialysis population is a costly one. According to some sources, however, between 50% and 85% of lower extremity amputations associated with diabetes could be avoided or delayed through appropriate educational and treatment programs (Edmonds, 1987; Halpin-Landry & Goldsmith, 1999).

~ BNET ~

Preventive Foot Care in Hemodialysis Patients

Comprehensive care of hemodialysis patients poses a significant challenge for nephrologists. Although protocol driven approaches by hemodialysis centers have significantly improved standardized care, significant gaps remain in overall medical care provided to hemodialysis patients. Admittedly, with improvement in care, mortality rate for dialysis patients has decreased by 10 percent from its peak in 1988; however, it still stands at a disturbing figure of 248 deaths per 1,000 patient-years. The life expectancy of ESRD patients is one-fourth to one-sixth of the age-matched general population, with cardiovascular disease being the most likely cause of death.

Diabetics on hemodialysis have even worse prognosis than other patients. Patients with diabetes and ESRD are admitted to the hospital on average 2.3 times per year, and only 27 percent of these patients will survive five years on hemodialysis. With improvement in overall care, mortality has improved in hemodialysis patient population, but perhaps not to the expected level for multiple reasons. One likely explanation is that although mortality may be less with improvement in one area of care, mortality in other neglected areas of care may negate these potential gains. It therefore remains imperative that the nephrology community does not lose sight of the fact that only comprehensive care of these patients will realize the goal of improvement in mortality and morbidity in this hemodialysis population.
Focus on Foot Care

One such area of care which remains under the radar is morbidity and mortality related to peripheral vascular disease and foot care. For the most part, at this stage, foot care attracts attention only after a problem has already arisen. There are no screening protocols in hemodialysis centers to identify the problem earlier on. As a result, preventive strategies to reduce morbidity and mortality related to this issue remain unaddressed. The magnitude of this problem is unrealized until you add to the equation that the majority of hemodialysis patients are diabetics as well. As a result, there remains a significant issue of lower extremity amputations in hemodialysis patients. Overall, 40 percent of patients in the United States starting chronic dialysis count diabetes mellitus as the primary cause of renal failure, making it the number one cause of CKD (Berman et al., 2001).

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.

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).
Improving Foot Care

The real question is: Why is it so difficult to provide much needed foot care and how best to do it? One has to take into account the fact that it is not easy for a hemodialysis patient to keep multiple subspecialty appointments. Once-a-year visits for foot examination are not very likely to identify and trigger an early referral. Yet three times a week they are available to a hemodialysis nurse for simple inspection and basic exam of feet. It is logical to think that foot care protocols would be part of patient care. It is possible that it poses some legal and monetary issues for the hemodialysis companies in an era of shrinking reimbursements for hemodialysis patients. These concerns, for the most part, are not true. Legally, it is always safer to prevent than treat an issue after it has been allowed to manifest in medical care set up. Improving care of hemodialysis patients with foot care should theoretically keep patients out of hospitals and on a hemodialysis chair for monetary gains of the hemodialysis center.

Finally, of course one cannot put cost on saving a patients from morbidity and mortality associated with poor foot care. However, planning this care would require careful insight into all practical aspects of care and caregivers. To begin with, the screening process should be very basic level, which hemodialysis nurses are comfortable with. Time spent and protocol has to be very straightforward. It should simply identify and focus on confirming a “NORMAL” exam from “NOT NORMAL” requires physician evaluation. Hemodialysis nurses should then be able to pass that information in a quick computerized manner to nephrologists triggering referrals to podiatrist, interventional cardiologist/interventional radiologists committed to his/her group preferably again by the same computerized network. Unnecessary time spent on telephone calls have to be avoided using protocol driven care and computerized network. Information then would have to be exchanged seamlessly between hemodialysis centre nursing staff, nephrologists, interventionalist and podiatrist. The whole network would have to be HIPAA compliant and be easy to learn and adapt to the needs to dialysis facility and physician groups involved. Ideally the network should be able to blend in with existing networks involved in hemodialysis care as well as communicate with subspecialty groups.

In summary, preventive foot care for hemodialysis patients is lost in efforts and time spent to provide care in other much politicized areas of care. But ignoring prevention in this area leads to significant morbidity and mortality. There are no randomized controlled trials of intensive education and care management versus usual care of feet in diabetic dialysis patients. Nonetheless, diabetic dialysis patients are likely to benefit from examination of the foot as part of the routine dialysis care. Given the fact that prevention can be easily done in hemodialysis center by hemodialysis nursing staff, there is little reason not to introduce it. Three times a week contact between hemodialysis nurses and patient is a potential opportunity to assess risks, educate and provide early intervention for foot issues in CKD population. Simple measures such as routine foot screening and education for this high risk population can prevent ulcer-initiating events and detect small ulcers when they may heal with proper intervention. Preventive strategies should include protocol based strategy for referral to specialist. Computerized network should allow this to happen seamlessly and effortlessly to benefit all involved in hemodialysis care. In this regard, all involved in medical care of hemodialysis patients can no longer afford to ignore the importance of preventive care of hemodialysis patients.

~ Renal Business Today ~

Zahid Ahmad, MD.
Dr. Ahmad is an assistant professor of medicine of interventional nephrology at the University of Oklahoma’s Section of Nephrology & Hypertension. For more information visit

How Do I Know if I Have Leg Ischemia?

Ischemia of the lower extremities will manifest itself in many different ways ranging from asymptomatic (simply the presence of a blockage) to gangrene of the leg or a part of it. Quite often a patient will have an asymptomatic blockage (one that they do not know is there) that is manifested simply by an absent pulse in the foot, behind the knee or in the groin or an abnormal angiogram that is usually done at the time that a cardiac catheterization (heart catheterization) is performed. A person will have no symptoms referable to this blockage and will only know of the abnormality because their physician informs them of such! This is generally referred to as Fontaine’s Class I.

The next “level” of ischemia is that of claudication. This is manifest by cramping pain that occurs with walking. It most often affects the calf muscles and generally occurs at a rather fixed distance (usually measured in blocks.) Depending on the severity of the ischemia—either by its level of lifestyle interference or by distance at which symptoms begin—it is referred to as Fontaine’s Class IIa or IIb.

Rest Pain is the next Stage (III) in the Fontaine classification of leg ischemia. This is typified by pain that occurs even in the absence of significant stress on the legs. It often occurs in the evenings awakening the patient from sleep. Quite often, hanging the leg from the side of the bed will improve the painful symptoms that are experienced. The foot will often turn a light purple or deep red-violet color as it is held in a dependent condition—often referred to as “dependent rubor.” This is a sign of significant leg ischemia and warrants aggressive intervention.

The final stage of leg ischemia (Fontaine Level IV) is tissue loss—seen as a non-healing sore or gangrene. This level (along with rest pain) is appropriately referred to as “limb-threatening ischemia” and must be evaluated appropriately by those with expertise in this area. Ignoring this degree of ischemia will very likely lead to limb loss (amputation) at some point in the future!

~ The Cardiovascular Care Group ~


Peripheral vascular disease (PVD) can affect the arteries, the veins or the lymph vessels. The most common and important type of PVD is peripheral arterial disease, or PAD, which affects about 8 million Americans. It becomes more common as one gets older, and by age 65, about 12 to 20 percent of the population has it. Diagnosis is critical, as people with PAD have a four to five times higher risk of heart attack or stroke.
~ American Heart Association ~

Peripheral Vascular Disease

What is peripheral vascular disease?

This refers to diseases of blood vessels outside the heart and brain. It's often a narrowing of vessels that carry blood to the legs, arms, stomach or kidneys. There are two types of these circulation disorders:

* Functional peripheral vascular diseases don't have an organic cause. They don't involve defects in blood vessels' structure. They're usually short-term effects related to "spasm" that may come and go. Raynaud's disease is an example. It can be triggered by cold temperatures, emotional stress, working with vibrating machinery or smoking.

* Organic peripheral vascular diseases are caused by structural changes in the blood vessels, such as inflammation and tissue damage. Peripheral artery disease is an example. It's caused by fatty buildups in arteries that block normal blood flow.

What is peripheral artery disease?

Peripheral artery disease (PAD) is a condition similar to coronary artery disease and carotid artery disease. In PAD, fatty deposits build up in the inner linings of the artery walls. These blockages restrict blood circulation, mainly in arteries leading to the kidneys, stomach, arms, legs and feet. In its early stages a common symptom is cramping or fatigue in the legs and buttocks during activity. Such cramping subsides when the person stands still. This is called "intermittent claudication." People with PAD often have fatty buildup in the arteries of the heart and brain. Because of this association, most people with PAD have a higher risk of death from heart attack and stroke.

How is peripheral artery disease diagnosed and treated?

Techniques used to diagnose PAD include a medical history, physical exam, ultrasound, X-ray angiography and magnetic resonance imaging angiography (MRA).

Most people with PAD can be treated with lifestyle changes, medications or both. Lifestyle changes to lower your risk include:

Stop smoking (smokers have a particularly strong risk of PAD).
Control diabetes.
Control blood pressure.
Be physically active (including a supervised exercise program).
Eat a low-saturated-fat, low-cholesterol diet.

PAD may require drug treatment, too. Drugs include:

medicines to help improve walking distance (cilostazol and pentoxifylline).
antiplatelet agents.
cholesterol-lowering agents (statins).

In a minority of patients, lifestyle modifications alone aren't sufficient. In these cases, angioplasty or surgery may be necessary.

Angioplasty is a non-surgical procedure that can be used to dilate (widen) narrowed or blocked peripheral arteries. A thin tube called a catheter with a deflated balloon on its tip is passed into the narrowed artery segment. The balloon is then inflated, compressing the plaque and dilating the narrowed artery so that blood can flow more easily. Then the balloon is deflated and the catheter is withdrawn.

Often a stent — a cylindrical, wire mesh tube — is placed in the narrowed artery with a catheter. There the stent expands and locks open. It stays in that spot, keeping the diseased artery open.

If the narrowing involves a long portion of an artery, surgery may be necessary. A vein from another part of the body or a synthetic blood vessel is used. It's attached above and below the blocked area to detour blood around the blocked spot.

~ American Heart Association ~

Foot Pain and Diabetes

Foot pain can certainly be caused by any number of reasons. However, foot pain resulting from diabetes is both painful and very common for those living with diabetes.

Diabetes and foot pain is generally defined by four different types.

A nerve problem (where the nerves themselves are affected by the disease) called peripheral neuropathy is the most common source of foot pain tied to diabetes. Peripheral neuropathy comes in the form of sensory, motor, and autonomic neuropathy.

Sensory neuropathy is the most common and is defined by symptoms where the amount of pain is much greater than the source that is causing the pain. As an example, just touching, or lightly pulling on your socks triggers a painful reaction. Also, with sensory neuropathy you may experience some numbness along with tingling, burning, or even stabbing type pain symptoms.

Because blood sugar can be a player in this type of pain, check your blood sugar levels for the past several weeks to see if perhaps there is an upward trend toward high levels.

Relief is of the utmost importance in these cases and can come from various applications. Massaging your feet or using a foot roller can sometimes drop the level of pain. Anything you can do from a shoe perspective such as cushioned supports and inserts can assist as well. Anything to help mitigate the pressure and pounding of daily activities on the foot and/or any rubbing or chaffing is beneficial. There are also prescription drugs that your doctor can recommend that will often times work.

When the nerves to the muscles become affected by diabetes (motor neuropathy), your muscles will begin to feel weak and achy. Although the smaller muscles of the feet aren't usually the first to be affected, your balance can eventually become affected which may cause alignment problems and/or rubbing on the feet which ultimately results in pain. Support, exercise, stretching, and massage are your best weapon against motor neuropathy. Keeping your muscles healthy and flexible is a key element in relieving this type of foot pain.

Autonomic neuropathy affects the nerves that we don't consciously control, hence the 'auto' of autonomic. With this condition existing your sweating triggers are altered and as such you may suffer from dry or cracked skin. For your feet this may result in a build up of foot calluses, thickened nails and such that lead to foot pain. The daily use of conditioning agents formulated specifically for diabetes can aid or prevent this problem.

With diabetic people proper circulation is a primary concern. Circulation problems in the feet can cause severe pain. Addressing circulation problems should always be done in conjunction with your medical doctor. Various approaches may include an exercise program, physical therapy, medication, or even surgical procedures, but again, consult with your physician before considering any strategy that involves addressing a circulation issue.

With diabetic people muscle and joint pain is not uncommon. If tendons and joints begin to stiffen coupled with imbalances associated with peripheral neuropathy and walking alignment occurs, the foot and the joints become painful. In fact, if the walking misalignments continue, this can lead to other foot disorders such as corns, bunions, and hammertoe.

People living with diabetes are more susceptible to infections within their body because of the changes that have taken place in their body. If a bacterial infection attacks the foot, the foot can become red, experience swelling, feel warm, and be painful. Keeping the immune system as healthy as possible by controlling your blood sugar, proper nutrition, and exercise, should be a top priority in your defense against infections.

If you are afflicted with diabetes, in addition to being mindful of the above information, work closely with your primary care physician to ensure that you receive proper information and care for your personal situation.

~Ezine Articles ~

Tuesday, October 6, 2009

Diabetes: PAD and Limb Loss

Peripheral Arterial Disease (PAD) and Limb Loss

Peripheral arterial disease (PAD) is a form of artheroscelorisis (hardening of the arteries). In PAD, fat builds up inside the artery (blood vessel) walls. Over time, this causes a blockage that can keep your blood from flowing properly. PAD may result in blockages in the brain, arms, kidneys, and legs.

Diabetes is a major cause of PAD. People with diabetes are unable to properly digest the sugar they eat. This sugar builds up and causes changes in their blood vessels. These changes lead to circulation problems. PAD is a risk factor for foot ulcers that can lead to amputation in diabetic patients.

How many people have PAD?

* As many as 10 million people in the United States have PAD.
* In 1996, an estimated 128,588 individuals lost a limb because of PAD.

What are the risk factors?

* Diabetes. People with diabetes are at greater risk for severe PAD. People with diabetes are five times more likely to have an amputation due to PAD.
* Age. The risk of limb loss due to PAD increases with age. People 65 or older are two to three times more likely to have an amputation.
* Gender. Men with PAD are twice as likely to undergo an amputation as women.
* Race/ethnicity. Some racial and ethnic groups have a higher risk of amputation (i.e., African Americans, Latino Americans, and Native Americans). This is because they are at increased risk for diabetes and cardiovascular disease.

~ dLife ~