Impact of Chronic Kidney Disease on Survival After Amputation in Individuals with Diabetes

Overview

Journal Diabetes Care

Specialty Endocrinology

Date 2010 Aug 27

PMID 20739688

Citations 66

Authors

Lawrence A Lavery

Nathan A Hunt

Agbor Ndip

David C Lavery

William van Houtum

Andrew J M Boulton

Affiliations

Soon will be listed here.

Abstract

Objective: To identify factors that influence survival after diabetes-related amputations.

Research Design And Methods: We abstracted medical records of 1,043 hospitalized subjects with diabetes and a lower-extremity amputation from 1 January to 31 December 1993 in six metropolitan statistical areas in south Texas. We identified mortality in the 10-year period after amputation from death certificate data. Diabetes was verified using World Health Organization criteria. Amputations were identified by ICD-9-CM codes 84.11-84.18 and categorized as foot, below-knee amputation, and above-knee amputation and verified by reviewing medical records. We evaluated three levels of renal function: chronic kidney disease (CKD), hemodialysis, and no renal disease. We defined CKD based on a glomerular filtration rate<60 ml/min and hemodialysis from Current Procedural Terminology (CPT) codes (90921, 90925, 90935, and 90937). We used χ2 for trend and Cox regression analysis to evaluate risk factors for survival after amputation.

Results: Patients with CKD and dialysis had more below-knee amputations and above-knee amputations than patients with no renal disease (P<0.01). Survival was significantly higher in patients with no renal impairment (P<0.01). The Cox regression indicated a 290% increase in hazard for death for dialysis treatment (hazard ratio [HR] 3.9, 95% CI 3.07-5.0) and a 46% increase for CKD (HR 1.46, 95% CI 1.21-1.77). Subjects with an above-knee amputation had a 167% increase in hazard (HR 2.67, 95% CI 2.14-3.34), and below-knee amputation patients had a 67% increase in hazard for death.

Conclusions: Survival after amputation is lower in diabetic patients with CKD, dialysis, and high-level amputations.

Citing Articles

Application of metagenomic next-generation sequencing (mNGS) to describe the microbial characteristics of diabetic foot ulcers at a tertiary medical center in South China.

Xie H, Chen Z, Wu G, Wei P, Gong T, Chen S BMC Endocr Disord. 2025; 25(1):18.

PMID: 39849445 PMC: 11758752. DOI: 10.1186/s12902-025-01837-z.

Survival rate of diabetic-related lower extremity amputees in hospitals in the Eastern Cape.

Mgibantaka A, Musekiwa A, Zunza M Afr J Disabil. 2024; 13:1503.

PMID: 39650092 PMC: 11621866. DOI: 10.4102/ajod.v13i0.1503.

Targeting Matrix Metalloproteinase-9 for Therapeutic Intervention in Diabetic Foot Ulcers.

Chang M ACS Pharmacol Transl Sci. 2024; 7(10):2901-2911.

PMID: 39421656 PMC: 11480886. DOI: 10.1021/acsptsci.4c00263.

A Qualitative Study of Patients' Lived Experiences of Free Tissue Transfer for Diabetic Foot Disease.

Goodall R, Borsky K, Harrison C, Mavromatidou G, Shirley R, Ellard D Plast Reconstr Surg Glob Open. 2024; 12(5):e5842.

PMID: 38798930 PMC: 11124632. DOI: 10.1097/GOX.0000000000005842.

Evaluating the impact of an interdisciplinary integrated limb preservation service operating concurrently with a single-specialty service.

Bazikian S, Pyun A, Zheng H, Padula W, Khan T, Ziegler K J Foot Ankle Res. 2024; 17(2):e12013.

PMID: 38613833 PMC: 11080699. DOI: 10.1002/jfa2.12013.

References

. WHO Expert Committee on Diabetes Mellitus: second report. World Health Organ Tech Rep Ser. 1980; 646:1-80. View

Halkos M, Puskas J, Lattouf O, Kilgo P, Kerendi F, Song H . Elevated preoperative hemoglobin A1c level is predictive of adverse events after coronary artery bypass surgery. J Thorac Cardiovasc Surg. 2008; 136(3):631-40. DOI: 10.1016/j.jtcvs.2008.02.091. View

Kunadian B, Dunning J, Millner R . Modifiable risk factors remain significant causes of medium term mortality after first time Coronary artery bypass grafting. J Cardiothorac Surg. 2007; 2:51. PMC: 2233623. DOI: 10.1186/1749-8090-2-51. View

Levey A, Bosch J, Lewis J, Greene T, Rogers N, Roth D . A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med. 1999; 130(6):461-70. DOI: 10.7326/0003-4819-130-6-199903160-00002. View

Powe N, Jaar B, Furth S, Hermann J, Briggs W . Septicemia in dialysis patients: incidence, risk factors, and prognosis. Kidney Int. 1999; 55(3):1081-90. DOI: 10.1046/j.1523-1755.1999.0550031081.x. View

Izumi Y, Satterfield K, Lee S, Harkless L, Lavery L . Mortality of first-time amputees in diabetics: a 10-year observation. Diabetes Res Clin Pract. 2008; 83(1):126-31. DOI: 10.1016/j.diabres.2008.09.005. View

Ndip A, Lavery L, Lafontaine J, Rutter M, Vardhan A, Vileikyte L . High levels of foot ulceration and amputation risk in a multiracial cohort of diabetic patients on dialysis therapy. Diabetes Care. 2010; 33(4):878-80. PMC: 2845045. DOI: 10.2337/dc09-2007. View

Resnick H, Carter E, Lindsay R, Henly S, Ness F, Welty T . Relation of lower-extremity amputation to all-cause and cardiovascular disease mortality in American Indians: the Strong Heart Study. Diabetes Care. 2004; 27(6):1286-93. DOI: 10.2337/diacare.27.6.1286. View

Gandhi G, Roger V, Bailey K, Palumbo P, Ransom J, Leibson C . Temporal trends in prevalence of diabetes mellitus in a population-based cohort of incident myocardial infarction and impact of diabetes on survival. Mayo Clin Proc. 2006; 81(8):1034-40. DOI: 10.4065/81.8.1034. View

10.

OHare A, Feinglass J, Reiber G, Rodriguez R, Daley J, Khuri S . Postoperative mortality after nontraumatic lower extremity amputation in patients with renal insufficiency. J Am Soc Nephrol. 2004; 15(2):427-34. DOI: 10.1097/01.asn.0000105992.18297.63. View

11.

Gunarathne A, Patel J, Potluri R, Gammon B, Jessani S, Hughes E . Increased 5-year mortality in the migrant South Asian stroke patients with diabetes mellitus in the United Kingdom: the West Birmingham Stroke Project. Int J Clin Pract. 2007; 62(2):197-201. DOI: 10.1111/j.1742-1241.2007.01580.x. View

12.

McGrath N, Curran B . Recent commencement of dialysis is a risk factor for lower-extremity amputation in a high-risk diabetic population. Diabetes Care. 2000; 23(3):432-3. DOI: 10.2337/diacare.23.3.432. View

13.

Lavery L, Ashry H, van Houtum W, Pugh J, Harkless L, Basu S . Variation in the incidence and proportion of diabetes-related amputations in minorities. Diabetes Care. 1996; 19(1):48-52. DOI: 10.2337/diacare.19.1.48. View

14.

Boulton A, Vileikyte L . The diabetic foot: the scope of the problem. J Fam Pract. 2000; 49(11 Suppl):S3-8. View

15.

Eggers P, Gohdes D, Pugh J . Nontraumatic lower extremity amputations in the Medicare end-stage renal disease population. Kidney Int. 1999; 56(4):1524-33. DOI: 10.1046/j.1523-1755.1999.00668.x. View

16.

Hambleton I, Jonnalagadda R, Davis C, Fraser H, Chaturvedi N, Hennis A . All-cause mortality after diabetes-related amputation in Barbados: a prospective case-control study. Diabetes Care. 2008; 32(2):306-7. PMC: 2628698. DOI: 10.2337/dc08-1504. View

17.

Lavery L, van Houtum W, Armstrong D, Harkless L, Ashry H, Walker S . Mortality following lower extremity amputation in minorities with diabetes mellitus. Diabetes Res Clin Pract. 1997; 37(1):41-7. DOI: 10.1016/s0168-8227(97)00058-2. View

18.

Lavery L, van Houtum W, Armstrong D . Institutionalization following diabetes-related lower extremity amputation. Am J Med. 1997; 103(5):383-8. DOI: 10.1016/s0002-9343(97)00163-0. View

19.

van Houtum W, Lavery L, Harkless L . The impact of diabetes-related lower-extremity amputations in The Netherlands. J Diabetes Complications. 1996; 10(6):325-30. DOI: 10.1016/1056-8727(95)00088-7. View

20.

Tribouilloy C, Rusinaru D, Mahjoub H, Tartiere J, Kesri-Tartiere L, Godard S . Prognostic impact of diabetes mellitus in patients with heart failure and preserved ejection fraction: a prospective five-year study. Heart. 2008; 94(11):1450-5. DOI: 10.1136/hrt.2007.128769. View