ULCER
,Dr.ARekha ,RaghavendraRaoM.V1 thIV yearMBBS,SaveethaMedicalCollegeandHospital,Thandalam,Kancheepuram,Chennai,India.
2Professor,DepartmentofGeneralSurgery,SaveethaMedicalCollegeandHospital,Thandalam,Kancheepuram,Chennai,India.
3Scientist-Emeritus, Director, Central Research Laboratory, Apollo Institute of Medical Sciences and Research, Jubilee Hills, Hyderabad,TS,India.
ABSTRACT
Diabetesmellitusisametabolicdiseaseconditionwherethecontrolofglucoselevelsinbloodisinadequate.EstimatedGlomerular
rate(GFR)referstothe rateofflowofthefluidthatisfilteredthroughtheglomerulusinthekidney,
isestimated
Diabeticpatientstendtodevelopulcerationofthe footduetoperipheralsensoryneuropathy So,preventingandmanagingChronickidneydisease(CKD)isalsoimportantinpatientswithdiabeticfootulcer,alongwith preventionofamputations.
Aimofthestudy:
(a)Tolookatthedemographicsofthepatientswithdiabeticfootulcer
(b)Toseetheextentoftheinjuryinfoot-clinicalandamputationstatus (c)Tostudytheoxygensaturationlevelsintheperiphery (d)TocalculatetheeGFRinpatientswithdiabeticfootulcer
MaterialsandMethods:
(a)It'saprospectivestudyconductedon80patientswithdiabeticfootulcerwhoattendedtheOutpatientDepartmentofSurgeryinSaveethaMedicalCollegeand Hospital,atertiarycarehospitalinChennai,India.
(b)Weconductedclinicalandradiologicalexamination (c)WecalculatedeGFRthroughapredeterminedscoringsystem
Result:Outofthe80patients,around70patientswerefoundtobeabovetheageof50.Mostnumberofpatientswerebelongingtostage3(40%)oftheWagner`s diabeticfootulcerclassification.About59patientswerefoundtohaveminimumof5yearsofdiabetichistory 17patientshadhighserumcreatininelevels.Around65 patientsintotalwerefoundtobeanaemic.Around55patientshadhighHbA1Cvalues.MeanHbA1Cwasfoundtobe10.2±2.83mg/dl.Maximumnumberofpatients (58.7%) belonged to stage 1 CKD based on the eGFR levels. 17 patients had high serum creatinine levels.About 45% patients underwent amputation.About 28 patientshadperipheralSpO2lessthan97.Around21ofthemhadgangrenousdiabeticfootulcer
Conclusion:Theamputationstatusingangrenousandnon-gangrenousdiabeticfootulcerwhencompared,wasfoundtobestatisticallysignificant. Thoughother factorslikehighHbA1Clevels,highserumcreatininelevels,loweGFRduetorenalimpairmentinchronickidneydiseasewerealsofoundtobeimportantriskfactors but they were not statisticallysignificant.The renal function could becomeimpaired,which could lead on to CKD in patients,presenting with diabeticfoot ulcer Therefore,specialattentionshouldbegivenonregularscreeningofdiabeticpatientswhodevelopafootulcer Implementingvariousdiabetesawarenessprograms, takingadequatefootcare,effectivelymanagingdiabeticfootulcerscouldreducetheseverityofcomplicationslikepreventableamputations.
KEYWORDS:estimatedGFR,chronickidneydisease,amputation,peripheralneuropathy,diabeticfootulcer
INTRODUCTION:
Diabetesmellitusisametabolicdiseaseconditionwherethecontrolofglucose levelsinbloodisinadequate.Ithasmanytypesliketype1DM,type2DM,gestationaldiabetes,maturityonsetdiabetesoftheyoung(MODY),etc.Middle-aged alongwitholderadultsareusuallyaffectedbytype2DM.1Usually,sedentary lifestyleanddietaryimbalanceandchoicesplaysanimportantroleinitsdevelopment, apart from the genetic predisposition. It affects many systems and organsincludingretina,kidneys,peripheralnerves.Kidneyisthemostimportant target, when we consider the microvascular damage that is seen in diabetes. Whenthisdamagehappens,slowlythefunctionofkidneysalsogetsdisturbed.
The functioning of the kidney can be assessed by the glomerular filtration rate (GFR).Glomerularfiltrationrate(GFR)referstotherateofflowofthefluidthat isfilteredthroughtheglomerulusinthekidney Itcanbeestimatedindirectlyby fewformulas.Hence,wecallittheestimatedglomerularfiltrationrate(eGFR). Onestimation,GFRismostreliabletochecktheamountoftheresidualfunction ofthekidneysinpatientswithchronickidneydiseasealso.Almost50%oftype2 diabetic patients and 33.3% of type 1 diabetic patients were found to develop CKD.2 So, preventing and managing CKD due to impaired renal function, is importantinpatientswithdiabeticfootulcer
Diabeticfoot(DF)canbedefinedasinfection,ulceration,orthedestructionoftissuesofthefootofanindividualwithpreviouslyorcurrentlydiagnoseddiabetes mellitus.3Diabeticpatientstendtodevelopulcerationofthefootduetoperipheralsensoryneuropathy Hence,amajorcauseofmorbidityinpatientswithkid-
neyfailureisduetodiabeticfootulceration.Thisusuallyaffectsoneintendiabetics,duringtheirlifetime.4Thehighbloodglucoselevelsoftendirectlydamage the nerves and blood vessels. If the extent of injury, due to the ulcerative lesionindiabeticfootismore,itaffectsthevascularityandperipheraloxygensaturation.Ifitbecomesanonhealingulcerthatcausesseveredamagetotissuesand bone,wemayneedtooptforamputationofatoe,footorapartofleg.Hence,it's importanttopreventsuchamputationsinpatientswithdiabeticfootulcer
Thefollowingresearchaimedatanalysingthedemographicsofthepatientswith diabeticfootulcer,atseeingtheextentoftheinjuryinfootbyclinicalandamputationstatus;atstudyingtheoxygensaturationlevelsintheperipheryandatcalculatingtheeGFRinpatientswithdiabeticfootulcer
METHODS:
It's a prospective study conducted on 80 patients with diabetic foot ulcer, who attendedtheOutpatientDepartmentofSurgeryinSaveethaMedicalCollegeand Hospital,atertiarycarehospitalinChennai,IndiaduringtheperiodofJanuary 2021toMarch2021.Thisstudyhasbeendoneafterreceivingtheapproval,by theInstitutionalReviewofBoard(IRB).
Weconductedbothclinicalandradiologicalexamination.Datawascollectedon apre-approvedproforma.Adetailedhistorywasobtainedregardingtheduration of the diabetes and its type.Adetailed history was obtained about the mode of onset,durationandprogressionthefootulcers.Adetailedexaminationofthefoot wasperformedandtheulcerswereclassifiedonthebasisofWagner'sclassifica-
tion.5Itisoneofthemostwidelyusedanduniversallyacceptedgradingsystems forevaluatingandmanagingpatientswithdiabeticfootulcer,consistingofsix simplisticwoundgradestoassessulcerdepth.(Grades0to5).
Grade-0 FootatRisk Prevention
Grade-I Localized,superficialulcer Antibiotics&glycemic control
Grade-II DeepUlcertobone,ligament,or joint Debridement,Antibiotics andglycemiccontrol
Grade-III Deepabscess,osteomyelitis Debridement,someformof amputation
Grade-IV Gangreneoftoes,forefoot Widedebridementand amputation
Grade-V Gangreneofentirefoot Belowkneeamputation
Hence,wecancallthediabeticfootulcerstobegangrenousiftheyareofgrade4 or5.BloodsamplesweretakentomeasureSerumcreatinine,HbandHbA1Clevels.Thevascularitywascheckedindistalpulses.Theperipheraloxygensaturationinoneofthetoesoftheaffectedfootwasmeasured,exceptforthepatients who already underwent amputation of all 5 toes as in whole forefoot or below knee or above knee amputation. We collected the X-Rays of both the foot, to checkthebonyinvolvement.WecalculatedeGFRthroughapredeterminedscoringsystemusingCKD-EPIequation.6eGFRwasusedtodeterminetheseverity stageofCKD,thatcorrespondstotheKidneyDiseaseOutcomesQualityInitiativestaging.7
Stage1:CKDwithnormaleGFR-eGFR≥90mL/minper1.73m2
Stage2:mildCKD-eGFRliesbetween60to89mL/minper1.73m2
Stage3:moderateCKD-eGFRbetween30to59mL/minper1.73m2
Stage4:severeCKD-eGFRbetween15to29mL/minper1.73m2
Stage5:end-stagerenaldisease-eGFRof<15mL/minper1.73m2
Our criteria for inclusion were patients with Diabetic foot ulcer of Grade I to GradeIV,whowerewillingtoparticipateinthestudy Patientswereexcludedif they were known cases of type 1 DM, acute metabolic disorders like diabetic ketoacidosis.
Data entry was executed in Microsoft Excel and data analysis was done using AnalysisToolPak add on option which is available in Microsoft Excel.Various factorsthatwereassociatedwiththestudywereanalysed. Theassociationwas calculatedusingtheChi-squaretestforthequalitativedataat0.05levelofsignificance. TheChi-squarevalueandPvaluetogether,furthersuggestediftheparticularassociationwasstatisticallysignificantornot.Descriptivestatisticswere givenintheformoffrequencygraphsandtables.
RESULTS:
Themajorityofthestudyparticipantsweremales-70(87.5%)andonlyabout10 women(12.5%). Mostnumberofpatientswerebelongingtostage3(40%)of theWagner`s diabetic foot ulcer classification, followed by stage 2 (30%), followedbystage4(20%),followedbystagebystage5(6.25%),followedbystage 1(3.75%). [Table1,Graph1,Picture1]
Thepatientshadameanageof58.5±9.7yearsofstandarddeviation(range,29 to80years).ThedurationofbeingaffectedbyDMwasbetween2monthsand30 years (mean, 10.2 ± 6.89 years of standard deviation). Mean serum creatinine levelwas1.05±0.82mg/dl(range,0.4mg/dLto6.2mg/dL).MeanHbA1Cwas foundtobe10.2±2.83mg/dl(range,5.8to16.5mg/dL).MeaneGFRlevelswere foundtobe103.8±49.9witharangeof10mg/dlto253mg/dl. [Table2]. Outofthe80patients,maximumnumberofpatients(58.7%)belongedtostage1 CKDbasedontheeGFRlevels,whileleastnumberofpatientsbelongedtostage 5(1.2%).[Graph2]
Amultifactorial comparision was done with the severity of diabetic foot ulcer, accordingtoWagner`sclassification.Around70patientswerefoundtobeabove the age of 50.Around 65 patients in total were found to be anemic.Around 55 patientshadhighHbA1Cvalues(morethan9mg/dl).Onlyabout17patientshad high serum creatinine levels (more than 1.3 mg/dl). About Thirty-six patients (45.0%)underwentamputation,whiletheother55%werenonamputees.About 59 patients were found to have minimum of 5 years of diabetic history Only 4 patients were in severe CKD and end stage renal disease category About 28 patientshadperipheraloxygensaturationlevelslessthan97.Around59ofthem werefoundtohavenongangrenousfootulcer,while21ofthemhadgangrenous diabeticfootulcer(stage4or5).Theamputationstatusinpatientswithgangrenous and non-gangrenous foot ulcer, when compared, was found to be statistically significant with chi square value of 11.1925 and p value of 0.00082 (less than 0.05), while other factors were not found to be statistically significant. [
Table3,Graph3]
DISCUSSION:
Diabeticfootulcerisoneofthemostcommoncomplicationofdiabetesmellitus, whichaffects15%ofdiabeticpatientsintheirlifetime.Diabeticfootulcersare maincauseofhospitalizationindiabeticpatientsanditismajorcauseofmorbidityaspatientshadtoundergosurgicalinterventionslikeamputations.Therenal function,whichismeasuredbytheestimatedglomerularfiltrationrate(eGFR) needstocorrelatedwiththeseverityofdiabeticfootulcers,astheyareanimportantriskfactorfortheneedforamputations.
In such diabetic patients, chronic hyperglycaemia can often lead to impaired wound healing, due to increased susceptibility to many infections, chronic inflammatorystate,diabeticmicropathyandmacroangiopathy,whichthenleads todiminishedvascularity,impairedcollagensynthesis,impairedautonomicdysfunctionandotherabnormalitiesinhumoralmediatedimmunityandphagocytic functioning.8Ahighglycatedhaemoglobin,alsoimpairstheendotheliummediated vasoactive responses. Shape of erythrocytes is affected by a high glucose level,makingthebloodmoreviscous,impedingthebloodflowandfacilitating theformationofthrombus.Thereby,increasingtheriskofamputation.9Hence, glycaemiccontrolisessentialinhealingofulcersindiabetics10
Thispresentstudywascarriedoutwithanaimandobjectivetoanalysethedemographicsofthepatientswithdiabeticfootulcer,atseeingtheextentoftheinjury infootbyclinicalandamputationstatus;atstudyingtheoxygensaturationlevels intheperipheryandatcalculatingtheeGFRinpatientswithdiabeticfootulcerto correlatethestageofchronickidneydisease.
In our study, it was observed that the majority of the study participants were males-70(87.5%)andonlyabout10women(12.5%).Inourstudy,thepatients hadameanageof58.5±9.7yearsofstandarddeviation(range,29to80years). Similarly, in a study done by Shabhay et al.11, the mean age was observed as 60.06.
In the study ofAhmad W et al 12, male dominated the study population with majoritywithintheagerangeof40-70years.InthestudybyMisbahMehrajetal 13,maleswereaffectedmorefrequentlywithdiabeticfootulcer(66%),ascomparedtofemales(34%).SimilarincidencewasalsoseeninthestudybyAliSMet al14,astheyhad65%malesand35%females.InastudydonebyShabhayetal., 58.33%ofpatientsweremales.
Inourstudy,itwasobservedthatabout59(73.7%)patientswerefoundtohave minimumof5yearsofdiabetichistory WhileinastudybyDr Misbahetal,Durationofdiabeteswasgreaterthantenyearsin58%ofthepatients,while91.3% patientshaddiabetesofmorethan5yearsduration.InastudybyShabhayetal., about56.67%ofthepatientshaddurationofdiabetesformorethan5years.
Thecutoffpointforthediagnosisofanaemia,accordingtoWHO,isahemoglobinlevelof12.0g/dlforfemalesand13.0g/dlformales15,16.Diabeticshavea twicemorechancesofdevelopinganaemiathanthenon-diabeticpopulation1619.Indiabeticfootulcerspatients,whoareanaemic,theprognosisofhealingof theulcerispoor Costaetal.hadasimilarfindingwhere89.6%ofpatients,who underwentamputationswereanaemicandanaemiawasasignificantriskfactor formajorlimbamputation20.
Inourstudy,itwasobservedthat65patients(81.25%)wereanemic.Inastudy donebyShabhayetal.,70%patientshadahaemoglobinlevelbelow12g/dlwith ameanhaemoglobinlevelof10.2
Inourstudy,itwasobservedthatmostofthepatientswerebelongingtostage3 (40%) of the Wagner`s diabetic foot ulcer classification, followed by stage 2 (30%), followed by stage 4 (20%), followed by stage by stage 5 (6.25%), followed by stage 1 (3.75%).While, in a study by Dr Misbah et al, most patients belonged to Grade 4 that comprised of 34 patients, followed by Grade 2 in 22 patients,followedbyGrade3in16patients.While,inastudydonebyShabhayet al.,Twenty-eightpatients(46.67%)hadMeggitt-Wagnerclassificationgrade3.
Inourstudy,themeanserumcreatininelevelwas1.05±0.82mg/dl(range,0.4 mg/dLto6.2mg/dL)whiletheMeanHbA1Cwasfoundtobe10.2±2.83mg/dl (range,5.8to16.5mg/dL).Thefindingswerealmostsimilartoastudydoneby SarwatAshraf et al21 on frequency of Chronic Kidney Disease inType 2 Diabetic Patients Presenting with Diabetic Foot Ulcer, where the mean serum creatinine (mg/dl) value was reported to be 1.17 ± 0.45 while HbA1c (g/dl) of studypopulationwasfoundtobearound8.34±0.59.InastudydonebyShabhay et al., almost two thirds of the study population i.e., 42/60(70.00%) had poor glycaemiccontrol.
In our study, maximum number of patients (58.7%) belonged to stage 1 CKD based on eGFR values, while least number of patients belonged to stage 5 (1.2%).It'squitesimilartothestudyresultsofSarwatAshrafetal,wheremaximumnumberofpatients(48%)belongedtostage1CKDbasedon24Hoursurinary creatinine clearance, while least number of patients belonged to stage 4 (1.2%).
The incidence of amputation is higher in diabetic foot ulcer patients who were foundtohaveassociatedkidneyinjurysuchasinchronickidneydisease,when comparedtothepatientswhodidnothavechronickidneydisease22.Eventhe rateofhealingandcureisaffectedifthepatientsalsohadchronickidneydisease 23.FewStudieshavedocumentedthat60-80%ofthecasespresentingwithdiabeticfootulcersusuallyhadCKD24,25.
InastudybyMargolisetal.26,about33%ofthetypeIIdiabeticpatientswitha foot ulcer were found to have Chronic Kidney Disease. A strong association betweenCKDandDiabeticfootulcerwasseenwithlowerextremityamputation inapopulationbasedsamplingofdiabeticpatientswithintheUnitedKingdom.
In our study, about 36 patients (45.0%) underwent amputation, while the other 55% were non amputees.About 3 patients underwent below knee amputation whileonly1 patientunderwentabovekneeamputation.Out of the36 patients, only5patientswerefemale(13.8%).Theamputationstatusinpatientswithgangrenousandnon-gangrenousfootulcer,whencompared,wasfoundtobestatisticallysignificantinourstudy InthestudybyShabhayetal.,about51.67%ofthe patients underwent amputation. In the study by Dr Misbah et al, 35 (35.0%) patientsneededsomesortofamputationwhile5%ofpatientsneededmultiple amputations.Intheirstudy,about12patientsunderwentbelowkneeamputation while10patientsunderwentabovekneeamputations.
InthestudyofViswanathanetal.27,theprevalenceoffootcomplicationssuchas peripheral neuropathy, peripheral vascular disease (PVD), amputations and infectionsweredetermined.Theprevalenceofinfectionwasfoundtobe6-11% andprevalenceofamputationwasfoundtobe3%intype2diabeticpatients.Few studiessuggestedthateffectivefootcareadviceshouldbeappropriatelydoneto reducetheburdenofdiabeticfootcomplications,especiallyindevelopingcountrieslikeIndia.
Amultidisciplinaryapproachhasbeenrecommendedfortheadequatetreatment ofthediabeticfootulcer,bymeansofinvasiveinfectiondrainage,debridement ofthenecrosedareasandbystartingtheempiricalantibiotictherapypromptly Later, once healing is achieved, we can do an appropriately complete vascular reconstructionbyplasticandvascularsurgeries.Negativepressurewoundtherapy(NPWT)isbeingsuggestedforseverediabeticfootulcercases.
CONCLUSION:
Adirect relationship was found between the age, gender, duration of diabetes, glycaemic control, peripheral neuropathy, grade of diabetic foot, incidence of accompanying osteomyelitis, intervention and the outcome of the disease.The amputation status in gangrenous and non-gangrenous diabetic foot ulcer when compared, was found to be statistically significant. Though other factors like highHbA1Clevels,highserumcreatininelevels,loweGFRduetorenalimpairmentinchronickidneydiseasewerealsofoundtobeimportantriskfactorsbut theywerenotstatisticallysignificant,duetotherelativelysmallerstudypopulation.
Implementingvariousdiabetesawarenessprograms,takingadequatefootcare, effectivelymanagingdiabeticfootulcerswithbetterresourcesformanaginglifestyleisneededtodecreasethenegativeimpactofdiabetesonthehealthandeconomy Therenalfunctioncouldbecomeimpaired,whichcouldleadontoCKDin patients,presentingwithdiabeticfootulcer Therefore,specialattentionshould begivenonregularscreeningofdiabeticpatients,whodevelopafootulcer
Diabetic foot when accompanied with CKD not only limits the mobility; also affectsthepsychologyandbehaviourofdiabeticsnegatively;thus,loweringthe qualityoflife.Effectivemanagementofdiabeticfootcanreduceseverityofcomplicationslikepreventableamputationsandpossiblemortality Italsoimproves theoverallqualityoflivingstandards.
LIMITATIONS:
It has been a small scale, prospective study in only one centre.Amulticentric studywithlargersamplesize,couldbefollowedupforalongertimeinfurther researchstudies,toobtainstatisticallysignificantvalues.
Financialfundingandsponsorship:None
Conflictsofinterest:None
Ethicalapproval:Approved.
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