Diabetic Foot Profile in Patients under Regular Haemodialysis

Abstract

Introduction: Diabetic foot syndrome that affects patients under regular haemodialysis is a complex mechanism mainly based on patient metabolism, neurosensitive abnormalities, and plantar pressure dysfunctions. Patients and methods: Our work is based on a descriptive cross-sectional and multicenter study conducted during 45 days and concerning 43 diabetic patients among a total of 193 patients undergoing regular haemodialysis in three haemodialysis centers in Tunisia. Data collection relied on patients clinical records, all data were collected anonymously and we use 3 sheets respectively for: Data collection, clinical examination and neuropathic pain evaluation. Some biological parameters which are associated with chronic kidney disease (CKD) were studied, as parathyroid hormone (PTHi), phosphatemia, hemoglobin (Hb), glycosylated haemoglobin (HbA1c). Passive articular mobility was explored by a goniometer which is a tool for measuring joint amplitudes. Lower limbs arteriopathy exploration as: Ankle-brachial pressure index (ABPI) was performed using a pocket continuous wave doppler (8 Mhz) and a sphygmomanometer with a cuff width of at least the third of limb circumference. Protective skin sensitivity was explored by Semmes-Weinstein monofilamant 10g (SWM), and tactile skin sensitivity was explored by a cotton strand (wadding). As samples were small, we used Fisher's exact test for paired series for the statistical analysis of the relationship between certain parameters and diabetic foot. Results: The majority of the patients have type 2 diabetes. All had diabetic nephropathy and several comorbidities, 57% secondary hyperparathyroidism, 35% had a normalized proteins catabolic rate, and 44.1% had hypoalbuminemia. Fifty one percent of the patients have feet deformities as, toes claws (44.1%), hallux valgus (25.6%) and a history of ulceration or amputation (34.8%). Thirteen patients had diabetic neuropathy and 53.48% had sensory neuropathy. Neuropathic pain was found in 18.6% of patients. Regarding factors related to haemodialysis, the impact of “nutritional, inflammatory, anemic and disorders of the metabolism of calcium and of phosphorus” factors was clear. Diabetes inherent factors such as, duration of evolution, balance, and the tendency to obesity represent others complicating risk factors for our patients. Also, ABPI, which constitutes another risk factor, was greatly increased. Similarly, sensory and autonomic neuropathies were strongly present, as well as bone deformities. Conclusion: Obesity, malnutrition and comorbidities, as poorly balanced diabetes, anemia, disorders of the metabolism of calcium and phosphorus associated with a chronic inflammatory state, constitute risk factors that promote the occurrence of the diabetic foot complications. Presence of sensory and autonomic neuropathy, bone deformities and vascular calcification also contribute to the development of such pathology. Keyword Diabetes complications, Diabetic foot, Haemodialysis, Neuropathies List of Abbreviations ABPI: Ankle-Brachial Pressure Index; BMI: Body Mass Index; CKD: Chronic Kidney Disease; CRP: C Reactive Protein; CVD: Cardio-Vascular Disease; DP: Dorsalis Pedis; HbA1c: Glycosylated Haemoglobin; npcr: Normalized Protein Catabolic Rate; PAD: Peripheral Arterial Disease; PTA: Posterior Tibial Artery; PTHi: Parathyroid Hormone; SWM: Semmes-Weinstein Monofilament; UKPD: United Kingdom Prospective Diabetes Study Cohort; URR: Urea Reduction Ratio OrigiNal article