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Diabetes, Dialysis and the Diabetic Foot: a timely reminder

On July 28 2008, on this website I wrote about Dialysis and the diabetic foot, with a description of a foot ulcer patient.

Last week I was invited to speak to patients of the Cape Town Dialysis Clinics about foot care; during my preparation I came across some startling evidence proving that dialysis is an independent risk factor for foot ulceration if you have diabetes and require dialysis.

We already know that impaired kidney function increases the risk of foot ulcers – also referred to in my 2008 Blog – but this 2010 research proves that:

If you have diabetes and are receiving dialysis, you are 5 times more likely to develop foot ulcers, compared to someone with diabetes who is not on dialysis.

Scary but true clear evidence from a study completed at Manchester UK.

The research showed that patients on dialysis have more nerve damage, circulatory problems and a history of foot ulcers and amputations.

There is a 25% lifetime risk of people with diabetes developing foot ulcers so the key issue whatever your status is prevention.

Diabetic foot ulcers have multiple causes, some are: external trauma from footwear, neuropathy, arterial damage, poor self-care, lack of access to care, poor treatment.

However, as with all research you must ask – “so what?” This patient group did not include any people of colour, so it may not apply totally to South African patients.

So what to do? our objective is always to PREVENT complications.

Every person with diabetes must have an ANNUAL FOOT EXAMINATION so that they understand their level of risk for developing foot complications.

in addition individual education on self management of their diabetes. this is a team effort, paying attention to cardio-vascular health, eyesight, footwear selection and fitting, foot biomechanics (and possibly insoles or orthotics), plus probably the most important factor – can you invest in the care being offered?

Always “take care of your pair”.

Dialysis and the Diabetic Foot

The diabetic foot is often associated with patients who are on dialysis for kidney failure as a result of their diabetes. There is a well known ‘triad’ of eyes/kidneys/feet. What health professionals call retinopathy/nephropathy/neuropathy.

We are managing a gentleman who is suffering the effects of many years of poorly-controlled diabetes, acompanied by smoking. The effect of this has been serious damage to the circulation to his legs. As a result, he has needed arterial bypass surgery and now, three times a week he comes to the hospital for dialysis, because his kidneys are malfunctioning,so his specialist asked us to look after his feet.

On first view we got a real shock – the three outer toes on his right foot were dry, shrivelled and black – typical of dry gangrene. These toes will probably fall off by themselves! The back if the left heel is one large blood blister, fortunately it’s dry and not infected.

The principle of managing cases like this is to keep the areas clean and dry. For the patient they have to do their best to control their blood sugar. The targets for good blood sugar control for a person with diabetes are between 5.5 and 7.0 mmol/litre, so you can imagine my concern at the last visit when I found out that this gentleman was running 15mmol/litre.

Every time the dressings are changed there is the opportunity for bacterial infection and high blood sugar usually worsens the situation. Of course the state of the feet and limbs in an obvious potential cause for the raised blood sugar too.

So what’s the lesson?  Mismanage diabetes at your peril!  Damage to the nerves and circulation will have a major impact on your life the longer you live. The complications of diabetes are largely preventable, yet vast amounts of money are spent worldwide on managing the complications of diabetes.

Control of blood sugar and not smoking will protect both arteries and nerves from serious damage. Nephropathy or damage to kidneys is life threatening and not everybody can access a dialysis unit. Loss of sensation or neuropathy, where there is no sensation in the feet, allows for injuries to happen without the person noticing.

Don’t become a victim of circumstance – take control of your diabetes now – and avoid dialysis later.