Predictors of intra-hospital mortality in patients with diabetic foot ulcers in Nigeria: data from the MEDFUN Study.

Abstract Background/Objective : Diabetic foot ulcers (DFU) are associated with high morbidity and mortality globally. Mortality in patients hospitalized for DFU in Nigeria is unacceptably high. We sought to document contributory factors which predict mortality in patients hospitalized for DFU. Methods : Multi-centre Evaluation of Diabetic Foot Ulcer in Nigeria ( MEDFUN ), one-year observational study conducted in six tertiary healthcare institutions across the 6 geopolitical zones of Nigeria. Consecutive type 1 or 2 diabetic patients hospitalized for DFU who consented. Co-morbid complications were documented. Results : Mean age 55.9 12.5 years.96.1% had type 2 diabetes (DM), mean duration of DM was 8.5 ± 5.7 years. Duration of ulcer was 39 days with a range of 28 to 54 days. 79.2% presented with at least grade 3 DFU. About one-fifth of the patients died (20.5%). Highest mortality among subjects with Wagner grade 5. Middle-aged subjects ( 45-64 years) had significantly higher mortality- odds ratio (OR) 5.107, Confidence interval (CI) of 1.429-18.252, and P-value 0.022. Variables significantly associated with mortality with the respective p- values are DM duration more than 120 months (0.008), ulcer duration > one month (0.013), ulcer severity of Wagner grade 3 and above (0.001), peripheral arterial disease (0.002), foot gangrene (< 0.001). Laboratory variables associated with mortality ; proteinuria (<0.001), positive blood cultures (<0.001), severe vascular stenosis (0.001), moderate vascular stenosis(< 0.001), Low HDL (< 0.001). Co-morbid complications significantly associated with mortality; shock at presentation (<0.001), anemia (0.034), cardiac failure (0.020), renal impairment (<0.001). Sepsis was the strongest predictor of mortality (adjusted OR 5.128; 95% CI 2.614 – 10.060) followed by renal impairment (adjusted OR 2.831; 95% C.I. for OR 1.346 – 5.953). Conclusions : Mortality among Nigerian diabetic patients admitted for DFU is high, univariate predictors of mortality: older age, higher Wagner grade (≥ 3) ulcer, longer duration of DM, longer duration of ulcer, peripheral arterial disease, foot gangrene, renal impairment, low HDL- cholesterol, anemia, shock, and cardiac failure. Renal impairment and positive blood culture were independent determinants of mortality.

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Predictors of intra-hospital mortality in patients with diabetic foot ulcers in Nigeria: data from the MEDFUN Study.

10.21203/rs.2.16549/v2 ◽

2020 ◽

Author(s):

Olufunmilayo O Adeleye ◽

Ejiofor T Ugwu ◽

Ibrahim D Gezawa ◽

Innocent Okpe ◽

Ignatius Ezeani ◽

...

Keyword(s):

Renal Impairment ◽

Diabetic Foot ◽

Arterial Disease ◽

Foot Ulcers ◽

Diabetic Patients ◽

Diabetic Foot Ulcers ◽

Low Hdl ◽

Vascular Stenosis ◽

Grade 3 ◽

Peripheral Arterial

Abstract Background/Objective: Diabetic foot ulcers (DFU) are associated with high morbidity and mortality globally. Mortality in patients hospitalized for DFU in Nigeria is unacceptably high. This study is to document contributory factors that predict mortality in patients hospitalized for DFU in Nigeria. Methods: Multi-centre Evaluation of Diabetic Foot Ulcer in Nigeria (MEDFUN), an observational study conducted in six tertiary healthcare institutions across the 6 geopolitical zones of Nigeria. Consecutive type 1 or 2 diabetic patients hospitalized for DFU who consented. Co-morbid complications were documented. Results: Mean age 55.9 +/- 12.5 years. 96.1% had type 2 diabetes (DM), the mean duration of DM was 8.5 ± 5.7 years. The duration of ulcers was 39 days with a range of 28 to 54 days. 79.2% presented with at least grade 3 DFU. About one-fifth of the patients died (20.5%). Highest mortality among subjects with Wagner grade 5. Middle-aged subjects (45-64 years) had significantly high mortality- odds ratio (OR) 5.107, Confidence interval (CI) of 1.429-18.252.Variables significantly associated with mortality with the respective p- values are DM duration more than 120 months (0.008), ulcer duration > one month (0.013), ulcer severity of Wagner grade 3 and above (0.001), peripheral arterial disease (0.002), foot gangrene (< 0.001). Laboratory variables associated with mortality; proteinuria (<0.001), positive blood cultures (<0.001), severe vascular stenosis (0.001), moderate vascular stenosis (< 0.001), Low HDL (< 0.001). Co-morbid complications significantly associated with mortality; shock at presentation (<0.001), anaemia (0.034), cardiac failure (0.020), renal impairment (<0.001). Sepsis was the strongest predictor of mortality (OR 5.128; 95% CI 2.614 – 10.060) followed by renal impairment (OR 2.831; 95% CI 1.346 – 5.953). Conclusions: Mortality among Nigerian diabetic patients admitted for DFU is high. The majority who died during hospitalization for DFU belong to the working-age population. Predictors of mortality were older age, higher Wagner grade (≥ 3) ulcer, longer duration of DM, longer duration of ulcer, peripheral arterial disease, foot gangrene, renal impairment, low HDL- cholesterol, anaemia, shock, and cardiac failure. Renal impairment and positive blood culture were independent determinants of mortality.

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Predictors of intra-hospital mortality in patients with diabetic foot ulcers in Nigeria: data from the MEDFUN Study.

10.21203/rs.2.16549/v3 ◽

2020 ◽

Author(s):

Olufunmilayo O Adeleye ◽

Ejiofor T Ugwu ◽

Ibrahim D Gezawa ◽

Innocent Okpe ◽

Ignatius Ezeani ◽

...

Keyword(s):

Renal Impairment ◽

Hospital Mortality ◽

Cardiac Failure ◽

Diabetic Foot ◽

Foot Ulcers ◽

Diabetic Patients ◽

High Morbidity ◽

Diabetic Foot Ulcers ◽

Grade 3

Abstract Background: Diabetic foot ulcers (DFU) are associated with high morbidity and mortality globally. Mortality in patients hospitalized for DFU in Nigeria is unacceptably high. This study was undertaken to determine factors that predict mortality in patients hospitalized for DFU in Nigeria.Methods:The current study was part of Multi-centre Evaluation of Diabetic Foot Ulcer in Nigeria (MEDFUN), an observational study conducted in six tertiary healthcare institutions across the 6 geopolitical zones of Nigeria. Consecutive type 1 or 2 diabetic patients hospitalized for DFU who consented to participate were recruited and subjected to relevant clinical, biochemical and radiological assessments and multidisciplinary care until discharge or death. Data for type 1 diabetes mellitus (DM) patients were expunged from current mortality analysis due to their small number.Results: Three hundred and twenty three type 2 DM subjects with mean age and mean duration of DM of 57.2 11.4 years and 8.7± 5.8 years respectively participated in this study. The median duration of ulcers was 39 days with a range of 28 to 54 days and majority (79.9%) presented with advanced ulcers of at least Wagner grade 3. Mortality of 21.4% was recorded in the study, with the highest mortality observed among subjects with Wagner grade 5. Variables significantly associated with mortality with their respective p values were DM duration more than 120 months (p 0.005), ulcer duration > one month (p 0.020), ulcer severity of Wagner grade 3 and above (p 0.001), peripheral arterial disease (p 0.005), proteinuria (p <0.001), positive blood cultures (p<0.001), low HDL (p <0.001), shock at presentation (p<0.001), cardiac failure (p 0.027),and renal impairment (p <0.001). On Multivariate regression analysis, presence of bacteraemia (OR 5.053; 95% CI 2.572-9.428) and renal impairment (OR 2.838; 95% CI 1.349 – 5.971) were significantly predictive of mortality independent of other variables.Conclusions: This study showed high intra-hospital mortality among patients with DFU, with majority of deaths occurring among those with advanced ulcers, bacteremia, cardiac failure and renal impairment. Prompt attention to these factors might be helpful in improving survival from DFU in Nigeria.

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Wound management of chronic diabetic foot ulcers: From the basics to regenerative medicine

Prosthetics and Orthotics International ◽

10.1177/0309364614534296 ◽

2015 ◽

Vol 39 (1) ◽

pp. 29-39 ◽

Cited By ~ 41

Author(s):

Karen L Andrews ◽

Matthew T Houdek ◽

Lester J Kiemele

Keyword(s):

Peripheral Arterial Disease ◽

Diabetic Foot ◽

Arterial Disease ◽

Current Treatment ◽

Foot Ulcers ◽

Foot Deformities ◽

Minor Trauma ◽

Diabetic Foot Ulcers ◽

Number Of Patients ◽

Peripheral Arterial

Background: Hospital-based studies have shown that mortality rates in individuals with diabetic foot ulcers are about twice those observed in individuals with diabetes without foot ulcers. Objective: To assess the etiology and management of chronic diabetic foot ulcers. Study design: Literature review. Methods: Systematic review of the literature discussing management of diabetic foot ulcers. Since there were only a few randomized controlled trials on this topic, articles were selected to attempt to be comprehensive rather than a formal assessment of study quality. Results: Chronic nonhealing foot ulcers occur in approximately 15% of patients with diabetes. Many factors contribute to impaired diabetic wound healing. Risk factors include peripheral neuropathy, peripheral arterial disease, limited joint mobility, foot deformities, abnormal foot pressures, minor trauma, a history of ulceration or amputation, and impaired visual acuity. With the current treatment for nonhealing diabetic foot ulcers, a significant number of patients require amputation. Conclusion: Diabetic foot ulcers are optimally managed by a multidisciplinary integrated team. Offloading and preventative management are important. Dressings play an adjunctive role. There is a critical need to develop novel treatments to improve healing of diabetic foot ulcers. The goal is to have wounds heal and remain healed. Clinical relevance Diabetic neuropathy and peripheral arterial disease are major factors involved in a diabetic foot ulcer. Despite current treatment modalities for nonhealing diabetic foot ulcers, there are a significant number of patients who require amputations. No known therapy will be effective without concomitant management of ischemia, infection, and adequate offloading.

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Effectiveness of Platelet-Rich Plasma to Enhance Healing of Diabetic Foot Ulcers in Patients With Concomitant Peripheral Arterial Disease and Critical Limb Ischemia

The International Journal of Lower Extremity Wounds ◽

10.1177/1534734615575829 ◽

2015 ◽

Vol 15 (1) ◽

pp. 45-51 ◽

Cited By ~ 20

Author(s):

Nikolaos Kontopodis ◽

Emmanouhl Tavlas ◽

George Papadopoulos ◽

Dimitrios Pantidis ◽

Alexandros Kafetzakis ◽

...

Keyword(s):

Peripheral Arterial Disease ◽

Critical Limb Ischemia ◽

Diabetic Foot ◽

Platelet Rich Plasma ◽

Limb Ischemia ◽

Arterial Disease ◽

Foot Ulcers ◽

Diabetic Foot Ulcers ◽

Peripheral Arterial

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Determinants of wound healing in patients hospitalized for diabetic foot ulcer: results from the MEDFUN study

Endocrine Regulations ◽

10.2478/enr-2020-0023 ◽

2020 ◽

Vol 54 (3) ◽

pp. 207-216

Author(s):

Ignatius U. Ezeani ◽

Ejiofor T. Ugwu ◽

Funmi O. Adeleye ◽

Ibrahim D. Gezawa ◽

Innocent O. Okpe ◽

...

Keyword(s):

Wound Healing ◽

Renal Impairment ◽

Diabetic Foot ◽

Foot Ulcer ◽

Diabetic Foot Ulcer ◽

Arterial Disease ◽

Adverse Outcomes ◽

Diabetic Patients ◽

Chi Square ◽

Grade 3

AbstractObjective. The high amputation rates from diabetic foot ulcer (DFU) in Nigeria and prolonged hospitalization due to poor wound healing is a source of concern. Furthermore, factors that affect wound healing of DFUs have not yet been well studied in Nigeria, whereas knowing these factors could improve DFU outcomes. Therefore, the objective of this study was to determine the factors that are associated with the wound healing in patients hospitalized for DFU.Methods. The Multi-Center Evaluation of Diabetic Foot Ulcer in Nigeria (MEDFUN) was an observational study involving 336 diabetic patients hospitalized for DFU and managed by a multi-disciplinary team until discharge or death. Demographic, clinical, and biochemical characteristics were documented. Test statistics used were chi square, t-test, univariate, and multivariate logistic regression. The study endpoints were ulcer healing, LEA, duration of hospitalization, and mortality. Here we present data on wound healing.Results. The mean ± SD age was 55.9±12.5 years. Univariate predictors of wound healing were ulcer duration more than 1 month prior to hospitalization (p<0.001), peripheral arterial disease (PAD) (p<0.001), foot gangrene (p<0.001), Ulcer grade ≥3 (p=0.002), proteinuria (p=0.005), anemia (p=0.009), renal impairment (p=0.021), glycated hemoglobin ≥7% (0.012), and osteomyelitis (p<0.001). On multivariate regression, osteomyelitis was the strongest independent predictor of wound healing after adjusting for all other variables (OR 0.035; 95% CI 0.004–0.332). This was followed by PAD (OR 0.093; 95% CI 0.028–0.311), ulcer duration >1 month (OR 0.109; 95% CI 0.030–0.395), anemia (OR 0.179; 95% CI 0.056–0.571).Conclusion. Presence of osteomyelitis, duration of ulcer greater than 1 month, PAD, Wagner grade 3 or higher, proteinuria, presence of gangrene, anemia, renal impairment, and HbA1c ≥7% were the significant predictors of wound healing in patients hospitalized for DFU. Early identification and prompt attention to these factors in a diabetic foot wound might significantly improve healing and reduce adverse outcomes such as amputation and death.

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New possibilities of maximal revascularization of the foot as a limb salvage procedure in diabetics

VASA ◽

10.1024/0301-1526/a000044 ◽

2010 ◽

Vol 39 (3) ◽

pp. 278-283 ◽

Cited By ~ 2

Author(s):

Sauvant ◽

Hüttenmoser ◽

Soyka ◽

Rüttimann

Keyword(s):

Diabetic Foot ◽

Arterial Disease ◽

Major Amputation ◽

Transluminal Angioplasty ◽

Lower Limbs ◽

Foot Ulcers ◽

Diabetic Patients ◽

Salvage Procedure ◽

Critical Ischemia ◽

Peripheral Arterial

Diabetics and patients with chronic renal insufficiency often have severe peripheral arterial disease of the distal lower limbs with obstructions of crural and pedal arteries and the imminent risk of critical ischemia and major amputation. Neuroischemic foot ulcers have been shown to fail to heal even after successful arterial revascularization. We report on two diabetic patients with the neuroischemic diabetic foot syndrome and different clinical outcomes after percutaneous transluminal angioplasty of chronic occluded crural arteries and discuss, whether endovascular revascularisation of infrapopliteal and pedal arteries, if possible with complete plantar arch, could promote ulcer healing in neuroischemic diabetic foot ulcers.

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Nonpharmacological Management of Diabetic Foot Ulcers: An Update

The International Journal of Lower Extremity Wounds ◽

10.1177/1534734620963561 ◽

2020 ◽

pp. 153473462096356 ◽

Cited By ~ 1

Author(s):

Ioanna Eleftheriadou ◽

Georgia Samakidou ◽

Anastasios Tentolouris ◽

Nikolaos Papanas ◽

Nikolaos Tentolouris

Keyword(s):

Diabetic Foot ◽

Standard Of Care ◽

Arterial Disease ◽

Treatment Modalities ◽

Foot Ulcers ◽

Diabetic Foot Ulcers ◽

Skin Substitutes ◽

Cultured Fibroblasts ◽

Impaired Wound Healing ◽

Peripheral Arterial

Diabetic foot ulcers (DFUs) are a common and serious complication of diabetes mellitus that is associated with increased morbidity and mortality, as well as substantial economic burden for the health care system. The standard of care for DFUs includes pressure off-loading, sharp debridement, and wound moisture balance, along with infection control and management of peripheral arterial disease. A variety of advanced modalities that target distinct pathophysiological aspects of impaired wound healing in diabetes are being studied as possible adjunct therapies for difficult to heal ulcers. These modalities include growth factors, stem cells, cultured fibroblasts and keratinocytes, bioengineered skin substitutes, acellular bioproducts, human amniotic membranes, oxygen therapy, negative pressure wound therapy, and energy therapies. Additionally, the use of advanced biomaterials and gene delivery systems is being investigated as a method of effective delivery of substances to the wound bed. In the present narrative review, we outline the latest advances in the nonpharmacological management of DFUs and summarize the efficacy of various standard and advanced treatment modalities.

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PENATALAKSANAAN ULKUS KAKI DIABETES SECARA TERPADU

JURNAL BIOMEDIK (JBM) ◽

10.35790/jbm.3.2.2011.864 ◽

2013 ◽

Vol 3 (2) ◽

Author(s):

Yuanita A. Langi

Keyword(s):

Wound Healing ◽

Growth Factors ◽

Peripheral Arterial Disease ◽

Diabetic Foot ◽

Foot Ulcer ◽

Diabetic Foot Ulcer ◽

Arterial Disease ◽

Foot Ulcers ◽

Diabetic Foot Ulcers ◽

Peripheral Arterial

Abstract: A diabetic foot ulcer is a common and fearful chronic complication of diabetes mellitus often resulting in amputation, and even death. A diabetic foot ulcer can be prevented by early screening and education in high risk individuals, and the management of underlying conditions such as neuropathy, peripheral arterial disease, and deformity. The prevalence of diabetic foot ulcer patients is 4-10% of the general population, with a higher prevalence in elderly people. Around 14-24 % of diabetic foot ulcer patients need amputations with a recurrence rate of 50% after three years. The main pathogenesis of diabetic foot ulcer is neuropathy and peripheral arterial disease (PAD). PAD contributes to diabetic foot ulcers in 50% of cases; however, it rarely stands alone. Other factors such as smoking, hypertension, and hyperlipidemia may contribute, too. In addition, PAD reduces the access of oxygen and antibiotics to the ulcers. Management of diabetic foot ulcers includes treatment of ischemia by promoting tissue perfusion, debridement for removing necrotic tissues, wound treatment for creating moist wound healing, off-loading the affected foot, surgery intervention, management of the co-morbidities and infections, and prevention of wound recurrences. Other adjuvant modalities include hyperbaric oxygen treatment, GCSF, growth factors, and bioengineered tissues. Key words: diabetic ulcer, debridement, off loading. Abstrak: Ulkus kaki diabetes (UKD) merupakan salah satu komplikasi kronik diabetes melitus yang sering dijumpai dan ditakuti oleh karena pengelolaannya sering mengecewakan dan berakhir dengan amputasi, bahkan kematian. UKD dapat dicegah dengan melakukan skrining dini serta edukasi pada kelompok berisiko tinggi, dan penanganan penyebab dasar seperti neuropati, penyakit artei perifer dan deformitas. Prevalensi pasien UKD berkisar 4-10% dari populasi umumnya, dengan prevalensi yang lebih tinggi pada manula. Sekitar 14-24% pasien UKD memerlukan amputasi dengan rekurensi 50 % setelah tiga tahun. Patogenesis utama UKD yaitu neuropati dan penyakit arteri perifer (PAP). PAP berkontribusi 50% pada pasien UKD, tetapi hal ini jarang dijumpai tunggal. Terdapat faktor-faktor lain yang turut berperan seperti merokok, hipertensi dan hiperlipidemia. Selain itu PAP menurunkan akses oksigen dan antibiotik ke dalam ulkus. Penatalaksanaan UKD meliputi penanganan iskemia dengan meningkatkan perfusi jaringan, debridemen untuk mengeluarkan jaringan nekrotik, perawatan luka untuk menghasilkan moist wound healing, off-loading kaki yang terkena, intervensi bedah, pananganan komorbiditas dan infeksi, serta pencegahan rekurensi luka. Terapi ajuvan meliputi terapi oksigen hiperbarik, pemberian granulocyte colony stimulating factors (GCSF), growth factors dan bioengineerd tissues. Kata kunci: ulkus diabetes, debridemen, off loading.

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Peripheral arterial disease in patients with renal-diabetic foot ulcers

Journal of Wound Care ◽

10.12968/jowc.2021.30.8.660 ◽

2021 ◽

Vol 30 (8) ◽

pp. 660-664

Author(s):

Marco Meloni ◽

Valentina Izzo ◽

Laura Giurato ◽

Valerio Da Ros ◽

Daniele Morosetti ◽

...

Keyword(s):

Peripheral Arterial Disease ◽

Diabetic Foot ◽

Independent Predictor ◽

Arterial Disease ◽

Foot Ulcers ◽

Anterior Tibial Artery ◽

Diabetic Foot Ulcers ◽

Arterial Lesions ◽

Patient Groups ◽

Peripheral Arterial

Objective: To describe the angiographic characteristics of peripheral arterial disease (PAD) in persons with diabetic foot ulcers (DFUs) on dialysis treatment. Method: The study is a retrospective analysis of patients with DFUs and PAD who had been referred to our diabetic foot clinic. All patients had been managed by a pre-set limb salvage protocol including revascularisation of the affected limb. Arterial lesions (stenosis between 50–99% and occlusions) were retrospectively evaluated through angiogram analysis. According to the presence or not of dialysis, patients were divided into two patient groups: renal-diabetic foot (RDF) and diabetic foot (DF). Distribution of PAD and immediate revascularisation outcome (technical revascularisation outcome) for RDF and DF were separately reported and compared. Results: The sample included 239 patients: mean age was 71.8 years; 72.4% were male; 87.4% had type 2 diabetes; mean diabetes duration was 21.4 years; and the mean HbA1c was 63±22mmol/mol. The RDF group compared with the DF group reported higher numbers of vessels affected (n=5±1.6 versus 3.9±1.5, respectively, p<0.0001), greater involvement of the superficial femoral artery (90.2% versus 75.8%, respectively, p=0.003), the tibial-peroneal trunk (53.7% versus 25.5%, respectively, p=0.01), the anterior tibial artery (93.9% versus 80.9%, respectively, p=0.03) and below-the-ankle (BTA) arteries (70.7% versus 35.7%, respectively, p=0.0001). The RDF group showed a higher rate of revascularisation failure in comparison to DF patients (43.9% versus 15.3%, respectively, p<0.0001). BTA arterial disease (odds ratio 9.5; 95% Confidence Interval: 3.5–25.4; p=0.0001) resulted as the only independent predictor of revascularisation failure. Conclusion: In this study, RDF patients showed a widespread distribution of arterial lesions with a higher involvement of foot arteries in comparison with DF patients. BTA arterial disease was found to be an independent predictor of revascularisation failure.

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