Britishrenal.org



Long term mortality rates in end-stage renal disease patients after lower limb amputationsI Elsayed1, A Khwaja11 Sheffield Teaching Hospitals.Introduction: Patients with Diabetes constitute 35% of end-stage renal disease (ESRD) patients in the UK. The rate of leg amputations in people with diabetes is over 15 times higher than in people without. Peripheral vascular disease is common in ESRD & is associated with excessive mortality & morbidity. Studies & registry data analysis have shown that diabetes was strongly associated with PVD (DM had the strongest association in DOPPS study). Mortality at hospital discharge & 30-day post-amputation , for diabetic patients is higher than that for CABG, stroke or breast cancer patients, however there is little reported on long term mortality data especially among renal patients. The aim of this service evaluation, is to detect the effect of renal disease on long term mortality in diabetic patients receiving lower limb amputation in our hospital. Methodology: ICD-10 coding was used to identify records of patients receiving lower-extremity amputations between October 2004 & October 2013 in a teaching hospital. Medical records of 1592 patients were abstracted & analysed retrospectively. Means, standard deviations & medians were used for description of continuous variables. Survival was analysed from the time of procedure to a maximum of 112 months & the median survival post-amputation in months (abbreviated as “median survival”) was reported. Table 1- Overall median survival in monthsDiabetic = 33Non-Diabetic = 29p=0.000ESRD patients = 28 CKD patients = 34p=0.007AKA = 20BKA = 34p=0.000Results: We identified 1,610 episodes of amputations performed on 1592 patients. Mean age was 64 years (SD=15). Among these patients 785 were diabetic. 134 patients had CKD & 59 patients were ESRD. 357 patients received above knee amputations & 1234 received below knee (including foot) amputations. Overall survival to date was significantly lower among diabetic, ESRD patients & those with high level amputations (table 1).Among patients with CKD & ESRD, survival at two years for ESRD was 55% & 74% for patients with CKD, while at five years survival for CKD was 65% & 39% for ESRD (p=0.008). There was not a statistically significant difference between survival of diabetic & non-diabetic patients at 2 & 5 years (p=0.349 & p=0.130 respectively), nor was there a statistically significant difference in survival based on level of amputation (p=0.581).The Cox proportional hazard model of overall survival showed that; there was an 85% increase in the hazard of death among patients receiving higher level amputation, (HR: 1.846, 95% CI 1.56-2.18) & 52% increase in the hazard of death in diabetic patients compared with non-diabetic (HR 1.518, 95% CI 1.29-1.77). Patients with ESRD were 77% more likely to die compared with patients with non-renal disease (HR 1.769, 95% CI 1.2-2.59), when all other factors were kept constant. ESRD was associated with 97 % increase in the hazard of death at one year, compared to non-renal patients (HR 1.97, 95% CI 1.12-3.45), 80% increase in the hazard of death at two years, compared to non-renal patients (HR 1.79, 95% CI 1.08-2.98), 140% increase in the hazard of death at five years, compared to non-renal patients (HR 2.44, 95% CI 1.46-4.07), when all other factors were kept constant. Conclusion: ESRD patients receiving amputations suffer much worse long term mortality rates than those without renal disease. Quality of life & prevalence of depression are much higher in patients receiving amputations. ESRD patients suffer longer hospital stay after amputations. Recommendations: There is evidence that access to multidisciplinary foot care teams (MDTs) can lead to faster healing, fewer amputations and improved survival. Savings to the NHS can substantially exceed the cost of the team. The use of visual media highlighting the importance of diabetic foot care in dialysis units & including diabetic feet care in regular dialysis MDTs & may offer sensible cost-effective measures in steps towards reducing PVD-related mortality among ESRD patients, as well as improve quality of lives of ESRD patients. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download