title: Diabetes is the strongest risk factor for lower-extremity amputation in new hemodialysis patients.
abstract: OBJECTIVE
  End-stage renal disease (ESRD) patients, especially those with diabetes, have an increased risk of nontraumatic lower-extremity amputation (LEA). The present study aims to examine the association of demographic and clinical variables with the risk of hospitalization for LEA among incident hemodialysis patients.
  
  
  METHODS
  The study population consisted of incident hemodialysis patients from the study years 1996-1999 of the ESRD Core Indicator/Clinical Performance Measures (CPM) Project. Cox proportional hazard modeling was used to identify factors associated with LEA.
  
  
  RESULTS
  Four percent (116 of 3,272) of noncensored incident patients had an LEA during the 12-month follow-up period. Factors associated with LEA included diabetes as the cause of ESRD or preexisting comorbidity (hazard ratio 6.4, 95% CI 3.4-12.0), cardiovascular comorbidity (1.8, 1.2-2.8), hemodialysis inadequacy (urea reduction ratio [URR] <58.5% (1.9, 1.1-3.3), and lower serum albumin level (1.6, 1.1-2.3). Among patients with diabetes, hemodialysis inadequacy and cardiovascular comorbidity were risk factors for LEA (2.6, 1.4-4.8, and 1.7, 1.1-2.6, respectively).
  
  
  CONCLUSIONS
  These data suggest that diabetes is a potent risk factor for LEA in new hemodialysis patients. In ESRD patients with diabetes, a multipronged approach may reduce the rate of LEA. Potentially beneficial strategies include adherence to hemodialysis adequacy guidelines, aggressive treatment of cardiovascular comorbidities, and the utilization of LEA prevention strategies recommended for the general population of patients with diabetes.
authors.affiliation: Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.
authors.forename: Rebecca A
authors.initials: RA
authors.lastname: Speckman
authors.forename: Diane L
authors.initials: DL
authors.lastname: Frankenfield
authors.forename: Sheila H
authors.initials: SH
authors.lastname: Roman
authors.forename: Paul W
authors.initials: PW
authors.lastname: Eggers
authors.forename: Marjorie R
authors.initials: MR
authors.lastname: Bedinger
authors.forename: Michael V
authors.initials: MV
authors.lastname: Rocco
authors.forename: William M
authors.initials: WM
authors.lastname: McClellan
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000671:Amputation, Surgical / Q000706:statistics & numerical data*; D003920:Diabetes Mellitus / Q000453:epidemiology*; D017719:Diabetic Foot / Q000453:epidemiology / Q000601:surgery*; D003928:Diabetic Nephropathies / Q000453:epidemiology*; D005260:Female; D006801:Humans; D015994:Incidence; D007676:Kidney Failure, Chronic / Q000453:epidemiology*; D007866:Leg / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D006435:Renal Dialysis; D012307:Risk Factors; D013997:Time Factors