The association of chronic kidney disease and dialysis treatment with foot ulceration and major amputation.
OBJECTIVE
The objective of this study was to investigate the risk of chronic kidney disease (CKD) stage 4-5 and dialysis treatment on incidence of foot ulceration and major lower extremity amputation in comparison to CKD stage 3.


METHODS
In this retrospective study, all individuals who visited our hospital between 2006 and 2012 because of CKD stages 3 to 5 or dialysis treatment were included. Medical records were reviewed for incidence of foot ulceration and major amputation. The time from CKD 3, CKD 4-5, and dialysis treatment until first foot ulceration and first major lower extremity amputation was calculated and analyzed by Kaplan-Meier curves and multivariate Cox proportional hazards model. Diabetes mellitus, peripheral arterial disease, peripheral neuropathy, and foot deformities were included for potential confounding.


RESULTS
A total of 669 individuals were included: 539 in CKD 3, 540 in CKD 4-5, and 259 in dialysis treatment (individuals could progress from one group to the next). Unadjusted foot ulcer incidence rates per 1000 patients per year were 12 for CKD 3, 47 for CKD 4-5, and 104 for dialysis (P < .001). In multivariate analyses, the hazard ratio for incidence of foot ulceration was 4.0 (95% confidence interval [CI], 2.6-6.3) in CKD 4-5 and 7.6 (95% CI, 4.8-12.1) in dialysis treatment compared with CKD 3. Hazard ratios for incidence of major amputation were 9.5 (95% CI, 2.1-43.0) and 15 (95% CI, 3.3-71.0), respectively.


CONCLUSIONS
CKD 4-5 and dialysis treatment are independent risk factors for foot ulceration and major amputation compared with CKD 3. Maximum effort is needed in daily clinical practice to prevent foot ulcers and their devastating consequences in all individuals with CKD 4-5 or dialysis treatment.
Department of Nephrology, Ziekenhuisgroep Twente, Almelo and Hengelo, The Netherlands.
Jeroen
J
Otte
Department of Surgery, Ziekenhuisgroep Twente, Almelo and Hengelo, The Netherlands. Electronic address: jv.netten@zgt.nl.
Jaap J
JJ
van Netten
Department of Nephrology, Ziekenhuisgroep Twente, Almelo and Hengelo, The Netherlands.
Arend-Jan J
AJ
Woittiez
D000368:Aged; D000671:Amputation, Surgical / Q000706:statistics & numerical data*; D005260:Female; D016523:Foot Ulcer / Q000453:epidemiology* / Q000209:etiology / Q000601:surgery; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D006435:Renal Dialysis / Q000009:adverse effects*; D051436:Renal Insufficiency, Chronic / Q000145:classification / Q000150:complications* / Q000628:therapy; D012189:Retrospective Studies; D012307:Risk Factors