title: Risk factors for foot ulceration and lower extremity amputation in adults with end-stage renal disease on dialysis: a systematic review and meta-analysis.
abstract: BACKGROUND
  Adults with end-stage renal disease are at increased risk of foot ulceration and lower extremity amputation. However, the central determinants of lower limb injury and loss are incompletely understood.
  
  
  METHODS
  We conducted a systematic review of non-randomized studies that quantified the major risk factors for foot ulceration and amputation in adults treated with dialysis and analysed patient populations in which risks were greatest. Random-effects meta-analysis was used to generate summary estimates.
  
  
  RESULTS
  Thirty studies (48 566 participants) were identified. Risk factors for foot ulceration and amputation included previous foot ulceration (odds ratios, OR, 17.56 and 70.13), peripheral arterial disease (OR, 7.52 and 9.12), diabetes (OR, 3.76 and 7.48), peripheral neuropathy (OR, 3.24 and 3.36) and coronary artery disease (OR, 3.92 and 2.49). Participants with foot ulceration or amputation had experienced a longer duration of diabetes (mean difference, MD, 4.04 and 6.07 years) and had lower serum albumin levels (MD, -0.23 and -0.13 g/dL). Risk factors for foot ulceration also included retinopathy (OR, 3.03), previous amputation (OR, 15.50) and higher serum phosphorus levels (MD, 0.40 mg/dL), while risk factors for amputation also included male sex (OR, 1.50), current smoking (OR, 2.26) and higher glycated haemoglobin levels (MD, 0.75%).
  
  
  CONCLUSIONS
  Dialysis patients who have markedly higher risks of ulceration or amputation include those with previous foot ulceration or amputation, peripheral neuropathy, diabetes or macrovascular disease. The temporal relationship between these risk factors and the development of foot ulceration and/or limb loss is uncertain and requires further study. Stable estimates of the key risk factors for ulceration and amputation can inform the design of future trials investigating clinical interventions to reduce the burden of lower limb disease in the dialysis population.
authors.affiliation: Discipline of Podiatry, and Lower Extremity and Gait Studies Program, La Trobe University, Melbourne, Victoria 3086, Australia Department of Podiatry, Eastern Health, Melbourne, Victoria 3156, Australia.
authors.forename: Michelle R
authors.initials: MR
authors.lastname: Kaminski
authors.affiliation: Discipline of Podiatry, and Lower Extremity and Gait Studies Program, La Trobe University, Melbourne, Victoria 3086, Australia.
authors.forename: Anita
authors.initials: A
authors.lastname: Raspovic
authors.affiliation: Department of Renal Medicine and Obstetric Medicine, Eastern Health Clinical School, Monash University, Melbourne, Victoria 3128, Australia.
authors.forename: Lawrence P
authors.initials: LP
authors.lastname: McMahon
authors.affiliation: Diaverum Medical Scientific Office, Lund, Sweden School of Public Health, University of Sydney, Sydney, New South Wales, Australia University of Bari, Bari, Italy Amedeo Avogadro University of Eastern Piedmont, Novara, Italy Diaverum Academy, Bari, Italy.
authors.forename: Giovanni F M
authors.initials: GF
authors.lastname: Strippoli
authors.affiliation: Department of Medicine, University of Otago Christchurch, Christchurch 8140, New Zealand.
authors.forename: Suetonia C
authors.initials: SC
authors.lastname: Palmer
authors.affiliation: Diaverum Medical Scientific Office, Lund, Sweden Amedeo Avogadro University of Eastern Piedmont, Novara, Italy.
authors.forename: Marinella
authors.initials: M
authors.lastname: Ruospo
authors.affiliation: Department of Podiatry, Eastern Health, Melbourne, Victoria 3156, Australia.
authors.forename: Sarah
authors.initials: S
authors.lastname: Dallimore
authors.affiliation: Discipline of Podiatry, and Lower Extremity and Gait Studies Program, La Trobe University, Melbourne, Victoria 3086, Australia.
authors.forename: Karl B
authors.initials: KB
authors.lastname: Landorf
mesh_terms: D000328:Adult; D000671:Amputation, Surgical / Q000706:statistics & numerical data*; D017719:Diabetic Foot / Q000209:etiology* / Q000601:surgery; D005121:Extremities / Q000601:surgery*; D005260:Female; D016523:Foot Ulcer / Q000209:etiology* / Q000601:surgery; D006801:Humans; D007676:Kidney Failure, Chronic / Q000150:complications* / Q000628:therapy; D008297:Male; D006435:Renal Dialysis / Q000009:adverse effects*; D012307:Risk Factors
keywords: amputation; dialysis; foot ulcer; risk factors; systematic review