The role of chronic kidney disease as a predictor of outcome after revascularisation of the ulcerated diabetic foot

• Published in: Diabetologia Vol. 54; no. 12; pp. 2971 - 2977
• Main Authors: Venermo, M., Biancari, F., Arvela, E., Korhonen, M., Söderström, M., Halmesmäki, K., Albäck, A., Lepäntalo, M.
• Format: Journal Article
• Language: English
• Published: Berlin/Heidelberg Springer-Verlag 01.12.2011; Springer; Springer Nature B.V
• Subjects: Aged; Aged, 80 and over; Amputation; Angioplasty; Associated diseases and complications; Biological and medical sciences; Classification; Cohort Studies; Diabetes; Diabetes. Impaired glucose tolerance; Diabetic Foot - surgery; Endocrine pancreas. Apud cells (diseases); Endocrinopathies; Etiopathogenesis. Screening. Investigations. Target tissue resistance; Female; Foot - blood supply; Foot - surgery; Foot diseases; Gangrene; Gangrene - surgery; Human Physiology; Humans; Internal Medicine; Ischemia; Ischemia - physiopathology; Ischemia - surgery; Kidney diseases; Kidney Failure, Chronic - complications; Kidneys; Leg ulcers; Limb Salvage - methods; Male; Medical prognosis; Medical sciences; Medicine; Medicine & Public Health; Metabolic Diseases; Middle Aged; Nephrology. Urinary tract diseases; Nephropathies. Renovascular diseases. Renal failure; Patients; R&D; Regression analysis; Renal failure; Research & development; Risk Factors; ROC Curve; Treatment Outcome; Urinary system involvement in other diseases. Miscellaneous; Vascular Patency; Vascular surgery; Vascular Surgical Procedures - methods; Veins & arteries; Finland; Ulcer; Chronic kidney disease; Revascularisation; Diabetic foot; Endocrinopathy; Kidney disease; Skin disease; Nervous system diseases; Urinary system disease; Diabetic Foot; Diabetes mellitus; Renal failure; Disease of the foot; Ulceration
• ISSN: 0012-186X; 1432-0428
• DOI: 10.1007/s00125-011-2279-1

Aims/hypothesis The aim of the study was to stratify the risk of diabetic patients with leg ulcer or gangrene undergoing infrainguinal revascularisation for critical limb ischaemia. Methods The study cohort included 732 revascularisation procedures performed in 597 diabetic patients with ulcer or gangrene. Logistic regression and CART analysis were used for identification of predictors of 1-year outcome. Results Logistic regression showed that chronic kidney disease (CKD) class (OR 1.38, 95% CI 1.16, 1.65) was an independent predictor of 1-year leg salvage (area under the receiver operating characteristic [ROC] curve 0.60, 95% CI 0.54, 0.65). The terminal nodes of the CART for 1-year leg salvage were CKD classes 4–5, the level (infrapopliteal vs femoropopliteal revascularisation), type of revascularisation (bypass surgery vs percutaneous transluminal angioplasty) and gangrene (area under the ROC curve 0.62, 95% CI 0.57, 0.68). Logistic regression showed that pulmonary disease (OR 1.76, 95% CI 1.11, 2.78), CKD class (OR 1.43, 95% CI 1.24, 1.65), foot gangrene (OR 1.76, 95% CI 1.21, 2.60) and patient age (OR 1.02, 95% CI 1.01, 1.04) were independent predictors of 1-year amputation-free survival (area under the ROC curve 0.65, 95% CI 0.60, 0.69). The terminal nodes of the CART for 1-year amputation-free survival were CKD classes 3–5, patient’s age of ≥75 years and foot gangrene (area under the ROC curve 0.64, 95% CI 0.60, 0.68). Conclusions/interpretation CKD is a formidable risk factor for poor intermediate outcome after infrainguinal revascularisation in diabetic patients with foot ulcer or gangrene. CART analysis indicates that foot gangrene is also a significant risk factor for adverse outcome.