透析和糖尿病患的足部溃疡有关


  【24drs.com】June 1, 2010 — 根据在线发表于5月18日糖尿病照护(Diabetes Care)期刊的横断面研究报告结果,透析治疗和糖尿病患与第4或第5期慢性肾脏(CKD)患者的足部溃疡有独立关联。
  
  英国曼彻斯特中央曼彻斯特大学医院、NHS信托基金会的Agbor Ndip医师等人写道,足部溃疡是糖尿病患的一个严重问题,会造成庞大的额外经济负担。造成足部溃疡的原因相当多元,包括生理和机械因素、自我照护与治疗因素,糖尿病肾病变已被确认是足部溃疡和截肢的一个重要风险因素。
  
  研究目标是检视透析是否是足部溃疡的独立风险因素,研究对象是326名糖尿病患与第4或第5期CKD患者,就诊于曼彻斯特的诊所,平均年纪为64岁,61%是男性,78%有第2型糖尿病,11%有足部溃疡。
  
  评估有接受和没有接受透析病患的糖尿病周边神经病变(diabetic peripheral neuropathy,DPN)、周边动脉疾病(peripheral arterial disease,PAD)、之前的足部溃疡与截肢、足部自我照护。使用逻辑回归检视盛行足部溃疡的风险因素。
  
  相较于未接受透析者的各项发生率,接受透析病患有较高的DPN (79% vs 65 %)、PAD (64% vs 43%)、之前有截肢(15% vs 6.4%)、之前有足部溃疡(32% vs 20%)、足部溃疡盛行率(21% vs 5%;各项的P值都 < .05)。在单一变项分析中,与足部溃疡有关的因素包括使用客制化鞋子(胜算比[OR]为5.6;95%信心区间[CI]为2.5 - 13)、透析(OR,5.1;95% CI,2.3 - 11)、曾有足部溃疡(OR,4.8;95% CI,2.3 - 9.8)、PAD (OR,2.8;95% CI 1.3 - 6.0)以及罹患糖尿病的年数(OR,1.0;95% CI,1.0 - 1.1;各项的P值都< .01)。
  
  不过,在多变项逻辑回归中,与足部溃疡盛行率有关的唯一因素是透析治疗(OR,4.2;95% CI,1.7 - 10;P = .002) 和曾有足部溃疡(OR,3.1;95% CI,1.3 - 7.1;P = .008)。
  
  研究作者写道,透析治疗和足部溃疡有独立关联,指引中应强调透析是足部溃疡的一个重要风险因素,需要加强足部照护。
  
  研究限制包括,横断面研究设计、无法推论相关的因果关系;无法一般化到非白人的族群;未能比较透析组和非透析组之足部溃疡位置。此外,也未系统性评估周边水肿的位置和严重度、PAD的严重度。
  
  研究作者结论表示,我们的发现有重要的临床意涵,因为提醒了健康照护执业者,透析是足部溃疡的独立风险因素,因此需要额外的警惕与足部照护。目前的糖尿病指引及建议未能认知到透析治疗和足部溃疡之间的关联强度。我们的发现提出,就足部溃疡风险而言,透析治疗应列为和「曾有足部溃疡」一样的风险等级(即风险等级3,糖尿病足国际研究小组(IWGDF [International Working Group on the Diabetic Foot])分类[风险等级0 (无风险因素),风险等级1 (肾病变,无其它风险因素),风险等级2 (PAD并有或未并有肾病变),风险等级3 (目前有足部溃疡,足部溃疡或截肢病史),风险等级4 (目前有足部溃疡,曾有足部溃疡、或曾有截肢)])。
  
  Diabetes UK以及曼彻斯特NIHR生医研究中心和曼彻斯特学院健康科学中心支持本研究。部分研究作者宣告和英格兰高等教育资金委员会;国家健康研究中心;KCI;Diabetica Solutions;LaseCure;National Healing;Advanced Biohealing;Pfizer;Cytomedix公司 和/或 Diabetic Solutions有各种财务关系。
  
  Diabetes Care. 在线发表于2010年5月18日。

Dialysis Linked to Foot Ulceration in Diabetic Patients

By Laurie Barclay, MD
Medscape Medical News

June 1, 2010 — Dialysis treatment is independently associated with foot ulceration in patients with diabetes and stage IV or V chronic kidney disease (CKD), according to the results of a cross-sectional study reported online May 18 in Diabetes Care.

"Foot ulceration is a serious problem for people with diabetes which additionally results in huge economic costs," write Agbor Ndip, MD, from Central Manchester University Hospitals NHS Foundation Trust in Manchester, United Kingdom, and colleagues. "Causal pathways to foot ulceration are multifactorial and involve combinations of physiologic and mechanical factors, self-care and treatment factors. Diabetic nephropathy has been identified to be an important risk factor for foot ulceration and amputation."

The goal of the study was to examine whether dialysis is an independent risk factor for foot ulceration in 326 consecutive patients with diabetes and stage IV or V CKD who were attending clinics in Manchester. Mean age was 64 years, 61% were men, 78% had type 2 diabetes, and 11% had prevalent foot ulceration.

Patients receiving dialysis treatment and those not receiving dialysis were evaluated for diabetic peripheral neuropathy (DPN), peripheral arterial disease (PAD), prior foot ulceration and amputation, and foot self-care. Logistic regression identified risk factors for prevalent foot ulceration.

Patients receiving dialysis had a higher prevalence of DPN vs patients not receiving dialysis (79% vs 65 %), PAD (64% vs 43%), prior amputations (15% vs 6.4%), prior foot ulceration (32% vs 20%), and prevalent foot ulceration (21% vs 5%; all P < .05). Factors associated with foot ulceration in univariate analyses were use of custom-made footwear (odds ratio [OR], 5.6; 95% confidence interval [CI] 2.5 - 13), dialysis (OR, 5.1; 95% CI, 2.3 - 11), prior foot ulceration (OR, 4.8; 95% CI, 2.3 - 9.8), PAD (OR, 2.8; 95% CI 1.3 - 6.0), and years of diabetes (OR, 1.0; 95% CI, 1.0 - 1.1; P < .01 for all).

However, the only factors associated with prevalent foot ulceration in multivariate logistic regression were dialysis treatment (OR, 4.2; 95% CI, 1.7 - 10; P = .002) and prior foot ulceration (OR, 3.1; 95% CI, 1.3 - 7.1; P = .008).

"Dialysis treatment was independently associated with foot ulceration," the study authors write. "Guidelines should highlight dialysis as an important risk factor for foot ulceration requiring intensive foot care."

Limitations of this study include cross-sectional design, precluding inference about causal relationships; lack of generalizability to nonwhite ethnic groups; insufficient power to compare the site of foot ulceration in dialysis and no-dialysis groups. In addition, the site and severity of peripheral edema and the severity of PAD were not systematically evaluated.

"Our findings have important clinical implications as they alert health care practitioners that dialysis is an independent risk factor for foot ulceration thus requiring extra vigilance and foot care," the study authors conclude. "Current diabetes guidelines and recommendations fail to recognise the strength of the link between dialysis-treatment and foot ulceration. Our findings suggest that in terms of foot ulcer risk, dialysis treatment should be ranked equivalent to a history of previous foot ulceration (i.e. risk category 3, IWGDF [International Working Group on the Diabetic Foot] classification [risk 0 (no risk factors), risk 1 (neuropathy and no other risk factors), risk 2 (PAD with/without neuropathy), risk 3 (current foot ulcer, history of foot ulcer or amputation), and risk 4 (current foot ulcer, history of foot ulcer, or prior amputation)])."

Diabetes UK supported this study, as well as the Manchester NIHR Biomedical Research Centre and the Manchester Academic Health Science Centre. Some of the study authors have disclosed various financial relationships with Higher Education Funding Council for England; National Institutes of Health; KCI; Diabetica Solutions; LaseCure; National Healing; Advanced Biohealing; Pfizer; Cytomedix, Inc; and/or Diabetic Solutions.

Diabetes Care. Published online May 18, 2010.

    
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