Amputations and mortality in in-hospital treated patients with peripheral artery disease and diabetic foot syndrome
Introduction
The prevalence of diabetes mellitus (DM) is increasing worldwide (Murray et al., 2015, Zimmet et al., 2014) just as the diabetes-associated complications (Gregg, Li, Wang, et al., 2014) such as peripheral artery disease (PAD) and especially diabetic foot syndrome (DFS). Patients with DM have a lifetime probability of 15%–25% for developing foot ulcers (Abbott et al., 2002, Singh et al., 2005, Wild et al., 2004) which are a precursor of limb amputation, particularly in the presence of ischemia and infection. Concomitant PAD is present in approximately 50%–70% of diabetic foot ulcers and is a strong predictor of adverse outcome in ulcer healing, limb amputation, morbidity, and mortality (Prompers et al., 2007, Prompers, Schaper, et al., 2008). Moreover, both PAD and DM are associated with extensive resource utilization and costs (Prompers, Huijberts, Schaper, et al., 2008).
Measures such as campaigns to increase the awareness of DM-associated vascular complications (World Health Organization: Diabetes Care and Research in Europe: The St. Vincent Declaration. Geneva, World Health Org, 1989) alongside with the progress in medical and interventional treatment modalities during the last decades might be suggestive of an improved outcome of patients with DM and PAD. Indeed, a continuous advance in integrated management of DM has resulted in considerable decrease of DM-related complications during the last two to three decades (Gregg, Li, et al., 2014, Gregg, Zhuo, et al., 2014). Even in patients with DFS a dedicated multidisciplinary approach resulted in favorable short- and long-term outcome (Apelqvist et al., 2011, Apelqvist et al., 2008; Apelqvist and Larsson, 2000, Krishnan et al., 2008). However, those data were derived from single-centers with excellent expertise in diabetic foot care, hence not representative of the up-to-date real-world practice. Contemporary data confirming or reputing such assumptions in the real-world setting are lacking. Therefore, we conducted a thorough retrospective analysis in a large German nation-wide cohort to determine the frequency of DFS and of PAD with and without concomitant DM and the current practice of care regarding revascularization, and to assess the acute and long-term outcome in terms of limb amputation and mortality.
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Subjects, materials and methods
The entities of the German diagnosis related groups (G-DRG) and of the patient allocation have previously been described in details (Reinecke, Unrath, Freisinger, et al., 2015).
Anonymized data of a large German health insurance (BARMER GEK, covering approximately eight million people, respective 10% of the entire German population) were analyzed. All patients hospitalized between 2009 and 2011 with a main diagnosis of PAD of the lower limb (GM-ICD-10 codes I70.20–I70.24) or with a main
Baseline characteristics and comorbidities
Among 40,335 analyzed patients, the distribution of DFS, PAD+DM, and of PAD alone was 17.3%, 21.5%, and 61.2%, respectively. Baseline characteristics of these three subgroups are presented in Table 1.
Compared to patients with PAD+DM and PAD, DFS patients were younger and had a higher proportion of male gender and of obesity, yet lower proportions of smoking and dyslipidemia (P < 0.001, Table 1). The frequencies of chronic kidney disease and chronic heart failure were highest among DFS, followed
Discussion
This contemporary, nation-wide study demonstrates the continuing poor prognosis of patients with DFS and documents the detrimental impact of diabetes on the short- and long-term outcome regarding limb amputation and mortality in patients with atherosclerotic vascular disease. To the best of our knowledge, this is the study with the largest cohort of DFS patients (n = 6996) and the first nation-wide, population-based study in patients with and without concomitant DM reporting detailed information
Acknowledgments
We thank Mrs. Susanne Schüler and Dr. Christiane Engelbertz, both Division of Vascular Medicine, Department of Cardiovascular Medicine, University Hospital Muenster, for their excellent assistance during manuscript preparation.
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2022, Diabetes and Metabolic Syndrome: Clinical Research and ReviewsCitation Excerpt :Another study was a general practitioner (GP)-based analysis that included all diabetic patients with a known history of DFUs or CKD or both conditions and looked into both groups of patients as separate sub-analyses; hence it was also included in this review. Lastly, national-wide data with sub-analyses for diabetic foot syndrome was also included [18,22]. All studies evaluated diabetes-related LLA, and eight specifically analysed amputation as an outcome of DFUs [18,19,21,23,27–29,31].
The impact of diabetes mellitus on major amputation among patients with chronic limb threatening ischemia undergoing elective endovascular therapy- a nationwide propensity score adjusted analysis
2021, Journal of Diabetes and its ComplicationsCitation Excerpt :It should be emphasized, however, that leg revascularization is just one key element in the complex management of DM and CLTI. A multidisciplinary therapeutic approach including state-of-the-art wound care, biomechanical offloading of foot ulcers, edema and blood glucose control, and effective treatment of all underlying risk factors and comorbidities is necessary to be able to improve limb salvage and mortality rates.27 The strengths of the present study are the use of data from two nationwide disease-specific registries, NDR and Swedvasc, along with information from other nationwide databases due to linkage of the unique personal identity number for every Swedish citizen.28
Funding: No sources of funding.
Conflict of interest: H. Reinecke has received grants for participation in multicenter trials from Bard, Bayer, Biotronik, and Pluristem and consultant fees from BMS and Pluristem. N.M. Malyar has received travel support from Bard, Bayer, Cordis, Daiichi-Sankyo, and Medtronic and speaker honoraria from Medac and UCB Pharma. The other authors have nothing to declare.