The Diabetic Foot in End Stage Renal Disease

Figures & data

Table 1 Pathogenesis of the diabetic foot and special features in ESRD

Pathogenesis of the Diabetic Foot

Peripheral arterial disease

Peripheral neuropathy

Infection

Special Pathogenetic Features in ESRD

Higher frequency of peripheral arterial disease

More frequent coexistence of peripheral arterial disease and aggravation by superimposed uremic neuropathy

Increased propensity to infection due to uremic toxins and/or poor nutrition

Increased risk of trauma: postural hypotension due to cardiovascular autonomic neuropathy and post-dialysis volume constriction

Reduced tissue oxygenation: anemia and edema

Systemic hypoxia in HD: pulmonary microatelectasis, activation of complement, change in the oxygen dissociation curve

Hemodynamic response in HD: intradialytic or post-dialysis hypotension leading to peripheral vasoconstriction and ischemia

Change in medical priorities due to HD: neglected foot care

HD: hemodialysis.

Table 2 Clinical examination for the prevention and care of the diabetic foot

Palpation of peripheral pulses (dorsalis pedis and tibialis posterior arteries)

Ankle-Brachial Index (Doppler study)

Ankle reflexes

Protective sensation (most simply, by 10 g Semmes Weinstein Monofilament)

Vibration perception (most simply, by 128 Hz tuning fork)

Pain perception (pinprick)

Careful inspection of deformities (prominent metatarsal heads, claw or hammer toes etc), callosities, skin changes (dryness, fissures), nail pathology (ingrown nail, paronychia, onychomycosis), and ulceration

Inspection of shoes and socks (worn-out shoes, pressure areas, forgotten foreign bodies, inappropriate seams)

Figure 1. Gangrene of the right hallux in a patient with longstanding diabetes, peripheral arterial disease, and ESRD. The second and third toes have been amputated previously. Deep culture after drainage of the pus in the proximal phalanx of the hallux grew Enterococcus faecalis and Pseudomonas aeruginosa.