透析和糖尿病患的足部潰瘍有關
作者：Laurie Barclay, MD
出處：WebMD醫學新聞
June 1, 2010 — 根據線上發表於5月18日糖尿病照護(Diabetes Care)期刊的橫斷面研究報告結果，透析治療和糖尿病患與第4或第5期慢性腎臟(CKD)患者的足部潰瘍有獨立關聯。
英國曼徹斯特中央曼徹斯特大學醫院、NHS信託基金會的Agbor Ndip醫師等人寫道，足部潰瘍是糖尿病患的一個嚴重問題，會造成龐大的額外經濟負擔。造成足部潰瘍的原因相當多元，包括生理和機械因素、自我照護與治療因素，糖尿病腎病變已被確認是足部潰瘍和截肢的一個重要風險因素。
研究目標是檢視透析是否是足部潰瘍的獨立風險因素，研究對象是326名糖尿病患與第4或第5期CKD患者，就診於曼徹斯特的診所，平均年紀為64歲，61%是男性，78%有第2型糖尿病，11%有足部潰瘍。
評估有接受和沒有接受透析病患的糖尿病周邊神經病變(diabetic peripheral neuropathy，DPN)、周邊動脈疾病(peripheral arterial disease，PAD)、之前的足部潰瘍與截肢、足部自我照護。使用邏輯回歸檢視盛行足部潰瘍的風險因素。
相較於未接受透析者的各項發生率，接受透析病患有較高的DPN (79% vs 65 %)、PAD (64% vs 43%)、之前有截肢(15% vs 6.4%)、之前有足部潰瘍(32% vs 20%)、足部潰瘍盛行率(21% vs 5%；各項的P值都 < .05)。在單一變項分析中，與足部潰瘍有關的因素包括使用客製化鞋子(勝算比[OR]為5.6；95%信心區間[CI]為2.5 - 13)、透析(OR，5.1；95% CI，2.3 - 11)、曾有足部潰瘍(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數(OR，1.0；95% CI，1.0 - 1.1；各項的P值都< .01)。
不過，在多變項邏輯回歸中，與足部潰瘍盛行率有關的唯一因素是透析治療(OR，4.2；95% CI，1.7 - 10；P = .002) 和曾有足部潰瘍(OR，3.1；95% CI，1.3 - 7.1；P = .008)。
研究作者寫道，透析治療和足部潰瘍有獨立關聯，指引中應強調透析是足部潰瘍的一個重要風險因素，需要加強足部照護。
研究限制包括，橫斷面研究設計、無法推論相關的因果關係；無法一般化到非白人的族群；未能比較透析組和非透析組之足部潰瘍位置。此外，也未系統性評估周邊水腫的位置和嚴重度、PAD的嚴重度。
研究作者結論表示，我們的發現有重要的臨床意涵，因為提醒了健康照護執業者，透析是足部潰瘍的獨立風險因素，因此需要額外的警惕與足部照護。目前的糖尿病指引及建議未能認知到透析治療和足部潰瘍之間的關聯強度。我們的發現提出，就足部潰瘍風險而言，透析治療應列為和「曾有足部潰瘍」一樣的風險等級(即風險等級3，糖尿病足國際研究小組(IWGDF [International Working Group on the Diabetic Foot])分類[風險等級0 (無風險因素)，風險等級1 (腎病變，無其他風險因素)，風險等級2 (PAD併有或未併有腎病變)，風險等級3 (目前有足部潰瘍，足部潰瘍或截肢病史)，風險等級4 (目前有足部潰瘍，曾有足部潰瘍、或曾有截肢)])。
Diabetes UK以及曼徹斯特NIHR生醫研究中心和曼徹斯特學院健康科學中心支持本研究。部分研究作者宣告和英格蘭高等教育資金委員會；國家健康研究中心；KCI；Diabetica Solutions；LaseCure；National Healing；Advanced Biohealing；Pfizer；Cytomedix公司 和/或 Diabetic Solutions有各種財務關係。
Diabetes Care. 線上發表於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.
