The following sections have been prepared to ensure that the state of the art and science related to CVD includes novel concepts, therapeutic strategies, and emerging areas of pathophysiological and practical importance to the care of dialysis patients.
The reader will notice that the format of this section is different, reflecting its different perspective: namely, the relative lack of evidence on which to base plausible guideline statements. The evidence that does exist, and is cited in this section, is either completely in nondialysis populations, or is purely associative information, with no intervention in any population yet tested. Thus, it would be a problem to include guideline statements or recommendations.
Nonetheless, this section describes the current status of knowledge with respect to risk factors and biomarkers, and represents an overview of key areas for future clinical trials. The reader is encouraged to review this section, and examine his or her current understanding and practice within the context of these highlights.
The literature review has been conducted using the same systematic strategy as for the previous guidelines in this document. The reviews presented here have been thoughtfully constructed so that clinicians can adopt different practices based on them. However, for reasons cited above, the ability to truly recommend or suggest changes in practice would be premature at this time.
In 1994, the annualized rate of amputation among Medicare diabetic and nondiabetic patients on dialysis was 11.8 and 2.3 per 100 respectively.144 Compared to dialysis patients with glomerulonephritis as the cause of kidney failure, diabetic dialysis patients had 8.9-fold higher odds of undergoing amputation.144 The 30-day perioperative mortality in dialysis patients who underwent amputation was 16%.729 Thus, there is an exceedingly high risk of amputation in diabetic dialysis patients, with its attendant loss of quality of life and high perioperative mortality. Hence, it is imperative to implement measures to decrease the amputation rates in diabetic dialysis patients. Adoption of preventive care of the diabetic foot has been outlined in the American Diabetic Association (ADA) Position Statement,730 and these recommendations, with certain modifications, may be applied to CKD patients.
Several clinical studies in the nondialysis diabetic population have shown that coordinated programs to screen for high-risk feet and to provide regular foot care decreased lower extremity amputation rates.731,732 In a controlled study, 45 HD patients were assigned to intensive education and care management that included preventive foot care and 38 HD patients were assigned to usual care.733 Over the 12-month follow-up period, there were no amputations in the study group while there were five lower extremity amputations and two finger amputations in the control group.
The ADA Position Statement has discussed several measures that can be implemented for preventive foot care in diabetic patients.730 Foot examination at the initiation of dialysis is likely to reveal high-risk foot conditions, such as peripheral neuropathy, altered biomechanics, PVD, ulcers, and severe nail pathology. Identification of any of these risk factors may necessitate further regular examinations. Minor conditions may be treatable to prevent complications; however, other conditions (e.g., increased plantar pressure) may require referral to a foot-care specialist.
A major issue will be raising the awareness of preventive foot care in diabetic dialysis patients, and patient education in preventive foot care measures is desirable as part of routine care. Education of dialysis health-care professionals is also important.
Long-term studies are warranted to examine the effectiveness of screening with ABI, and early diagnosis of PVD, on reducing the development of critical limb ischemia and the rates of amputation. Randomized, controlled trials are needed to study the effects of antiplatelet agents and statins in asymptomatic and symptomatic PVD on the development of critical limb ischemia and the rates of amputation.
There are no randomized controlled trials of intensive education and care management versus usual care of feet in diabetic dialysis patients. Nonetheless, diabetic dialysis patients are likely to benefit from examination of the foot as part of the routine dialysis care. In this regard, recommendations made by the ADA are applicable to the care of diabetic dialysis patients.
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