Diabetes, established renal failure and the risk to the lower limb

Abstract

Abstract The aim of this article is to review the extent of the association between established renal failure, foot ulcers, gangrene and amputation in diabetes, and to consider the possible mechanisms and clinical implications. In order to do this we used our personal knowledge of the literature, supplemented by searches of Medline and PubMed using appropriate key words. The available literature confirms the close association between established renal failure, peripheral vascular disease, foot ulcers, gangrene and amputation, and indicates that this association is between three and five times greater in diabetes. Once they occur, foot complications are associated with a high mortality. There are multiple possible mechanisms underlying the association, and these include those leading to accelerated peripheral arterial disease, as well as the anaemia and metabolic features of renal failure. There is also evidence that the process of dialysis is itself associated with worsening tissue hypoxia. The results of lower limb revascularisation in established renal failure are poor. We conclude that there is a need for further detailed studies into the factors leading to this association, as well as into the effectiveness of potential interventions. The place of pre‐emptive vascular intervention needs to be established. In the meantime, all those responsible for the management of impending and established renal failure in diabetes should remain aware of the possibility of foot disease and should ensure that a structured programme of preventive foot care is implemented. Copyright © 2006 John Wiley & Sons, Ltd.