Assessment of risk factors in diabetic foot ulceration and their impact on the outcome of the disease

Abstract

Aims

The current study aims to identify risk factors for diabetic foot ulcer and their impact on the outcome of the disease.

Methods

Three hundred diabetic patients were enrolled in the study. One hundred eighty subjects with diabetic foot ulcer and 120 diabetic controls without foot lesions. All expected risk factors were studied in all patients and after a follow up period, patients with diabetic foot ulcer were classified into group A (patients with healed ulcers) and group B (patients with persistent ulcer or ended by amputation). The risk factors were reanalyzed in both groups to find out their impact on the outcome of the disease.

Results

The following variables were significant factors for foot ulceration: Male gender (P = 0.009), previous foot ulcer (P = 0.003), peripheral vascular disease (P = 0.004), and peripheral neuropathy (P = 0.006). Also lack of frequent foot self-examination was independently related to foot ulcer risk. The outcome was related to longer diabetes duration (P = 0.004), poor glycaemic control (P = 0.006) and anaemia (P = 0.003) and presence of infection (P < 0.001).

Conclusions

Peripheral vascular disease and peripheral neuropathy together with lack of foot self-examination, poor glycaemic control and anaemia are main significant risk factors for diabetic foot ulceration.

Introduction

Diabetes mellitus is a major cause of morbidity and mortality; it is often referred to as a silent killer because it annually contributes to approximately 18% of all deaths among patients who are age 25 and older. The prevalence of diabetes mellitus worldwide has increased dramatically during the past few decades, and it is expected to increase even more in the future [1], [2], [3]. It is now considered the fourth or fifth leading cause of death in most developed countries, with about 194 million people suffering from the disease worldwide, its incidence is approaching the epidemic proportions [4].

Further, the prevalence of disease complications is two to four times higher among adults with diabetes than among adults without it [2]. These complications can be prevented or delayed with optimal health care and improved preventive care practices [2], [5]. However, the clinical care received by many persons with diabetes and their preventive care practices are suboptimal [6], [7].

Foot ulceration is one of the most serious and costly complications of diabetes worldwide. The prevalence of diabetic foot ulcers has been estimated to be 3–8% [8]. Further, the lifetime risk of a person with diabetes for developing a foot ulcer is estimated at 15–25% [9], [10], [11]. In recent years, major progress has been in the recognition of the problem and in the understanding and management of the disease. Foot ulcerations usually result from the interpretations of many factors including neuropathy, bone affection and peripheral angiopathy [12]. The prevention of foot disease relies on the identification of high-risk patients and avoidance of triggering events, such as ill-fitting shoes, smoking, walking barefoot or poor self-care [13].

The worst and most feared outcome of diabetic foot ulcers is lower limb amputation [14]. Diabetes continues to be the leading cause of lower limb amputation worldwide. The WHO has estimated that there is approximately 250,000 lower limb amputation per year in diabetic patients in Europe alone [15]. A foot ulcer precedes and is responsible for 85% of these amputations [16], [17], [18]. 15–27% of all foot ulcers result in surgical removal of bone. In addition to radically affecting the quality of life of the patient; this represents a major problem economically for health care systems [19], [20], [21], [22], [23].

Several studies suggest that amputations can be reduced by 40–85% when high-risk patients are identified and provided with a multispecialty treatment approach that focuses on preventive strategies [24], [25]. So, identification of patients at risk of foot ulceration is of paramount importance. Many efforts have been initiated to find out these factors which are implicated in the development and persistence of diabetic foot ulcer. Avoidance of these risk factors will help in establishment of efficacious treatments and preventive care measures. It is therefore of interest to investigate these factors and their impact on the disease [26].