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Published online April 4, 2008
Diabetes Care 31:1331-1336, 2008
DOI: 10.2337/dc07-2244
© 2008 by the American Diabetes Association
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Epidemiology/Health Services Research
Original Research

Association Between Renal Failure and Foot Ulcer or Lower-Extremity Amputation in Patients With Diabetes

David J. Margolis, MD, PHD1,2, Ole Hofstad, MA2 and Harold I. Feldman, MD, MSCE2,3

1 Department of Dermatology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
2 Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
3 Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania

Corresponding author: David J. Margolis, margo{at}mail.med.upenn.edu

OBJECTIVE—The objective of this study was to evaluate the association between foot ulcers (DFU) and lower-extremity amputation (LEA) and chronic kidney disease (CKD) in patients with diabetes.

RESARCH DESIGN AND METHODS—This was a retrospective cohort study of individuals enrolled between 2002 and 2006 who were aged ≥35 years, had a history of diabetes, and were cared for in general practice. The physicians participated in The Health Information Network of the U.K.

RESULTS—The presence of DFU or LEA and estimated glomerular filtration rate (eGFR) were evaluated in 90,617 individuals with a median time of observation of 2.4 years. Of these individuals 378 had an LEA and 2,619 had a DFU. CKD (eGFR <60 ml/min per 1.73 m2) was noted in 23,350 (26%) individuals in our cohort. For the development of DFU compared with our reference group (group 1 [eGFR ≥60 ml/min per 1.73 m2]), the hazard ratio (HR) for group 2 (eGFR ≥30 and <60 ml/min per 1.73 m2) was 1.85 (95% CI 1.71–2.01) and for group 3 (eGFR <30 ml/min per 1.73 m2) was 3.92 (3.23–4.75) (all P < 0.001). For LEA, the HR for group 2 was 2.08 (1.68–2.58) and for group 3 was 7.71 (5.29–11.26) (all P < 0.001).

CONCLUSIONS—In this observational study, there is a strong association between stage of CKD and DFU or LEA that is probably not just related to the presence of peripheral arterial disease. Individuals with even moderate CKD (eGFR <60 ml/min per 1.73 m2) have an increased risk for DFU and LEA.


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