limb amputation in indigenous australians on renal dialysis dr rajit gilhotra rmo, the royal...
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Limb Amputation in Indigenous Australians on Renal Dialysis
Dr Rajit GilhotraRMO, The Royal Brisbane Hospital
Diabetes Mellitus(1)
• Diabetes Mellitus (DM)– 7.4% of the adult Australian
population
– Leading cause of End Stage Renal Failure (ESRF), blindness, Lower Limb Amputations (LLA) and cardiovascular disease (CVD)
Diabetic Foot Syndrome (DFS)(2,3)
Diabetic neuropathy
Peripheral vascular disease (PVD)
Ischemia prevails
Amputation
End-Stage Renal Failure (ESRF) (4,5)
PVD (6-10)
Non-healing ulcers
LLAs
DM
Dialysis therapy and foot complications(10-12)
– Increased risk of foot ulcers
– Amputation is a frequent event
– Inconsistent data regarding role of ethnic background
Risk further increased with concurrent DM
ESRF and LLAs worldwideStudy Country Total cases Prevalence DM pts
amputatedNon-DM pts amputated
Speckman et al, 2004
USA 3272 HD 4% 6% 1%
Locking-Custolito et al, 2005
Canada 232 HD 13.4% 26.53% 3.73%
Reddy et al, 2007
USA 271 HD 13% - -
Combe et al, 2009
Multinational
29838 HD 6% 14.2% 1.6%
Ishii et al, 2012
Japan 1513 HD 1.72% 2.8% 0.6%
Plantinga et al, 2009
USA 1041 (767 HD, 274 PD)
13% - -
Australian data
• CVD: Indigenous population > non-Indigenous (13)
• Major diabetic amputations:Indigenous population 38x > non-Indigenous (14)
• Limited data in patients with ESRF (10,15)
Impact of amputations
• 1 amputation every 3 hours!(16)
• $16, 700 per person per year.(1)
• Individual: poor QOL, unemployment, comorbidities, chronic pain, prosthesis, death (17,18)
Aim1. To determine prevalence of non-traumatic
Amputations in patients on dialysis and document differences between Indigenous and non-Indigenous patients.
2. To determine the association of comorbidities linked with Amputations.
3. To determine the biochemical risk factors associated with Amputations.
Study details
Population
• All patients attending TTH or Northward Dialysis Centre
Size• 219 patient
Ethics
• Townsville HREC, SSA, PHA• JCU external ethics
Inclusion Exclusion
Age>18 Traumatic Amputations
HD or PD Neoplastic Amputations
Dialysis for at least 1 month
DM or non-DM
One off dialysis
Data Collection
Demographics Clinical History Biochemical
Excel sheet
AuslabPatient Charts
Data analysis
Descriptive analysis
IBM SPSS Statistics 22 software
p<0.05 (Statistically significant)
Univariate analysis
- Pearson’s chi squared - Student’s t test- Mann-Whitney U test
Multivariate analysis
- Binary logistic regression
Results – patient characteristics
Characteristics N (%)
n 219
Age (yr) 60.73 (14.48)
Male 109 (49.8%)
Indigenous 114 (52.1%)
HD 160 (73.1%)
DM Type I
143 (65.3%)5 (2.3%)
Ulceration 54 (24.7%)
PVD 68 (31.1%)
Characteristics N (%)
Retinopathy 64 (29.2%)
Neuropathy 61 (27.9%)
Foot deformity 11 (5%)
IHD 109 (49.8%)
CVA 35 (16%)
HPTN 204 (93.2%)
Dyslipidaemia 168 (76.7%)
Amputation 30 (13.7%)
Aim 1: Prevalence of Amputations 30/219 = 13.7%
CharacteristicsN=30
N (%)
Male 17 (56.7%)
Indigenous 23 (76.7%)
Diabetic nephropathy as cause of ESRF
24 (80%)
DMType 1
30 (100%)1 (3.3%)
HD 24 (80%)
Major amputation (AKA, BKA, TKA)Previous multiple minor amputations
9 (30%)
3 (33.33%)
UlcerationNeuro-ischaemic ulcers
27 (90%)12 (40%)
Characteristics N (%)
IHD 18 (60%)
CVA 6 (20%)
PVD 27 (90%)
Retinopathy 19 (63.3%)
Neuropathy 24 (80%)
Foot deformity 8 (26.7%)
HPTN 28 (93.3%)
Dyslipidemia 27 (90%)
Indigenous vs non-Indigenous
20%
80%
Indigenous
Amputatednon-Amputated
7%
93%
Non-Indigenous
Amputees Indigenous vs non-Indigenous
Male HD
Ulcerati
onIH
DCVA
PVD
Retinopathy
Neuropath
y
Foot d
eformity
Dyslipidae
mia0
20
40
60
80
100
120
non-IndigenousIndigenous
%
Association OR [95% CI] Pearson’s Chi Squared with continuity correction
Ulceration 81 [18.201 - 360.478] <0.001
PVD 31.285 [9.016 - 108.556] <0.001
Neuropathy 19.719 [7.052 - 55.141] <0.001
Dyslipidemia 4.596 [1.053 – 20.052] 0.049
Indigenous 3.39 [1.38 – 8.33] 0.01
Male 1.298 [.592 – 2.846] 0.651
DM present 1.673 [1.488-1.88] <0.001
HD 1.494 [.576-3.874] 0.545
IHD 1.526 [.691-3.369] 0.395
CVA 1.439 [0.539-3.841] 0.647
Retinopathy 6.080 [2.636 – 14.023] <0.001
Foot deformity 23.619 [5.816 – 95.925] <0.001
HPTN 0.997 [0.213 – 4.665] 1
Aim 2: Demographics and comorbidities
Indigenous background OR 3.39 [1.38 – 8.33] p=0.01
Logistic regression for risk of LLAs
B S.E. Wald df Sig. Exp(B)95% C.I.for EXP(B)
Lower UpperUlceration 2.518 .876 8.271 1 .004 12.408 2.230 69.036PVD 2.005 .865 5.380 1 .020 7.429 1.364 40.449Retinopathy .616 .642 .921 1 .337 1.852 .526 6.515Neuropathy .971 .727 1.783 1 .182 2.641 .635 10.991Foot deformity 2.016 1.005 4.019 1 .045 7.507 1.046 53.863
Dyslipidemia 1.570 1.156 1.844 1 .175 4.808 .498 46.387
Indigenous 1.606 .685 5.490 1 .019 4.98 1.3 19.23
Constant -1.615 1.030 2.457 1 .117 .199
Mean five year Vitamin D levels
*p<0.05, **p<0.01, ***p<0.0001
Mean five year Albumin levels
Student’s t test* Student’s t test**
Aim 3: Biochemical risk factors
Mean five year Haemoglobin levels
Student’s t test*
*p<0.05, **p<0.01, ***p<0.0001
Mann-Whitney U test**
Median five year C-reactive protein levels
Median five year HbA1c levels
Mann-Whitney U test**
*p<0.05, **p<0.01, ***p<0.0001
Logistic regression for risk of LLAs
B S.E. Wald df Sig. Exp(B)
95% C.I.for EXP(B)
Lower UpperVitamin D -.024 .027 .794 1 .373 .976 .926 1.029
Albumin -.405 .186 4.735 1 .030 .667 .463 .961
C-reactive protein -.003 .015 .034 1 .853 .997 .969 1.026
Haemoglobin -.090 .067 1.775 1 .183 .914 .801 1.043
HbA1c 1.078 .397 7.365 1 .007 2.940 1.349 6.406
Constant13.926 8.552 2.652 1 .103 1117069.315
Conclusion1. Prevalence of Amputations 13.7%2. Comorbidities and biochemical factors that
play major role in development of Amputations:
a. Indigenous background
b. Ulcerationc. Foot deformityd. PVD
a. Low serum Albumin (inflammation/poor nutrition)
b. High HbA1c (poor diabetic control)
Over-representation of the Indigenous population
6%
94%
Townsville population
Indigenous non-Indigenous
52%48%
Townsville Dialysis Centre
77%
23%
TTH amputations
Interesting findings• Low Vitamin D amongst
patients with LLAs• Wound healing, T cell function, DFS,
PVD, LLAs(19,20,21)
• Low Haemoglobin amongst patient with LLAs• Anaemia found to be independent
risk factor for limb loss in PVD patients.(22)
Impact and relevance • Ability to easily identify at risk population early
– Improved quality of clinical care– Foot checks– Optimizing biochemistry– Reduce hospital and government costs– Improve QOL
• Further research:– Prospective studies into optimising biochemistry to prevent limb loss.– Effects of Vitamin D supplementation in PVD patients.
Acknowledgement
• A/Prof Usman Malabu, Department of Diabetes, TTH• Dr Venkat Vangaveti, James Cook University• Data collection:
• Dr George Kan, Department of Nephrology, TTH• Elizabeth Messer, Department of Diabetes, TTH• A/Prof David Porter, Department of Pathology, TTH
• Guidance:– Dr Kunwarjit S Sangla– Dr Joseph Moxon– Beverly Rodrigues– Dr Ross Smith – Dr Divyajeet Rai – Dr Seth Delpachitra– Dylan Morris – Cedric Hensman
Thankyou! Questions?
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