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Limb Amputation in Indigenous Australians on Renal Dialysis Dr Rajit Gilhotra RMO, The Royal Brisbane Hospital

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Page 1: Limb Amputation in Indigenous Australians on Renal Dialysis Dr Rajit Gilhotra RMO, The Royal Brisbane Hospital

Limb Amputation in Indigenous Australians on Renal Dialysis

Dr Rajit GilhotraRMO, The Royal Brisbane Hospital

Page 2: Limb Amputation in Indigenous Australians on Renal Dialysis Dr Rajit Gilhotra RMO, 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)

Page 3: Limb Amputation in Indigenous Australians on Renal Dialysis Dr Rajit Gilhotra RMO, The Royal Brisbane Hospital

Diabetic Foot Syndrome (DFS)(2,3)

Diabetic neuropathy

Peripheral vascular disease (PVD)

Ischemia prevails

Amputation

Page 4: Limb Amputation in Indigenous Australians on Renal Dialysis Dr Rajit Gilhotra RMO, The Royal Brisbane Hospital

End-Stage Renal Failure (ESRF) (4,5)

PVD (6-10)

Non-healing ulcers

LLAs

DM

Page 5: Limb Amputation in Indigenous Australians on Renal Dialysis Dr Rajit Gilhotra RMO, The Royal Brisbane Hospital

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

Page 6: Limb Amputation in Indigenous Australians on Renal Dialysis Dr Rajit Gilhotra RMO, The Royal Brisbane Hospital

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% - -

Page 7: Limb Amputation in Indigenous Australians on Renal Dialysis Dr Rajit Gilhotra RMO, The Royal Brisbane Hospital

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)

Page 8: Limb Amputation in Indigenous Australians on Renal Dialysis Dr Rajit Gilhotra RMO, The Royal Brisbane Hospital

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)

Page 9: Limb Amputation in Indigenous Australians on Renal Dialysis Dr Rajit Gilhotra RMO, The Royal Brisbane Hospital

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.

Page 10: Limb Amputation in Indigenous Australians on Renal Dialysis Dr Rajit Gilhotra RMO, The Royal Brisbane Hospital

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

Page 11: Limb Amputation in Indigenous Australians on Renal Dialysis Dr Rajit Gilhotra RMO, The Royal Brisbane Hospital

Data Collection

Demographics Clinical History Biochemical

Excel sheet

AuslabPatient Charts

Page 12: Limb Amputation in Indigenous Australians on Renal Dialysis Dr Rajit Gilhotra RMO, The Royal Brisbane Hospital

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

Page 13: Limb Amputation in Indigenous Australians on Renal Dialysis Dr Rajit Gilhotra RMO, The Royal Brisbane Hospital

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%)

Page 14: Limb Amputation in Indigenous Australians on Renal Dialysis Dr Rajit Gilhotra RMO, The Royal Brisbane Hospital

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%)

Page 15: Limb Amputation in Indigenous Australians on Renal Dialysis Dr Rajit Gilhotra RMO, The Royal Brisbane Hospital

Indigenous vs non-Indigenous

20%

80%

Indigenous

Amputatednon-Amputated

7%

93%

Non-Indigenous

Page 16: Limb Amputation in Indigenous Australians on Renal Dialysis Dr Rajit Gilhotra RMO, The Royal Brisbane Hospital

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

%

Page 17: Limb Amputation in Indigenous Australians on Renal Dialysis Dr Rajit Gilhotra RMO, The Royal Brisbane Hospital

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

Page 18: Limb Amputation in Indigenous Australians on Renal Dialysis Dr Rajit Gilhotra RMO, The Royal Brisbane Hospital

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

Page 19: Limb Amputation in Indigenous Australians on Renal Dialysis Dr Rajit Gilhotra RMO, The Royal Brisbane Hospital

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

Page 20: Limb Amputation in Indigenous Australians on Renal Dialysis Dr Rajit Gilhotra RMO, The Royal Brisbane Hospital

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

Page 21: Limb Amputation in Indigenous Australians on Renal Dialysis Dr Rajit Gilhotra RMO, The Royal Brisbane Hospital

Median five year HbA1c levels

Mann-Whitney U test**

*p<0.05, **p<0.01, ***p<0.0001

Page 22: Limb Amputation in Indigenous Australians on Renal Dialysis Dr Rajit Gilhotra RMO, The Royal Brisbane Hospital

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

Page 23: Limb Amputation in Indigenous Australians on Renal Dialysis Dr Rajit Gilhotra RMO, The Royal Brisbane Hospital

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)

Page 24: Limb Amputation in Indigenous Australians on Renal Dialysis Dr Rajit Gilhotra RMO, The Royal Brisbane Hospital

Over-representation of the Indigenous population

6%

94%

Townsville population

Indigenous non-Indigenous

52%48%

Townsville Dialysis Centre

77%

23%

TTH amputations

Page 25: Limb Amputation in Indigenous Australians on Renal Dialysis Dr Rajit Gilhotra RMO, The Royal Brisbane Hospital

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)

Page 26: Limb Amputation in Indigenous Australians on Renal Dialysis Dr Rajit Gilhotra RMO, The Royal Brisbane Hospital

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.

Page 27: Limb Amputation in Indigenous Australians on Renal Dialysis Dr Rajit Gilhotra RMO, The Royal Brisbane Hospital

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

Page 28: Limb Amputation in Indigenous Australians on Renal Dialysis Dr Rajit Gilhotra RMO, The Royal Brisbane Hospital

Thankyou! Questions?

Page 29: Limb Amputation in Indigenous Australians on Renal Dialysis Dr Rajit Gilhotra RMO, The Royal Brisbane Hospital

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