Prevalence and risk factors of lower limb amputation in patients with end-stage renal failure on dialysis: a systematic review

Background: Renal dialysis has recently been recognised as a risk factor for lower limb amputation (LLA). However, exact rates and associated risk factors for the LLA are incompletely understood. Aim: Prevalence and risk factors of LLA in end-stage renal failure (ESRF) subjects on renal dialysis were investigated from the existing literature. Methods: Published data on the subject were derived from MEDLINE, PubMed, and Google Scholar search of English language literature from January 1, 1980, to July 31, 2015, using designated key words. Results: Seventy studies were identified out of which 6 full-text published studies were included in this systematic review of which 5 included patients on haemodialysis alone and one included patients on both haemodialysis and peritoneal dialysis. The reported findings on prevalence of amputation in the renal failure on dialysis cohort ranged from 1.7% to 13.4%. Five out of the six studies identified diabetes as the leading risk factor for amputation in subjects with ESRF on renal dialysis. Other risk factors identified were high haemoglobin A1c, elevated c-reactive protein, and low serum albumin. Conclusions: This review demonstrates high rate of LLA in ESRF patients receiving dialysis therapy. It has also identified diabetes and markers of inflammation as risk factors of amputation in ESRF subjects on dialysis

Worldwide prevalence of lower limb amputation in renal dialysis patients: a systematic review \ud

Background/Aims: Renal dialysis has recently been identified as a risk factor for lower limb amputation (LLA) however, exact rates are not known. \ud \ud Methods: A systematic review of existing literature investigating the prevalence of LLA in subjects that had end-stage renal failure (ESRF) and were on renal dialysis was conducted. A systematic literature search using the MeSH terms 'diabetes' AND 'amputations' AND 'renal dialysis' was conducted in PUBMED, Medline, Cochrane reviews and Google Scholar database for full text articles published in English from July 2003 to July 2013. \ud \ud Results: A total of 6 full text published studies conducted worldwide were included in this systematic review, 5 of which included patients on haemodialysis alone and one on both haemodialysis and peritoneal dialysis. The reported findings on prevalence of amputations in the renal failure cohort varied from 1.72% in Japan to 13.4% in Canada. Five out of the 6 studies identified presence of diabetes mellitus as the leading risk factor for amputation (p<0.05) in renal dialysis patients. Other risk factors identified were: high HbA1c, high c-reactive protein and low serum albumin. \ud \ud Conclusions: This review demonstrates high prevalence of LLAs in patients with ESRF receiving dialysis therapy. It has also identified the closely associated risk factors with the adverse outcome of amputation, the most important one being the presence of diabetes mellitus

Prevalence and risk factors of lower limb amputation amongst diabetic foot ulcer patients at the Townsville Hospital

Background/Aims: Diabetic foot ulcers (DFUs) are common amongst diabetic patients, occurring at a lifetime incidence of up to 15%. Lower limb amputation (LLA) is considered a frequent outcome, yet there is no local literature on the rates of LLA amongst DFUs patients in the diabetic population of North Queensland. The aim of this study is to find the prevalence of and risk factors for LLAs amongst DFU patients.\ud \ud Methods: A retrospective pilot study was conducted on patients attending The Townsville Hospital High Risk Foot Clinic (HRFC) between 2010- 2012. Non-parametric analysis and Chi-Square tests were performed using SPSS 20 to identify strongly associated variables with amputation.\ud \ud Results: A total of 106 subjects presented with a DFU at the HRFC during the study period, out of which (n= 43; 41%) underwent a LLA, with a male: female ratio of 1.7:1. The Indigenous subgroup comprised (n= 10; 23%) of the cohort. The mean age of amputation was 69.20 + 11.78 years, with no significant difference between the Indigenous and non-Indigenous cohorts. Diabetic retinopathy (OR 4.13 [95% CI 1.772-9.628] P = 0.001) and past history of coronary artery bypass graft surgery (CABG) (OR 4.0 [95% CI 1.094-14.624] P = 0.028) were factors strongly associated with amputation. Other variables that showed positive associations but fell short of statistical significance included Indigenous background, and history of hypertension, peripheral neuropathy and nephropathy. \ud \ud Conclusions: LLAs occurred in almost half of the DFU cohort at the HRFC, and were found to be closely linked with a history retinopathy and CABG surgery, however further prospective studies are required to confirm our findings

Prevalence and Risk Factors of Lower Limb Amputation in Patients with End-Stage Renal Failure on Dialysis: A Systematic Review

Background. Renal dialysis has recently been recognised as a risk factor for lower limb amputation (LLA). However, exact rates and associated risk factors for the LLA are incompletely understood. Aim. Prevalence and risk factors of LLA in end-stage renal failure (ESRF) subjects on renal dialysis were investigated from the existing literature. Methods. Published data on the subject were derived from MEDLINE, PubMed, and Google Scholar search of English language literature from January 1, 1980, to July 31, 2015, using designated key words. Results. Seventy studies were identified out of which 6 full-text published studies were included in this systematic review of which 5 included patients on haemodialysis alone and one included patients on both haemodialysis and peritoneal dialysis. The reported findings on prevalence of amputation in the renal failure on dialysis cohort ranged from 1.7% to 13.4%. Five out of the six studies identified diabetes as the leading risk factor for amputation in subjects with ESRF on renal dialysis. Other risk factors identified were high haemoglobin A1c, elevated c-reactive protein, and low serum albumin. Conclusions. This review demonstrates high rate of LLA in ESRF patients receiving dialysis therapy. It has also identified diabetes and markers of inflammation as risk factors of amputation in ESRF subjects on dialysis

Pattern of hyperprolactinemia in North Queensland: the Townsville Hospital Experience

Background/Aims: Hyperprolactinaemia is a common endocrine disorder of the hypothalamic-pituitary axis. Its etiology and clinical presentation varies widely, with few studies on this condition reported in Australia, and no available data in North Queensland. The aim of this study is to determine clinical presentation and management options in patients with hyperprolactinemia at The Townsville Hospital (TTH).\ud \ud Methods: Medical records of all patients with diagnosed hyperprolactinaemia attending the Endocrinology Clinic at TTH between 2003 and 2013 were retrospectively audited, using outpatient clinic letters. Data analysis evaluated patient demographic data, presenting symptoms, etiology, imaging studies and treatment regimens.\ud \ud Results: A total of 153 patients were reviewed with male: female ratio of 1:3. Mean age at diagnosis was 39 + 14.36 years. Menorrhagia was the commonest presenting symptom amongst females (n = 44; 38%), followed by galactorrhea amongst the entire cohort (n=33; 36%). Pituitary adenoma was most of the attributed cause of hyperprolactinaemia (n=92; 60%), 26 being male (28%) and 66 (72%) being female. All patients had magnetic resonant imaging of the pituitary which revealed adenoma in 98% of cases. Medical therapy with dopamine agonist was most prevalent (n= 55; 60%) followed by surgery (n=19; 21%), with (n=7; 8%) of patients received both surgical and medical therapies.\ud \ud Conclusion: Prolactinomas constitute a common presentation of hyperprolactinaemia. This audit reflects the prevalence of this condition at TTH Endocrine clinics. Interestingly, galactorrhea was the commonest clinical presenting symptom amongst both sexes. In line with other reports, hyperprolactinaemia was treated with dopamine agonists as preferred primary therapy in majority of the cohort.\u

Prevalence and risk factors for non-traumatic amputation of lower limbs in subjects with end-stage renal failure on hemodialysis in north Queensland

BACKGROUND: Data from Northern Queensland have shown high rate of diabetes and end stage renal failure (ESRF) 1; both conditions are known to lead to limb amputation2. In spite of these no study has been published that analyses the magnitude and risk factors for amputation in the sub-population.\ud \ud OBJECTIVES: The aims of the study was to document prevalence and identify risk factors of non-traumatic lower limb amputations in subjects treated with renal dialysis for chronic renal failure in North Queensland.\ud \ud METHODS: All subjects diagnosed to have ESRF who attended the Townsville Regional Hospital Dialysis Centre from 01/01/2008 till date, were retrospectively studied. Odds ratio and χ2 tests were performed to identify variables most strongly associated with amputation.\ud \ud RESULTS: We identified 8.8% prevalence of lower limb amputation in 114 subjects with ESRF on dialysis at our centre. The major risk factors of amputations in the cohort were indigenous background (Odds Ratio 0.2 [95% CI 0.03-1.2] P=0.007) and the presence of diabetes (Odds Ratio 1.9 [95% CI 1.62-2.3] P=0.003). Other variables were tested but fell short of statistical significance, these include: smoking history, gender and type of renal dialysis.\ud \ud CONCLUSION: Indigenous Australians with diabetes mellitus on renal dialysis are at risk of having lower limb amputations. Primary prevention of diabetes in the sub-population may help in reducing the limb loss. Further prospective studies on a larger population are needed to confirm our findings

Review of amputations in patients with end-stage renal failure on haemodialysis at the Townsville Hospital

Background / Aims: High rates of end stage renal failure (ESRF) have been reported in North Queensland. Furthermore haemodialysis has recently been identified as a risk factor for lower limb amputations. In spite of these no study has been published that analyses the magnitude and risk factors for amputation amongst haemodialysis patients. This study aims to document trends in prevalence and identify risk factors of non-traumatic lower limb amputations in subjects treated with haemodialysis in North Queensland.\ud \ud Methods: 102 current haemodialysis patients attending the Townsville Dialysis Centre were included in the study. Odds ratio and #967;2 tests were performed to identify variables most strongly associated with amputation.\ud \ud Results: We identified a 6.9% prevalence of lower limb amputation in 102 subjects on haemodialysis at our centre. The major risk factors of amputations in the cohort were history of ulceration (RR 4.57 [95%Cl 2.4-8.8] p=0.001) and the presence of diabetes (RR 2.5 [95%Cl 1.6-3.9] p=0.008). Other variables were tested but fell short of statistical significance, these included: Indigenous background, smoking history, gender and type of ulceration.\ud \ud Conclusion: Patients with ESRF on haemodialysis who have a past history of ulceration and have diabetes mellitus are at risk of having lower limb amputations. Primary prevention of diabetes in the sub-population may help in reducing the limb loss. Further prospective studies on a larger population are needed to confirm our findings

High rate of limb amputation in subjects on renal dialysis: is there a difference between haemodialysis and peritoneal dialysis?

Background/Aims: High rate of end stage renal failure (ESRF) requiring renal dialysis have been reported in North Queensland. Recent reports have identified dialysis as a risk factor for lower limb amputations but no study that has been done which compares the two modalities of dialysis therapy, namely, haemodialysis (HD) and peritoneal dialysis (PD). The aim of this study is to document differences between HD & PD as a risk factor of non-traumatic limb amputation in North Queensland.\ud \ud Methods: All patients currently attending the Townsville dialysis centre were included in this study. Odds ratio and χ2 tests were performed to identify variables most strongly associated with amputation.\ud \ud Results: We had a total of 219 patients (160 HD, 59 PD) attending the service. We identified higher prevalence of amputation amongst subjects on HD as compared to PD, 15% vs 10.2% (χ2 analysis showed significant association). All subjects in both groups had lower limb amputations except one in the HD group who had an upper limb amputation. \ud \ud Conclusion: We have shown PD might prove to be a safer option compared to HD for subjects with ESRF at risk of limb amputation. Further prospective studies on a larger population are needed to confirm our findings.\u

Pattern of major lower limb amputations at the Townsville Hospital: a retrospective review

Background / Aims: North Queensland has a high prevalence of diabetes and vascular disease, particularly amongst the Indigenous population. Both are believed to contribute to lower limb amputations (LLAs), yet no local study has been conducted looking into possible contributing factors and clinical features leading to amputation. This study aimed to determine the prevalence of major LLAs and their associated risk factors at the Townsville Hospital between the years 2009 to 2012.\ud \ud Methods: All major amputations done under vascular surgery at Townsville Hospital from 1/1/2009 to 31/12/2012 were retrospectively audited. Non-parametric analysis and Chi-Square tests were performed using SPSS 20 to identify strongly associated variables with amputation.\ud \ud Results: A total of 83 subjects had major LLAs during the period of the study, with a male: female ratio of 1.8:1. Diabetes was identified as the likely cause of LLA in 53% of patients, with the ATSI subgroup comprising 34% of the cohort. The mean age of amputation was significantly lower amongst the ATSI population (49.95 + 4.0 years), compared with non-ATSI (69.27 + 1.7 years) [P < 0.001]. The ATSI population with diabetes had a higher risk of getting amputated (RR 4.97 [95% CI 1.2-20.5] P = 0.01). When comparing previous endovascular intervention prior to amputation amongst patients, 38.5% of ATSI patients had previous intervention compared with 73% in the non-ATSI [P = 0.03].\ud \ud Conclusion: Younger ATSI subjects with diabetes were at higher risk of LLA compared to their Caucasian counterparts, however further prospective studies are needed to confirm our findings

Limb amputation in Indigenous Australians on renal dialysis: the Townsville Hospital experience

Background/Aims: North Queensland has high prevalence of diabetes, vascular disease and end stage renal failure (ESRF) requiring renal dialysis, particularly amongst the Indigenous Australians. Recent reports have identified dialysis as a risk factor for lower limb amputations but no study has been done to explore the differences in Indigenous Australians and the general population. The aim of this study was to document differences between Indigenous Australians and the general population for risk factor of non-traumatic limb amputation in North Queensland.\ud \ud Methods: All patients currently attending The Townsville dialysis centre were included in this study. Odds ratio and χ2 tests were performed to identify variables most strongly associated with amputation.\ud \ud Results: We had a total of 219 patients (114 Indigenous Australians) attending the service. We identified an overall prevalence of limb amputation of 13.7% in patients on renal dialysis (19.3% amongst Indigenous Australians on renal dialysis). Indigenous Australians were found to have a higher susceptibility to amputations (RR1.58 [1.27-1.98] p=0.005). The major risk factors of amputations in the overall cohort were history of ulceration (OR 81 [18-360.44] p<0.001) and presence of diabetes (OR 41 [2.5-682.6] p=0.009). \ud \ud Conclusion: Indigenous Australians with ESRF on dialysis who have a past history of ulceration and have diabetes mellitus are at higher risk of having amputations compared with non-Indigenous Australians. Primary prevention of diabetes in the sub-population may help in reducing the limb loss. Further prospective studies on a larger population are needed to confirm our findings.\u