Addressing Diabetes Complications to Help Reduce Amputations

Adapted from the DaVita Clinical Education and Training Team’s continuing education offering, Taking the Amputations Out of Diabetes, by Donna Swartzendruber, MSN, RN, CNN.

Anyone who works in dialysis knows diabetes can be a vicious disease. Vascular damage related to elevated blood glucose levels frequently causes retinopathy and neuropathy in patients with diabetes, putting them at a high risk for foot problems.  These include dry skin that can easily crack and lead to infections, calluses that can develop into ulcers, peripheral artery disease with poor circulation and an increased risk for foot or leg amputations. In 2010, approximately 73,000 non-traumatic lower-limb amputations were performed in adults aged 20 years or older with diagnosed diabetes. Approximately 60 percent of non-traumatic lower-limb amputations among people aged 20 years or older occur in people with diagnosed diabetes.

Fortunately, there are steps that a care team can take to help reduce amputation risk. Study after study has shown that continuous monitoring and ongoing patient education can do much to decrease the risk of amputation. The following list covers foot and limb complications that can result from diabetes, and actions that care teams can take to help prevent or manage the concern—with the ultimate goal to help to limit hospitalizations and amputations.

1. Limited sight and/or sensation of pain

• Be their eyes—examine their feet at least monthly
• Assure patients have had an eye exam in the past year
• Provide patient with basic self-care foot education

2. Neuropathy

• Again, be their eyes
• Consider a vasodilator (e.g., ACE inhibitors or α1-antagonists) to diminish the vasoconstriction seen with neuropathy, which can help increase the blood flow to the involved nerves and thereby improve nerve conduction
• Prevent or manage hypertension, obesity and smoking, which tend to worsen neuropathy

3. Poor serum glucose control

• Provide the patient with serum glucose self-monitoring education
• Evaluate need for glucometer and supplies
• If determined that no MD is managing the diabetes, refer the patient for a visit with primary care physician and/or endocrinologist based on patient and physician choice

Note: Studies show that for every percentage point drop in hemoglobin A1c blood test results, the risk of microvascular complications—such as eye, kidney and nerve diseases—are decreased by 40 percent.

4. Peripheral venous disease (PVD)

• Be their eyes—check their legs for:
  • Sores that are not healing
  • Changes in color (blueness or paleness)
  • Skin that is shiny
  • Coolness in temperature when compared to the other leg
• Manage cholesterol (high levels are linked with PVD)
• Work with patients to maintain a healthy weight and avoid smoking

5. Foot ulcer

• Be their eyes—look for new difficulties with walking, drainage on stocking or stocking adhering to the foot
• Surgically debride ulcer to remove:
  • Necrotic tissue
  • Peri-wound callus
  • Foreign bodies (remove down to viable tissue)
• Practice offloading affected foot
• Address the conditions that led to the ulcer
• Control and treat infections

Note: Foot ulcers related to diabetes often become infected and require hospital admissions. They account for more than 50 percent of non-traumatic lower limb amputations in diabetics.

6. Charcot foot

• Be their eyes—look for redness, swelling, warmth within the foot or an inability to fit a foot into a shoe
• Recommend use of a protective cast and offloading affected foot

7. Gangrene

• Be their eyes—look for a reddened skin color that eventually turns brown, then blackened and withered.
• Debride surgically
• Prevent infection (or if infection is already present, prevent it spreading)
• Address the conditions that led to gangrene

In addition, a care team should work with patients to control their blood glucose levels, blood pressure and cholesterol. They should also educate patients on proper foot etiquette (i.e., checking feet regularly, avoiding exposure to heating pads and encouraging good blood flow with exercises throughout the day) and the importance of not smoking, as smoking reduces blood flow to the feet.