SaO010
STANDARDIZED CLINICAL FOOT EXAMINATION IN PREVALENT DIABETIC HEMODIALYSIS PATIENTS - A EUROPEAN MULTICENTER ANALYSIS

INTRODUCTION AND AIMS: There is an increased risk for patients with diabetes to develop foot complications caused by diabetic neuropathy, peripheral artery disease (PAD) and microvascular problems. The same applies to patients on hemodialysis, adding uremic neuropathy and secondary hyperparathyroidism. Diabetic patients on hemodialysis have an increased risk for diabetic foot ulcers (FU), infections and limb amputation. Pain and other symptoms are often reduced due to neuropathy resulting in late diagnosis. The aim of this study was to analyze the frequency of foot complications following implementation of a standardized foot examination in a large cohort of prevalent diabetic hemodialysis patients in 26 DaVita centers in Germany (n=14), Poland (n=8) and Portugal (n=4). We analyzed differences and associations with demographic data, practices and laboratory data.

METHODS: A standardized foot examination was performed in 1025 prevalent diabetic hemodialysis patients in Germany (n=674), Poland (n=179) and Portugal (n=172). The protocol includes: history of the patient (previous FU, amputation etc.), inspection of feet (skin, nails), examination of the pedal pulses (a dorsalis pedis and tibialis posterior) and examination of foot sensory level using monofilament and tuning fork. Foot complications were classified according to Wagner (grade 0-5) and PAD was classified by clinical pulse measurement (normal =0, weak =1, missing=2).

RESULTS: The mean age in all patients was 70.4 (14 SD) yrs, with no statistical difference between countries. 8.7% of all patients had a previous amputation, being less common in patients in Germany (p<0.001). A normal pulse in left and right a dorsalis pedis was present in 45% and 44% respectively and absence of corresponding pulses were observed in 33% and 34% of patients, with significant differences between countries (p<0.001 and p<0.001 respectively). For left and right a tibialis posterior the corresponding figures are 37% and 37% for normal pulse and 43% and 42% for absence of pulse (p<0.001 between countries for both comparisons). The Wagner classification score was 0 or 1 in 95.5% of patients and 4-5 in 1.8% (NS between countries). In a subgroup of 351 pts from Poland and Portugal there were no significant correlations between the Wagner classification score and age, sex, BMI, Kt/V, vascular access, Charlson comorbidity index, Hb, s-Albumin, P and PTH. Patients with skin oedema were older (p<0.05), had higher Charlson comorbidity index (p<0.05), lower Hb (p<0.05), lower albumin (p=0.01) and higher P (p=0.004).

CONCLUSIONS: Implementation of a standardized foot examination protocol in a large cohort of European diabetic patients on hemodialysis showed a high prevalence of clinically significant complications that warrant close attention. This simple clinical tool is suitable to identify patients at high risk and could be the basis of a program to improve overall health outcomes.