Diabetic foot ulceration as a marker of increased frailty

First, may I wish all our readers a very happy and fulfilling 2017. I would like to ask you all to try to raise awareness of diabetic foot disease and suffering this coming year.

My attention when scanning through some recently published papers was drawn to several, with one, in particular, that I felt it was important to highlight. 

When diabetic foot complications are raised and discussed, the marker that is most frequently highlighted is lower extremity amputations. Of course, these are devastating and every effort should be employed and sustained to help reduce the risk of them. However, mortality associated with diabetic foot ulcers is often left in the shadows.

A recent paper published in Diabetic Medicine by Walsh and colleagues (summarised alongside) examined mortality associated with diabetic foot ulceration (DFU). It was a population-based cohort study within the UK that analysed data from 414 523 people with diabetes enrolled in practices associated with The Health Improvement Network (THIN) in the UK. Data from coded activity were collected between 2003 and 2012 from GP practices. All participants were at least 25 years old and the study focused upon type 2 diabetes. The primary aim of this paper was to examine the relationship between DFUs and mortality. Within the population cohort, 20 373 (5%) developed a DFU. Mortality risk variables, including cardiovascular disease, myocardial infarction, cerebrovascular accident, peripheral arterial disease, chronic renal failure (stages 3–5) and the Charlson comorbidity index, were collected. Other factors evaluated included gender, age, history of smoking, malignancy, HbA_1c values and regional variations. Data were analysed using proportional hazard models, with death as the primary outcome and DFUs as the primary exposure. 

The mortality data showed that 8.1% of people with new ulcers died within 12 months and 42.2% died within 5 years. This is not very surprising given data from other published studies.

The authors hypothesised that when risk-factor variables were considered, the association between DFUs and death would diminish (i.e. resulting in a DFU hazard ratio approaching 1), as we have always assumed that mortality in DFU patients was due principally to existing comorbidities. However, when they did control for these variables, the correlation between DFUs and death was surprisingly still strong, with a fully adjusted hazard ratio of 2.48. These data are concerning, as they suggest that DFUs may be a significant independent mortality risk factor.

Furthermore, those with a DFU were three times more likely to die at any time compared to those with diabetes alone. Of further interest was the regional variation showing death rates in the first year of between 2.8% and 12.0%, with the highest clustering in a leg-shape up the western side of the UK. Could this suggest some environmental influence?

This is a fascinating paper worthy of reading. It clearly states that patients with DFUs are medically frail, with poorer prognoses than most cancer patients. Optimising medical care, unhindered access to specialist centres with more funded research and raising awareness of diabetic foot disease should be our goal.

To read the article summaries, please download the PDF