Limb Amputation in Indigenous
Australians on Renal Dialysis
Dr Rajit Gilhotra
RMO, The Royal Brisbane Hospital
Diabetes
• 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)
)
(1
Mellitus
Diabetic Foot Syndrome (DFS)(2,3)
Diabetic
neuropathy
Peripheral
vascular
disease
(PVD)
Amputation
Ischemia
prevails
End-Stage Renal Failure (ESRF)
DM
PVD (6-10)
Non-healing ulcers
LLAs
(4,5)
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
ESRF and LLAs worldwide
Study
Country
Total cases
Prevalence
DM pts
amputated
Non-DM pts
amputated
Speckman
et al, 2004
USA
3272 HD
4%
6%
1%
LockingCustolito et
al, 2005
Canada
232 HD
13.4%
26.53%
3.73%
Reddy et al,
2007
USA
271 HD
13%
-
-
Combe et al, Multinationa 29838 HD
2009
l
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
13%
HD, 274 PD)
-
-
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)
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)
Aim
1. 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.
Study details
Population
• All patients attending
TTH or Northward
Dialysis Centre
• 219 patient
Size
Inclusion
Exclusion
Age>18
Traumatic
Amputations
HD or PD
Neoplastic
Amputations
Dialysis for at
least 1 month
DM or nonDM
Ethics
• Townsville HREC, SSA, PHA
• JCU external ethics
One off
dialysis
Data
Collection
Demographics
Clinical
History
Biochemical
Auslab
Patient Charts
Excel sheet
Data analysis
Descriptive analysis
IBM SPSS Statistics
22 software
Univariate analysis
- Pearson’s chi
squared
p<0.05 (Statistically - Student’s t test
significant)
- Mann-Whitney U
test
Multivariate analysis
- Binary logistic
regression
Results – patient characteristics
Characteristics
N (%)
Characteristics
N (%)
n
219
Retinopathy
64 (29.2%)
Age (yr)
60.73 (14.48)
Neuropathy
61 (27.9%)
Male
109 (49.8%)
Foot deformity
11 (5%)
Indigenous
114 (52.1%)
IHD
109 (49.8%)
HD
160 (73.1%)
CVA
35 (16%)
DM
Type I
143 (65.3%)
5 (2.3%)
HPTN
204 (93.2%)
Ulceration
54 (24.7%)
Dyslipidaemia
168 (76.7%)
PVD
68 (31.1%)
Amputation
30 (13.7%)
Aim 1: Prevalence of Amputations 30/219 = 13.7%
Characteristics
N=30
N (%)
Characteristics
N (%)
Male
17 (56.7%)
IHD
18 (60%)
Indigenous
23 (76.7%)
Diabetic nephropathy as
cause of ESRF
24 (80%)
CVA
6 (20%)
DM
Type 1
30 (100%)
1 (3.3%)
PVD
27 (90%)
HD
24 (80%)
Retinopathy
19 (63.3%)
Major amputation (AKA,
BKA, TKA)
Previous multiple minor
amputations
9 (30%)
Neuropathy
24 (80%)
3 (33.33%)
Foot deformity
8 (26.7%)
HPTN
28 (93.3%)
Ulceration
Neuro-ischaemic ulcers
27 (90%)
12 (40%)
Dyslipidemia
27 (90%)
Indigenous vs non-Indigenous
Indigenous
20%
Non-Indigenous
7%
Amputated
nonAmputated
80%
93%
Amputees Indigenous vs non-Indigenous
120
100
80
%
60
40
20
0
non-Indigenous
Indigenous
Aim 2: Demographics and comorbidities
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
Indigenous
background
OR 3.39 [1.380.01
– 8.33] p=0.01
3.39 [1.38 – 8.33]
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
Logistic regression for risk of LLAs
B
S.E.
Wald
df
Sig.
95% C.I.for EXP(B)
Exp(B) Lower Upper
Ulceration
2.518
.876
8.271
1
.004 12.408
2.230 69.036
PVD
2.005
.865
5.380
1
.020
7.429
1.364 40.449
Retinopathy
.616
.642
.921
1
.337
1.852
.526
Neuropathy
.971
.727
1.783
1
.182
2.641
.635 10.991
Foot 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
-1.615
1.030
2.457
1
.117
.199
Constant
1.3
6.515
19.23
Aim 3: Biochemical risk factors
Mean five year Vitamin D
levels
Mean five year Albumin
levels
Student’s t test*
Student’s t test**
*p<0.05, **p<0.01, ***p<0.0001
Mean five year Haemoglobin
levels
Median five year C-reactive
protein levels
Student’s t test*
Mann-Whitney U test**
*p<0.05, **p<0.01, ***p<0.0001
Median five year HbA1c levels
Mann-Whitney U test**
*p<0.05, **p<0.01, ***p<0.0001
Logistic regression for risk of LLAs
95% C.I.for EXP(B)
B
S.E.
Wald
df
Sig.
Exp(B)
Lower
Upper
Vitamin 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
13.926
8.552
2.652
1
.103 1117069.315
Constant
Conclusion
1. Prevalence of Amputations 13.7%
2. Comorbidities and biochemical factors that
play major role in development of
Amputations:
a. Indigenous
background
b. Ulceration
c. Foot deformity
d. PVD
a. Low serum
Albumin
(inflammation/poo
r nutrition)
b. High HbA1c (poor
diabetic control)
Over-representation of the
Indigenous population
Townsville population
Townsville Dialysis Centre
TTH amputations
6%
23%
48%
52%
94%
Indigenous
77%
non-Indigenous
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)
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.
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
Thankyou! Questions?
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