Comparison of the risk of non‐traumatic lower extremity amputation between haemodialysis and peritoneal dialysis patients with end‐stage renal disease

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Amputation of limbs is indicated in patients with failed revascularization, comorbidity or anatomic factors precluding revascularization, and extensive tissue loss or infection.1 The Dialysis Outcomes and Practice Patterns Study reported that patients with haemodialysis (HD) are at an increased risk of amputation with an incidence of 2 per 100 person‐years.2 Dialysis patients, especially with diabetes, are at a high risk for non‐traumatic lower‐extremity amputation.2 In an earlier study, Eggers et al. found a 10‐fold higher incidence of non‐traumatic amputation in patients with diabetes and end‐stage renal disease (ESRD) than in non‐ESRD diabetic patients.3 Amputation in these patients is associated with impaired mobility and quality of life, and increased morbidity and mortality.2 The risk of death is 1.5‐fold greater in HD patients undergoing amputation than those without amputation with a median survival time of 2.0 versus 3.8 years.2
Dialysis patients with loss of protective sensation due to neuropathy are susceptible to neuropathic ulceration because of repetitive stress or trauma.7 In addition, peripheral artery occlusive disease (PAOD) is common in dialysis patients with a prevalence of 20–25%.8 Dialysis patients are also more prone to infection because of altered host defense.11 Neuropathy, PAOD and increased susceptibility to infection with impaired wound healing are involved in the pathogenesis of amputation in dialysis patients.12
Treatment outcomes in patients with end‐stage renal disease (ESRD) vary by the modality of renal replacement therapy.14 HD is characterized by rapid ultrafiltration and fluctuation of fluid and electrolytes leading to haemodynamic changes and reduced cutaneous microcirculation on the limb.13 On the other hand, peritoneal dialysis (PD) patients who are dialyzed with glucose‐based solutions have a higher risk of insulin resistance, dyslipidaemia and metabolic syndrome, leading to atheroslcerosis.24 The risk of amputation may be different between HD and PD patients. There is a need to conduct population studies investigating the difference of amputation risk between HD and PD patients. In the present study, we used National Health Insurance Claims data of Taiwan to compare the risk of non‐traumatic lower extremity amputation between HD and PD patients, with and without diabetes. The 30‐day mortality after lower extremity amputation was also evaluated.
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