Saving the diabetic foot with special reference to the patient with chronic renal failure.

The chronic renal failure patient with diabetes has a lower limb amputation rate 10 times greater than the diabetic population at large. In studies of causal pathways leading to non-traumatic related lower extremity amputation, foot ulcers preceded approximately 84% of the amputations. Even though foot ulcers are more likely to develop in patients with diabetic nephropathy, they are no less likely to heal than are those in diabetic patients with normal renal function. Consequently, attempts to save the diabetic foot even in this high-risk population are justified. The pathogenesis of foot ulceration in the chronic renal failure patient with diabetes is primarily due to peripheral neuropathy. Loss of protective sensation due to sensory neuropathy combined with motor and autonomic neuropathy and macrovascular compromise result in increased risk for foot complications. Evaluation of the foot includes a selective history and a focused examination of skin integrity, presence of sensory neuropathy or vascular insufficiency, and biomechanical and footwear inspection. Effective treatment of diabetic foot complications include appropriate antibiotics (when indicated), meticulous wound care, off-loading, vascular surgery (when indicated), and selective/elective or prophylactic nonvascular surgery. Failure to heal an ulcer can often be traced to common pitfalls, which include: A "cavalier" attitude. W.N.L. exam (We Never Looked). Inadequate off-loading. Failure to establish depth of ulcer and miss "probe to bone." Non-healing means unrelieved pressure and/or no blood. Failure to correct edema. The multidisciplinary diabetic foot clinic model provides an ideal setting for early intervention, treatment, and assistance with preventive strategies.