Title:
RISK FACTORS FOR LOWER LIMB AMPUTATIONS (LLA) IN INCIDENT HAEMODIALYSIS PATIENTS FROM TWO EUROPEAN COUNTRIES

Anibal Ferreira¹ ;Anibal Ferreira² ;Anibal Ferreira³ ;Anibal Ferreira² ;Anibal Ferreira⁴ ;Anibal Ferreira⁴

Vila Franca de Xira ; 2. Fresenius Medical Care-Italy ; 3. Fresenius Medical Care Portugal Bad Homburg

E-mail address corresponding author:
anibalferreira@netcabo.pt

Background:
Haemodialysis (HD) patients have an increased incidence of LLA as described by many authors, most frequently based on retrospective studies of small populations.

Methods:
All patients without previous LLA and beginning dialysis in Fresenius Medical Care (FMC) centres in Portugal and in Italy from January 2000 to June 2004 were included in the present study. Data were collected prospectively by the European Clinical Database (EuCliD). 4593 incident patients were included. Several epidemiological and clinical parameters were evaluated: age, gender, time on dialysis, smoking habit, CRF etiology, serum calcium, serum phosphorus, calcium-phosphorous product (CaxP), intact parathyroid hormone (iPTH), C-reactive protein (CRP) and hypertension therapy. Laboratory data were assessed according to local protocols and are presented as overall mean ±SD. The results were evaluated by X2 and ANOVA statistics. Statistical significance was accepted with p<0.05.

Results:
74 patients (1.6%) were amputated during the follow-up. No statistically significant difference was found in age and gender between the non-amputated (nLLA) and LLA patients (63.3±16.5 vs 64.2±12.2 years). A high prevalence of active smokers (27.1%) was observed, with a similar distribution in both groups. The mean serum values of phosphorus (LLA: 4.4±1.1 vs nLLA: 4.4±1.2 mg/dL), serum calcium (LLA: 9.1±0.6 vs nLLA: 9.0±0.73 mg/dL), CaxP ion product (LLA: 39.9±10.2 vs nLLA: 40.1±11.9 mg2/dL2) were not statistically different. Patients undergoing LLA presented a lower iPTH (LLA: 246.2±233.3 vs nLLA: 274.8±268.7 ng/dL; p=NS) and a higher CRP value (LLA: 5.7±7.6 vs nLLA: 4.5±7.6 mg/dL; p=NS), both results being not statistically different. When considering K-DOQI guideline limits for calcium, phosphorus and CaxP ion product, the proportions of patients above the respective limits were not statistically different between the two groups during follow-up. 985 patients were diabetic (21.4%), 49 of them were amputated (5.0%) versus 0.7% of the non-diabetics (p<0.001). In the diabetic subgroup, iPTH was significantly higher in the LLA patients (LLA: 224.2±159.3 vs nLLA: 217.8±185.4 ng/dL; p=0.02).

Conclusion:
We conclude that in this large incident dialysis population, evaluated for a long time, only diabetes was identified as a risk factor for amputation. In the diabetic group the need for amputation was associated with higher iPTH levels. We emphasize that the majority of the patients stayed inside the related K-DOQI guideline limits, which may explain some of the different results from previous studies.

Subject:
Complications

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