diabetic foot in esrd · 2014-02-26 · trauma foot deformity d/t muscle atrophy hyperkeratosis,...
TRANSCRIPT
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Diabetic foot in ESRD
Gwak heui chul
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Various Spectrum !!
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Case I M/61
DEBRIDEMENT
Angioplasty and Several Debridement
2 개월 소요
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Case II F/ 32
Several Debridement
Several Debridement, VAC, STSG
2.5 개월 소요
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Case III M/ 59
Several Debridement
3 months later
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Case IV M/ 65
Initial Pop 6months later Last F/U
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Case V F/ 58
Several Debridement & VAC apply
VAC, STSG
5주 소요
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Contents
말기 신부전환자들은 당뇨발의 예후가 좋지 않다?
말기 신부전 환자는 일반당뇨환자보다 당뇨발의 발생율이
높고 예후도 좋지 않다.
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주된 사망 원인 중 하나
DM foot 발생율 : 일반 당뇨환자보다 2배 -ANNA J. 1996;23:381-6
- Diabetes Care. 2001:24:1689-90
Neglected
need for routine foot screening
DM foot in ESRD
View of Nephrology
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ESRD 자체의 증가
절단율이 높다.
절단율: 6.5-10 배 (vs DM) -Kidney Int. 1999;56:1524-33
- Infect Dis Clin North Am. 2001:15;953-81
RR of major amputation: 2.14 in HD - Diabetes Res Clin Pract 2006:71;272-9
Avoid of amputation despite revascularization: 50% -Ann Vasc Surg. 2005:19;805-11
ESRD in DM foot
View of Orthopedics
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수술 후 경과가 좋지 않다.
Association between ESRD and failure of
trans-metatarsal amputations to heel J foot Ankle Surg. 2006: 45;91-7
신기능이 나쁠수록 예후가 나쁘다.
절단 성공율 57% in HD vs 25% in ESRD -Diabetes Care. 2001:24:1689-90
RR of poor outcome: 9 배 in HD -Vasa. 2004: 33;36-41
-
ESRD in DM foot
View of Orthopedics
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peripheral arterial disease
longer duration of DM
vascular risk factor (calcium & phosphrus deposit)
Neuropathy
uremic neuropathy
uremic toxin
infection
poor nutrition -> hypoalbuminemia
Uremia ->immune dysregulation
Lymphopenia( reduced T4 & T8)
Why frequent and severe?
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Trauma foot deformity d/t muscle atrophy
hyperkeratosis, ulcer
postural hypotension autonomic neuropathy
post-HD volume contraction
poor vision d/t diabetic retinopathy
Tissue hypoxia intra, post-HD hypotension
anemia
tissue edema
Depressive disorder
neglect
poor compliance
Why frequent and severe?
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Model of foot care
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M/77 Rt. foot pain
PI) 내원 한달 전부터 발생한 Rt. 5th toe ulcer로 L/C 에서 5th toe ray amputation 시행하였으나 wound
aggravation되는 소견 있어 본원 ER 통해 내원함.
P/Hx) DM (20년전 진단, hemodialysis)
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2011.12.07 Angio CT
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2011.12.20 Intervention
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Debridement & VAC apply
2012.01.12 2012.01.26 2012.02.02
2012.02.06 2012.02.09
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2012.02.14 STSG & Ray ampu.
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Case F/45, Lt. Gt toe pain
PI) 내원 2개월 전부터 발생한 Lt. Gt toe wound develop
되어 L/C 에서 conservative Tx. 지속해 왔으나 wound
aggravation 되는 양상있어 OPD 통해 내원함.
P/Hx) DM (20년전 진단,hemodialysis)
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2011.07.19 ADM
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Debridement
2011.08.02 2011.07.26
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2011.09 Intervention
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Debridement
2011.09.29
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53/M, other hospital
2011.01.10 2011.01.27
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1개월후에
2011.03
2011.04
Total contact cast
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2011.06.24
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2011.10.25
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2012.05 외래 방문 당시 X-RAY
2014.02 X-RAY
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당뇨발 위험 요소 남자 , 40세 이상
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10년이상 의 당뇨 당조절이 안되는 사람
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흡연
과체중
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주2회이상 음주 혈액순환 장애
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합병증 있을때
(심장,눈,콩팥)
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당뇨발 위험 예측 1.발 변형 또는 뼈 돌출
2.궤양
3.신경병증(무감각)
4. 굳은살
5.관절 움직임 감소
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6.발 맥박 감소
7.발의 높이 따른 창백, 붉음
8.궤양 경험
9.절단
10.부적절한 신발
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발 예방 발 상태 매일 확인 매일 닦고, 건조하게
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열선, 핫팩 사용 금지 맨발 금지, 양말 혹은 실내화 착용
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굳은살 제거는 병원에서 신발 안 확인(이물질)
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보습제 사용 조이는,무릎 까지 양말 금지
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부드럽고 넓은 신발
필요시 깔창
다리 꼬지 않기
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발톱은 일자로 정기적 발 검진
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Thank you for
your attention !!!