OBJECTIVE -The objective of this study was to evaluate the association between foot ulcers (DFU) and lower-extremity amputation (LEA) and chronic kidney disease (CKD) in patients with diabetes. RESULTS -The presence of DFU or LEA and estimated glomerular filtration rate (eGFR) were evaluated in 90,617 individuals with a median time of observation of 2.4 years. Of these individuals 378 had an LEA and 2,619 had a DFU. CKD (eGFR Ͻ60 ml/min per 1.73 m 2 ) was noted in 23,350 (26%) individuals in our cohort. For the development of DFU compared with our reference group (group 1 [eGFR Ն60 ml/min per 1.73 m 2 ]), the hazard ratio (HR) for group 2 (eGFR Ն30 and Ͻ60 ml/min per 1.73 m 2 ) was 1.85 (95% CI 1.71-2.01) and for group 3 (eGFR Ͻ30 ml/min per 1.73 m 2 ) was 3.92 (3.23-4.75) (all P Ͻ 0.001). For LEA, the HR for group 2 was 2.08 (1.68 -2.58) and for group 3 was 7.71 (5.29 -11.26) (all P Ͻ 0.001). RESARCH DESIGN AND METHODSCONCLUSIONS -In this observational study, there is a strong association between stage of CKD and DFU or LEA that is probably not just related to the presence of peripheral arterial disease. Individuals with even moderate CKD (eGFR Ͻ60 ml/min per 1.73 m 2 ) have an increased risk for DFU and LEA.

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10Ecosystems provide services for many stakeholder groups, often with a conflict of interests that 11 hampers sustainability. Core to these conflicts is the challenge of trading-off monetary and non-12 monetary measures. Presenting a socio-ecologically integrated trade-off model, and using the boreal

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