Lower-Extremity Amputations in NIDDM: 12-Yr Follow-Up Study in Pima Indians

Nelson, Robert G.; Gohdes, Dorothy; Everhart, James E.; Hartner, Judith A; Zwemer, Frank L.; Pettitt, David J.; Knowler, William C.

doi:10.2337/diacare.11.1.8

Cited by 207 publications

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“…Despite their different incidences of ischaemic heart disease, both American Indian groups reported comparably high rates of lower extremity gangrene and/or amputation with rates in men exceeding those in women more than in the other centres, supporting the findings of other studies of diabetes in Pima and Oklahoma Indian people [16,17]. The common protocol firmly directed examination towards ischaemic disease as the cause of gangrene and amputation but it is likely that coexistent diabetic neuropathy and general disease management were also important contributory determinants.…”

Section: Discussionsupporting

confidence: 78%

Follow-up of the WHO multinational study of vascular disease in diabetes: general description and morbidity

et al. 2001

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Aims. The incidence of retinal, renal and cardiovascular complications and their relation to baseline risk factors was documented in this follow-up study of 10 of the 14 original centres of the WHO Multinational Study of Vascular Disease in Diabetes (WHO MSVDD). Methods. The incidence of specified items of vascular disease and some associated risk factors was ascertained after 7 to 9 years (11±12 years in Oklahoma, USA) follow-up, re-using baseline examination methodology in 3165 patients (66.9 %) and, through secondary information in 717 (15.2 %) of the 4729 original patients, of whom 540 (11.4 %) had died and 307 (6.5 %) were untraceable. Results. During follow-up, approximately one third of the patients developed hypertension and one third started insulin. Coronary heart disease incidence varied 10 to 20-fold among centres as did limb amputation rates. Inter-centre differences in incident retinopathy and severe visual impairment were smaller but incident clinical proteinuria and renal failure varied markedly. Vascular disease incidence of all categories was high in Native Americans though coronary heart disease incidence was relatively low in Pima Indians and absolutely low in Hong Kong and Tokyo patients. Specific vascular events and their relation with baseline risk factors are analysed in accompanying papers, summarised in the Epilogue. Conclusion/interpretation. These 10 centres reported very different incidence rates of vascular complications. Observer variation, selection biases and competing causes of mortality contributed to these differences but their validity is supported by the more objective outcome indicators. The following papers also suggest that baseline factors such as raised arterial pressure, cholesterol and fasting glucose (in the centres where it was measured) were important and potentially reversible predictors of risk. [Diabetologia (2001)

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Section: Discussionsupporting

confidence: 78%

Follow-up of the WHO multinational study of vascular disease in diabetes: general description and morbidity

et al. 2001

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“…Diabetic Native Americans have the highest reported risk of amputations in the world, which varies by tribe (11,12,29); data that compares Native Americans with other ethnicities in a national setting are lacking. Although the current study was unable to evaluate risk of amputation by tribe specifically, it confirmed the excess relative risk of amputation for a heterogeneous group of Native Americans compared with whites and other ethnic groups where access to care for all individuals was similar.…”

Section: Statistical Analysesmentioning

confidence: 99%

“…In addition, the risk for amputation is higher in males (4,10 -12,16) and increases with age (3,4,6,10). Various population-based studies, such as those conducted in Wisconsin natives (10,27), Native-American tribes (11,12,28,29), managed care populations (13), Medicare enrollees (3,18), and veteran populations (7-9,19,20,30,31) have identified consistent risk factors for lower-extremity amputations. These risk factors include glycemic control (7,8,10,12,13), duration of diabetes (7,8,10 -13), blood pressure control (7,8,10 -13), and history of foot ulcers (7,8,10,12).…”

Section: Statistical Analysesmentioning

confidence: 99%

“…Nationally, diabetes is associated with Ͼ65% of nontraumatic lowerextremity amputations performed, even though diabetic individuals account for Ͻ3% of the total U.S. population (1,2). Risk factors for amputations in individuals with diabetes include age (3-6), peripheral vascular disease (7-9), smoking (6,7,10,11), hypertension (6 -8,10,11), glycemic control (7,8,10,12,13), renal disease (7,9, 11,14,15), and race/ethnicity (3,4,6,9,11,12,(15)(16)(17)(18)(19)(20), although it remains controversial whether African Americans have an increased incidence of amputations (7,13,21). Conversely, most minority patients are at increased risk of lower-extremity amputations in the setting of end-stage renal disease (ESRD) (15); however, risk associated with renal disease before the initiation of dialysis has not been clearly established.…”

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confidence: 99%

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Effects of Ethnicity and Nephropathy on Lower-Extremity Amputation Risk Among Diabetic Veterans

et al. 2003

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OBJECTIVE -To describe ethnic differences in the risk of amputation in diabetic patients with diabetic nephropathy. RESEARCH DESIGN AND METHODS-A retrospective cohort study was conducted on a national cohort of diabetic patients who received primary care within the Veterans Affairs (VA) Health Care System. Hospitalizations for lower-limb amputations were established by ICD-9-CM procedure codes. Relative risk of amputation in diabetic patients with and without diabetic nephropathy was determined using Cox proportional hazard modeling for unadjusted and adjusted models.RESULTS -Of the 429,918 subjects identified with diabetes (mean age 64 Ϯ 11 years, 97.4% male), 3,289 individuals were determined to have had a lower-limb amputation during the study period. Compared with diabetic patients without amputations, amputees were on average older, more likely to belong to a minority group, and were more likely to have received treatment for more comorbid conditions. Asians were more likely to have toe amputations compared with whites or other ethnicities, while Native Americans were more likely to have below-the-knee amputations. Native Americans had the highest risk of amputation (RR 1.74, 95% CI 1.39 -2.18), followed by African Americans (RR 1.41, 95% CI 1.34 -1.48) and Hispanics (RR 1.28, 95% CI 1.20 -1.38) compared with whites. The presence of diabetic nephropathy increased the risk of amputation threefold in all groups. Asian subjects with diabetes had the lowest adjusted relative risk of amputation (RR 0.31, 95% CI 0.19 -0.50).CONCLUSIONS -Among diabetic patients, certain ethnic minority individuals have an increased risk of lower-extremity amputation compared with whites. Presence of diabetic nephropathy further increases this risk. Diabetes Care 26:495-501, 2003

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“…Vibration perception threshold (VPT), pressure perception threshold (PPT), temperature perception threshold (TPT), autonomic neuropathy, muscle strength, reflexes, and neuropathy disability score all predict foot ulceration to some degree (1)(2)(3)(4)(5)7,13). In addition, lower-limb amputation (LLA) can be predicted by VPT, PPT, and reflexes (6,8). However, the involvement of motor nerve conduction velocity (MNCV) in the development of foot problems in diabetic subjects has not been examined in a longterm study.…”

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confidence: 99%

Can Motor Nerve Conduction Velocity Predict Foot Problems in Diabetic Subjects Over a 6-Year Outcome Period?

et al. 2002

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OBJECTIVE -This study examined motor nerve conduction velocity (MNCV) and other peripheral nerve and vascular tests as predictors for foot ulceration, amputation, and mortality in diabetes over a 6-year follow-up period.RESEARCH DESIGN AND METHODS -We recruited 169 diabetic subjects (without significant peripheral vascular disease with an ankle brachial pressure index [ABPI] Ն0.75) for the study and separated them into groups (to ensure diversity of nerve function). The control group consisted of 22 nondiabetic people. At baseline, all subjects underwent assessment of MNCV; vibration, pressure, and temperature perception thresholds; peripheral vascular function; and other diabetes assessments.RESULTS -Over the 6-year outcome period, 37.3% of the diabetic subjects developed at least one new ulcer, 11.2% had a lower-limb amputation (LLA) (minor or major), and 18.3% CONCLUSIONS -This study shows that MNCV, which is often assessed in clinical trials of neuropathy, can predict foot ulceration and death in diabetes. In addition, tests of PPT and medial arterial calcification can be used in the clinic to predict LLA in diabetic subjects. Diabetes Care

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Lower-Extremity Amputations in NIDDM: 12-Yr Follow-Up Study in Pima Indians

Cited by 207 publications

References 0 publications

Follow-up of the WHO multinational study of vascular disease in diabetes: general description and morbidity

Follow-up of the WHO multinational study of vascular disease in diabetes: general description and morbidity

Effects of Ethnicity and Nephropathy on Lower-Extremity Amputation Risk Among Diabetic Veterans

Can Motor Nerve Conduction Velocity Predict Foot Problems in Diabetic Subjects Over a 6-Year Outcome Period?

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