CLINICAL INVESTIGATION OF DISEASE COMPLICATION LEVEL IN ADULT DIABETIC FOOT ULCER PATIENTS: PERIPHERAL NEUROPATHY, PERIPHERAL VASCULAR DISEASE, AND GLYCAEMIC CONTROL

Abstract

Peripheral diabetic neuropathy (PDN), peripheral vascular disease (PVD) and prolonged fluctuations in blood glucose level comprise the deadly triad of factors that transforms poorly managed diabetes mellitus type 2 (DM2) into limb-threatening diabetic foot ulcer (DFU). The measurement of the severity of these risk factors in DFU patients through well-defined tests is crucial to gauge disease complication level and plan treatment.

This study aimed to explore the clinical complication level of Diabetes Foot Ulcers (DFU) patients using four standardised tests Body Mass Index (BMI), Ankle Brachial Index (ABI) for PVD, 10g Monofilament Test (10g MFT) for PDN and HbA1c for chronic hyperglycaemia; to describe Wagner ulcer grades and linear regression between HbA1c and ABI.

Methods: 100 adult DFU patients (non-selective consecutive cross-sectional study) were investigated at OPD, GIMS in Khairpur, Pakistan from June, 2021 to January 2022. Body Mass Index (BMI) was based on weight and height. ABI was measured by a handheld Doppler (V20 Italian 8Mhz). PDN was tested via 10g Monofilament Test (10 points on the feet). HbA1c was analysed from venous blood, in a kit for diabetes. Wagner grading was by anatomical assessment. SPSS v20.2.0 was used for data analysis.

Results: Mean BMI was 23.99 ± 4.80 kg/m² (range 15.60-34.90). Mean ABI was 0.571 ± 0.201 (range 0.00-1.20); the cohort had moderate-to-severe PVD; 92% individuals had an ABI indicating arterial disease. Mean 10g MFT result was 2.484 ± 2.251 positive sites (of 10), corresponding to severe PDN; 94% of these patients had peripheral skin changes with neuropathy. Mean HbA1c was 9.581 ± 1.760% (range 7.00-14.50%); 30% had HbA1c >7%, 62% had HbA1c >8% (untreated diabetes). Wagner grade distribution: Grade 0 (1%), Grade 1 (11%), Grade 2 (32%), Grade 3 (33%), Grade 4 (14%), Grade 5 (8%). Multivariate regression identified a negative HbA1c-ABI relationship: this is consistent with the expected higher degree of vascular blockage as ABI falls with higher HbA1c.

Conclusions: These clinical data establish that we have a population with end stage, multi-faceted diabetic complications - almost universal peripheral neuropathy (94%), mostly moderate-to-severe PVD (92%), and sustained poor glycaemic control (62% with HbA1c >8%). This, together with the inverse/bivariate HbA1c-ABI correlation, confirms glycaemic control as the common upstream cause of vascular and neuropathy-related foot injury among the patients in this population. All diabetes clinic OPDs in Khairpur should adopt standards of clinical screening for PDN and PVD.