From the Guidelines
Chronic kidney disease (CKD) and diabetes mellitus (DM) significantly impair lower leg wound healing by affecting blood circulation, immune function, and tissue repair processes, with diabetes increasing the risk of lower extremity amputation by 5.48-fold and CKD associated with higher rates of cardiovascular death, MI, and ischemic stroke 1. CKD negatively impacts wound healing through:
- Poor blood circulation due to vascular damage
- Reduced immune function, increasing infection risk
- Anemia, limiting oxygen delivery to tissues
- Malnutrition, affecting tissue repair
- Fluid and electrolyte imbalances Diabetes hinders wound healing by:
- Peripheral neuropathy, reducing sensation and increasing injury risk
- Poor blood circulation due to vascular damage
- Impaired immune response, increasing infection risk
- High blood glucose levels, slowing cellular repair processes
- Decreased collagen production, affecting tissue strength To promote better wound healing in patients with CKD and diabetes:
- Maintain tight glucose control (target HbA1c <7%) as recommended by the IWGDF/IDSA guidelines 1
- Optimize nutrition with adequate protein and calorie intake
- Treat anemia (target hemoglobin 10-12 g/dL)
- Manage fluid and electrolyte balance
- Use proper wound care techniques, including regular debridement and appropriate dressings
- Consider hyperbaric oxygen therapy for severe, non-healing wounds
- Address underlying vascular issues through revascularization procedures if necessary, as CKD and diabetes are associated with a higher risk of major adverse cardiovascular events (MACE) and major adverse limb events (MALE) 1 Patients should closely monitor their wounds, maintain good foot hygiene, and seek prompt medical attention for any new or worsening wounds, as diabetes-related foot infections (DFIs) are associated with substantial morbidities and high healthcare costs 1. Regular follow-ups with a wound care specialist, nephrologist, and endocrinologist are crucial for optimal management.
From the Research
Impact of Chronic Kidney Disease (CKD) and Diabetes Mellitus (DM) on Lower Leg Wound Healing
- CKD and DM can negatively impact lower leg wound healing due to various factors, including poor glycemic control, hypertension, and dyslipidemia 2, 3, 4.
- Patients with CKD and DM are at a high risk of developing cardiovascular disease and end-stage kidney disease, which can further complicate wound healing 2, 5.
- The management of CKD and DM requires a holistic, patient-centered, collaborative care approach, including lifestyle modifications, blood pressure management, and achievement of glycemic targets 2, 5.
Factors Affecting Wound Healing in CKD and DM Patients
- Poorly controlled diabetes mellitus, neuropathy, peripheral vascular disease, chronic venous insufficiency, and aging are common risk factors for poor wound healing in patients with CKD and DM 6.
- Uremic toxins can affect local mechanisms of wound healing and also adversely affect the functioning of multiple systems, leading to impaired wound healing 6.
- The use of certain medications, such as metformin, sulfonylureas, and insulin, requires careful consideration in patients with CKD and DM, as they can affect renal function and increase the risk of hypoglycemia 3, 4.
Management of CKD and DM to Improve Wound Healing
- Early detection and initiation of appropriate therapeutic interventions can slow disease progression and prevent adverse outcomes in patients with CKD and DM 2, 5.
- The use of traditional agents, such as angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, as well as newer agents, such as sodium-glucose cotransporter 2 inhibitors and finerenone, can help preserve kidney function and improve wound healing outcomes 5.
- A multidisciplinary approach to care, including collaboration between healthcare providers, patients, and families, is essential for effective management of CKD and DM and improvement of wound healing outcomes 2, 5.