How should we manage a 64‑year‑old male with ESRD (end‑stage renal disease) on dialysis, DM (diabetes mellitus) with neuropathy, PVD (peripheral vascular disease), CHF (chronic heart failure), HTN (hypertension), HLD (hyperlipidemia), HPT (hyperparathyroidism), anemia, hypothyroidism, prior thromboembolic events, a left below‑knee amputation, recent right‑foot infection, and a 3‑inch unstageable pressure ulcer on the right heel (covered by eschar) who lives alone, uses a wheelchair without a footrest causing foot dragging, and is requesting a higher level of care?

Case Management Recommendations for High-Risk Dialysis Patient with Unstageable Heel Ulcer

This 64-year-old dialysis patient with an unstageable pressure ulcer, recent foot infection, peripheral vascular disease, and inadequate wheelchair equipment requires immediate multispecialty team-based care with urgent vascular assessment, pressure off-loading, wound management, and transition to a higher level of care given his inability to safely self-care at home. 1, 2, 3

Immediate Priorities (Within 24-48 Hours)

1. Urgent Vascular Assessment

• Measure ankle-brachial index (ABI) with Doppler arterial waveforms immediately, as clinical examination alone is unreliable in diabetes and this patient has documented peripheral vascular disease. 1, 2
• If ABI is non-compressible due to medial arterial calcification (common in dialysis patients), obtain toe-brachial index (TBI) and toe pressures. 1, 2
• Critical thresholds requiring urgent vascular imaging and revascularization consideration: toe pressure <30 mmHg, ankle pressure <50 mmHg, or ABI <0.5. 1, 2, 3
• The 1+ pitting edema to the right leg combined with peripheral vascular disease raises concern for inadequate perfusion to heal the heel ulcer. 1

2. Wound Assessment and Debridement

• The eschar-covered unstageable ulcer requires sharp debridement by a wound specialist or podiatrist to assess true depth and rule out underlying osteomyelitis. 1, 2
• Obtain wound cultures only after debridement if infection is suspected; do not treat colonization. 2
• Given the recent right foot infection requiring antibiotics, assess whether current wound shows signs of active infection (purulence, erythema extending >2 cm, warmth, fluctuance). 1, 2

3. Pressure Off-Loading (Critical and Currently Absent)

• The patient must immediately stop using the wheelchair without footrests, as foot dragging is directly causing ongoing trauma to the heel ulcer. 1, 2
• Prescribe a heel off-loading device or total contact boot specifically designed to eliminate pressure on the right heel. 1, 2
• The second wheelchair with footrests must be made operational or replaced—contact durable medical equipment (DME) provider for immediate assessment and repair. 1
• Consider hospital-grade air mattress or pressure-redistributing surface for bed to prevent further pressure injury. 2

4. Infection Control and Hygiene

• The dried feces on the wheelchair indicates significant self-care deficit and infection risk in a dialysis patient. 1
• Arrange immediate home health nursing for wound care, hygiene assistance, and infection prevention education. 1
• Dialysis patients with foot ulcers are at especially high risk for systemic infection and sepsis; monitor for fever, elevated white blood cell count, or hemodynamic instability. 1, 2, 3

Transition to Higher Level of Care

Skilled Nursing Facility (SNF) Placement Strongly Indicated

This patient meets criteria for SNF placement based on:

• Inability to safely perform activities of daily living (evidenced by fecal-soiled wheelchair, inability to operate appropriate wheelchair, living alone with multiple high-risk conditions). 1, 3
• Need for daily wound care and pressure off-loading supervision that cannot be reliably performed at home. 1, 2
• ESRD on dialysis combined with peripheral vascular disease yields 5-year survival of only ~19%, making aggressive wound management and complication prevention critical. 3
• High fall risk (documented history of falls, below-knee amputation, peripheral neuropathy, orthostatic hypotension evident from vital signs). 1

Alternative: Intensive Home Health if SNF Declined

If patient refuses SNF:

• Daily home health nursing for wound care, vital signs, medication management, and safety assessment. 1
• Physical therapy evaluation for wheelchair mobility training and fall prevention. 1
• Occupational therapy for adaptive equipment and activities of daily living training. 1
• Home-delivered meals given nutritional concerns (malnutrition increases 30-day mortality five-fold in this population). 3

Multispecialty Team Coordination

Immediate Referrals Required

• Podiatry or wound care specialist: For sharp debridement, ongoing wound management, and specialized footwear prescription. 1, 2
• Vascular surgery: For comprehensive arterial assessment and revascularization consideration if perfusion inadequate. 1, 2, 3
• Physical medicine and rehabilitation: For prosthetic evaluation and mobility optimization. 1
• Social work: For care coordination, SNF placement, and DME procurement. 1

Ongoing Dialysis Coordination

• Communicate with dialysis unit about wound status, infection risk, and need for frequent foot inspection during dialysis sessions. 1
• Dialysis patients should have feet examined at every dialysis visit given extremely high amputation risk. 1

Medical Optimization

Glycemic Control

• Current HbA1c unknown but critical to assess—**target HbA1c <7% to improve wound healing**, but avoid rapid reduction >3% over short period (risk of treatment-induced neuropathy). 1, 2
• Tradjenta (linagliptin) is appropriate for ESRD but may need insulin intensification. 1

Cardiovascular Risk Reduction

• Continue clopidogrel (already prescribed) as antiplatelet therapy is essential in peripheral vascular disease. 1, 2, 3
• Atorvastatin dose is appropriate for high cardiovascular risk. 1
• Blood pressure shows orthostatic hypotension (127/69 supine to 94/50 standing)—consider reducing carvedilol or adjusting dialysis ultrafiltration goals. 1

Pain Management

• Current 6/10 heel pain requires optimization—consider increasing gabapentin dose (already prescribed) or adding duloxetine for neuropathic pain. 1
• Avoid opioids if possible given fall risk and constipation concerns. 1

Mineral Bone Disease

• Continue sevelamer and consider cinacalcet if hyperparathyroidism uncontrolled, as vascular calcification accelerates peripheral vascular disease in dialysis patients. 4

Equipment and Footwear

Immediate Needs

• Wheelchair with functional footrests and cushioned seat (DME order). 1, 2
• Heel off-loading boot or total contact cast (once infection controlled). 1, 2
• Custom-molded therapeutic shoes for the right foot after ulcer heals to prevent recurrence. 1, 2
• Properly fitted prosthetic for left below-knee amputation if not already optimized—improper prosthetic increases fall risk and compensatory pressure on remaining limb. 1

Footwear Guidance

• The suggestion to wear a sandal is inadequate—this patient needs prescription therapeutic footwear with pressure redistribution. 1, 2
• Never walk barefoot, in socks only, or in thin-soled slippers. 2

Monitoring and Follow-Up

Wound Monitoring

• Weekly wound measurements (length, width, depth) to assess healing trajectory. 2
• If no improvement after 4 weeks of optimal care, reassess vascular status and consider advanced therapies (negative-pressure wound therapy, bioengineered skin substitutes). 1, 2

Amputation Risk Stratification

• This patient is IWGDF Risk Category 3 (neuropathy + history of amputation), requiring monitoring every 1-3 months. 2
• 30-day mortality after major amputation in ESRD patients ranges 4-30%; 1-year mortality 38-70%. 3
• Primary amputation should only be considered if multispecialty team exhausts revascularization options or if life-threatening sepsis develops. 3

Contralateral Limb Surveillance

• The left residual limb requires meticulous daily inspection as phantom limb pain (documented diagnosis) may mask early injury. 1
• Atherosclerotic disease is bilateral even when symptoms are unilateral—the left limb remains at high risk. 3

Critical Safety Interventions

Fall Prevention

• Remove environmental hazards during home safety evaluation. 1
• Consider personal emergency response system given living alone. 1
• Optimize orthostatic hypotension before discharge to any setting. 1

Infection Prevention

• Hand hygiene education for patient and all caregivers. 1
• Daily foot inspection protocol with mirror or caregiver assistance. 1, 2
• Immediate reporting instructions for new wounds, redness, warmth, or drainage. 1, 2

Prognosis and Goals of Care Discussion

Given this patient's constellation of ESRD on dialysis, diabetes with neuropathy, peripheral vascular disease, heart failure, prior amputation, and current pressure ulcer, his 5-year mortality approaches 62-85%. 3 A frank discussion about goals of care, quality of life priorities, and advance care planning is appropriate while pursuing aggressive limb salvage. 3

The combination of ESRD and peripheral vascular disease without adequate home support makes SNF placement the most appropriate recommendation to optimize wound healing, prevent major amputation, and maintain quality of life. 1, 3