The effect of anaemia and malnutrition on the healing of diabetic foot wound

The effect of anaemia and malnutrition on the healing of diabetic foot wound

Ahmed Osmane, MD; Naguib ElAskari, MD

Department of Vascular Surgery, Alexandria University, Alexandria, Egypt.

Background: Anaemia is a common problem in surgical patient, and it is an independent risk factor for blood transfusion,  peri-operative  infection,  mortality  and a longer in-patient stay. Diabetic  foot wound  results  from  the  interaction  of  several  contributory  factors,  the most important of which is neuropathy. With respect to the management of acute Charcot neuroarthropathy in diabetics, patients with diabetic foot wounds suffer from chronic inflammation, repeated infection, often undergo several invasive or operative treatments, and can have a protracted hospital stay. We hypothesised  that, for these  reasons, many patients with diabetic foot wound may suffer anaemia, require blood transfusion and suffer from poor nutrition.

Aim  of the work: Anaemia and nutritional status assessment as they affect the healing in patients presenting with diabetic foot wounds.

Patients and methods:  Two observational  studies were undertaken. Initially a retrospective series  of  20  patients  with  diabetic  foot  wounds.  Patient  demographics,  clinical  details, transfusion status and in-patient laboratory haemoglobin values (Hb) were recorded. In a prospective series of 33 patients, laboratory markers and nutritional status were assessed. Infection was excluded and managed appropriately by antibiotics and surgically by wound debridement or amputation. Other factors affecting wound healing were excluded as peripheral arterial diseases or debilitating diseases as renal failure.

Results:  In the retrospective series, 17 patients (85%) were anaemic (100%  females) with average haemoglobin of5g  (SD 2.4) below the lower limit of normal for the sex ofthe patients. Ten patients  (50%)  were  transfused.  The  average  trigger  haemoglobin  index  was  8.5 gldl (SD 0.8). Patients  who were transfused  had lower haemoglobin  on admission  (p  = 0.0016). Overall, at discharge, most of the patients were anaemic (92%). In the prospective  series on admission,  27 patients  (82%)  were anaemic,  also  anaemic  patients had a higher CRP  and lower albumin level. 17 patients (52%) had been scored to be undernourished. Clinical follow up with appropriate dressing ofthe wounds  and calculating the healing rate was observed.

Conclusion: Usually  anaemia as well as poor nutrition is the normal event and affecting

the healing of diabetic wounds. Multidisciplinary review should be undertaken in all patients.

Introduction:

Approximately    170  million   individuals are affected by diabetes worldwide including

23.6  million  in the  United  States (7-8%  of

the  population).1   In  Egypt,  the  percentage of  affected  population  is  reported  as  high as        20%.     Of    these     individuals,     28.5% have  diabetic  peripheral   neuropathy.   Poor glycaemic   control   is  associated   with   the presence  of  neuropathy  and  increased  risk

for wounds and amputations) Wounds of the foot are common in individuals with diabetes, with an annual incidence of 1-2 %.3

Diabetic foot wound represents a major medical, social and economic problem all over the world. While more than 5% of diabetic patients  have  a  history  of  foot  ulceration, the  cumulative   lifetime  incidence  may  be as  high  as   15%.  Ethnic  differences   exist

in  both  wound  and  amputation  incidences,

Am-ShamsJSurg2014;7(2):357-362

with  both  being  less  common  in  patients of Indian subcontinent origin living in the UK.4,5 Diabetic foot wound results from the interaction of several contributory factors, the most important of which is neuropathy. With respect to the management  of acute Charcot neuroarthropathy in diabetics, patients with diabetic foot wounds suffer from chronic inflammation,  repeated  infection,  often undergo several invasive or operative treatments, and can have a protracted hospital stay. For these reasons, many patients with diabetic foot wound may suffer anaemia, require  blood  transfusion   and  suffer  from poor nutrition.6-1 O

Anaemia is a common problem in surgical patient. Prevalence is reported from 5-78%. Anaemia  is  an  independent  risk  factor  for blood transfusion, peri-operative infection, mortality  and  a  longer  in-patient  stay.ll-13

Two main types of anaemia affect surgical patients,    iron-deficiency    anaemia    (IDA) and anaemia of chronic disease (ACD); the latter is more common in chronically  ill and hospitalised  patients.  ACD  can  be  difficult to  diagnose,  often being regarded  as a diagnosis of exclusion. A key feature of ACD is a disruption of normal iron homeostasis initiated by a cytokine-mediated immune response such as in chronic inflammatory disease, during infection or following surgery.l4-l 7

Malnutrition is one of the factors affecting wound healing, namely low caloric and protein intake. The relationship between nutritional status and the development of diabetic foot ulcer   has   been   investigated.   The  wound occurs when injury destroys tissue integrity. In this wound, thousands of cells will die of physical disruption, desiccation on exposure to  air,  and  exposure   to  non-physiological fluids.  Macrophages  play an important  role in the recognition of injury. In addition, local ischaemia  and  hypoxia  are  always  present in the centre of the wound and induce the production of lactate, which stimulates cell growth in wounds. Structural elements like collagen  and  proteoglycans  are  synthesized in the wound. Wound nutrition, like any massive  reconstruction,  uses a combination

of in-situ and remote synthesis.l8-21

Aim of the work

Was  to  assess  anaemia   and  nutritional status and their effects on healing in patients presenting with diabetic foot wounds.

Patients and  methods:

This study was done at Alexandria University Hospital. Initially, an observational retrospective study of 20 patients presented with  diabetic  foot  wounds  was  performed over 4 months. Demographic study as regards age and sex was recorded. Also haemoglobin levels and transfusion status were recorded.

The  other  study  was  the  prospective

one,   in  which   data   were   collected   over the subsequent 6 months on 33 patients. In addition,   the  aim  was  to  assess  anaemia and to determine, if possible, the cause of anaemia   using  certain   laboratory   tests  as the haemoglobin level, mean cell volume (MCV), C reactive protein (CRP), serum urea and creatinine, and serum albumin. Anaemia was defined as a laboratory haemoglobin concentration  of  less than  11.5g/dl for females and 13g/dl  for males. Trigger index was defined as the haemoglobin at which patients  were  transfused.   All  patients  had their nutritional status assessed by recording the height, weight, body mass index (BMI) using a validated scoring system Table(l). Clinical  wound  assessment  as  regards  the size and healing rate was performed weekly. Patients on dialysis with known renal failure were excluded.

Results:

Of  the  20  patients  m  the  retrospective series,  there  were   12  females  (60%)  and

18 males (40%). Average age was 57 years (SD 12.6). All patients underwent surgery in the form of debridement.  On admission,  17 patients (85%) were anaemic (100% females) with an average haemoglobin  of 5g (SD 2.4) below the lower limit of normal for the sex of the patients. Only 3 patients (15%) were not anaemic (100% males) on admission with an average haemoglobin of 0.8g (SD 0.5) above the  lower limit of normal for the sex of the

Figure (1): Photos of diabetic foot wound; first (0 week), second (3 weeks), third (20 weeks), and fourth (22 weeks).

Table(J); The scoring system.

Body mass index (kg/m2)

Food intake

No                                                                   0

Yes                                                                 2

Not known                                                      1

Unintentional weight loss

No

Up to 3 kg

More than 3 kg

Stress factor/ illness seve1ity

None Moderate Severe

Table(2); Risk factors at admission.

patients. Ten patients (50%) were transfused a median of two units (range 1-6 units), a total of 28 units. The average nigger haemoglobin index  was  8.5g/dl  (SO  0.8).  Patients  who

0

1

2

1

2

3

were n·ansfused had lower  haemoglobin  on admission (p=0.0016) and all of them were anaemic on admission (100%). The average increase   in  haemoglobin   after   n·ansfusion

Table(3); Haematological markers  for anaemic and non-anaemic patients at admission.

Table (4); Characteristics ofwounds.

 was 1.1g/dl. The non-transfused patients (50%), their haemoglobin fell on the average of 1.5g/dl (SD 0.5) during their admission. Overall,  at  discharge,  most  of  the  patients were anaemic (92%).

In the  prospective  series  of 33  patients, there were 19 females (58%) and 14 males (42%).  Average age was  62 years  (SD  12). All patients underwent surgery in the form of debridement of the infected necrotic tissues with or without lay-opened toe amputation (major limb amputation with primary wound closure   were  excluded).   Main  complaints on  admission  were tissue  loss (27  patients) and night fever associated with anorexia (13 patients); risk factors are given in Table(2).

On admission, 27 patients (82%) were anaemic, and those patients had a lower average  of MCV than non-anaemic patients. Also anaemic patients had a higher CRP and lower albumin level Table(3).

Nutritional assessment had been performed on all the patients, height and weight were measured and BMI was calculated. 17 patients (52%) had been scored to be undernourished. Patients who presented anaemic were more likely to be malnourished  (nutritional  score >3; n=15; p=0.049).  Length of hospital stay was longer in those patients presented with anaemia  and hypoalbuminaemia in order to correct both of them by transfusion  and high protein  diet (mean 21 days (SD  15) versus non-anaemic  9 days (SD 7) p=0.0125). Clinical follow up with appropriate dressing of   the  wounds   with   noting  the   changes towards healthy granulating tissues, and calculating the healing rate was observed as shown in Table(4).

Discussion:

In this sample of diabetic individuals, anaemia and malnutrition were significantly associated with diabetic footwounds. Anaemic patients were more likely to be malnourished. Anaemia should be corrected by transfusion and this increases the hospital length of stay. Actually routine haematological markers did not define a cause for the anaemia, although a raised CRP may suggest ACD. Most of the patients were malnourished on admission. Many received blood transfusion during their hospital stay, and most were anaemic on discharge.   Haemoglobin   usually  decreases at discharge  in those  admitted  patients  who were not transfused. Although this case series did  not  assess  blood  loss  at  intervention, it did show that most anaemic patients underwent transfusion. Several studies found that ACD is the most common anaemia of chronically  ill and hospitalised  patients.22-24

Diabetic patients suffer chronic inflammation from ulceration, and suggesting that they consequently also  suffer  from  anaemia of chronic   disease.23,24 ACD  is  better  treated by  detecting the  underlying disease,  and  its correction may  help  to  reduce  the  hospital stay.25

Data   collected  for   nutritional  status   is carried   on  Douglas   score   which   is  a  tool for   risk   assessment,  however  the   patients were rarely properly assessed and none had nutritional input. This may indicate that those patients  will be better assessed and corrected by dietician.  Breslow  et ai26 compared tube­ fed patients and noted that the patients with pressure  sores were in poorer nutritional condition,  as   assessed   by   albumin   level, despite of high protein intake. Similar results were found  by Green et ai27 worked on a community sample  of  175  elderly   patients, and by Allman  et ai28 evaluated among  286 hospitalised  patients   above  the  age  of  55. The 2006  NICE  guidance29 recommends simple  initial assessment and referral to a multidisciplinary nutritional support  team.

Our study here high-light the need to look at  every  aspect  of  management of  wounds in diabetic  patients,  as they are frequently malnourished and anaemic.  Also, a policy should  be put that  all  patients  with  diabetic foot wound should start on nutritional supplements  and  be  reviewed  by  the nutritional support team.

Conclusion

Anaemia as well  as poor  nutnt10n  1s usually  the  normal   event  and  affecting  the healing of diabetic wounds. Multidisciplinary review  of  the  haematological investigations by internist,  dietician, and surgeon  should  be undertaken in all patients.

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