Early-onset diabetic foot ulcers in CKD

Vanaja1*, Lucy Grace2, Jaya Menon3

1Staff Nurse, Kauvery Hospital, Tennur, Trichy

2Nurse Educator, Kauvery Hospital, Tennur, Trichy

3Nursing Superintendent, Kauvery Hospital, Tennur, Trichy

Abstract 

Chronic kidney Disease (CKD) significantly increases the risk of developing Diabetic foot ulcers (DFU) accelerates atherosclerosis, leading to narrowed blood vessels and reduced blood flow to the lower extremities. This diminished circulation impairs wound healing and heightens the risk of ulceration. CKD compromises the immune response, reducing the body’s ability to combat infections. This makes it more challenging to prevent and manage infections in foot ulcers. Diabetes often causes nerve damage, resulting in loss of sensation in the feet. CKD can exacerbate this condition, making patients unaware of minor injuries that can progress to ulcers. While DFU are more common in older adults, an increasing number of young CKD patients are developing these ulcers at an early age. Understanding the causes, risk factors, and management strategies is crucial for preventing and treating diabetic foot ulcer in young CKD patients.

Case presentation

A 27-years-old male, a chef working in the USA, came to India on vacation. He had been experiencing heel pain for the past one month and now presents with complaints of severe heel pain and giddiness. He has a known history of case of CKD and diabetes mellitus with no history of alcohol consumption or smoking.

On Examination

A heel abscess was suspected in the patient. Relevant blood investigations revealed raised creatinine levels 2.3 and low GFR. A foot X-ray was taken, which confirmed the diagnosis of a heel abscess. The patient is already known to have diabetes and uncontrolled hyperglycemia was noted. Plasma acetone levels were tested and the result was positive.

The patient was initially managed with an insulin infusion and then switched to short-acting insulin split doses. The patient underwent a comprehensive pre-operative evaluation and optimization. On 22nd January 2024, wound debridement and washout were performed under spinal anaesthesia to treat an abscess in the right foot, as confirmed by the foot X-ray. Pus was drained and the wound was irrigated with 2 litres of saline solution. Fungal culture was sent for further analysis.

Initially, the patient experienced foot pain following wound debridement, but the pain gradually subsided. Analgesics were administered and pillow support was provided to ensure additional comfort.

Pus was aspirated from the lesion and the culture revealed fungal hyphae. As a result, treatment with amphotericin and antibiotics, including clindamycin and meropenam was initiated. The patient was conscious and oriented.

Nursing Management

1. Haemodynamic monitoring

We closely monitored the patient using non-invasive methods, including blood pressure, pulse, temperature, skin colour, capillary refill time, and pulse oximetry. The patient experienced pain at the surgical site, with a pain score of 3. His vital signs included a blood pressure of 140/80 mmHg, SpO2 of 99% on room air, a pulse rate of 100 bpm, and a temperature of 99.8°F.

2. Pain Management

Initially, the patient experienced a pain score of 5 following wound debridement, overtime the pain gradually subsided with the patient later experiencing moderate pain scoring 2 Initially, intravenous analgesics were administered, including Inj. Paracetamol 1 gm IV three times a day (TDS) and Inj. Tramadol 50 mg IV twice a day (BD).

3. Comprehensive Assessment

Nurses conducted thorough inspections of patients’ feet to identify early signs of ulcers, such as cuts, blisters, redness, or swelling. Assessments for peripheral neuropathy were performed by testing sensation levels, as reduced sensation increased ulcer risk.

4. Intake and Output Monitoring

We monitored the patient’s intake and output every 2 hours to assess hydration status and fluid balance. Additionally, we educated the patient and their family members to monitor the amount and colour of urine, as well as observe the patient’s health for signs such as dizziness and urine output

5. Nutritional Support

The nursing team, in collaboration with doctors and dietitians, focused on providing the patient with a diabetic-friendly diet and salt restricted diet. Our team took on the challenge of ensuring proper nutrition, offering a well-balanced diet with adequate calories, proteins, and fibre, along with intravenous fluids.

The patient was discharged in stable condition. Prior to discharge, comprehensive education was provided on managing chronic kidney disease and diabetes mellitus emphasizing the importance of blood sugar control and regular monitoring.

Patient Education

  • Patients were instructed on daily foot hygiene, proper nail care
  • Blood Glucose Control: The role of maintaining optimal blood sugar levels to enhance wound healing and reduce infection risk was emphasized.
  • Appropriate dressings were applied to maintain a moist environment, facilitating tissue repair.
  • Regular Communication: Consistent information sharing among team members was ensured to coordinate care effectively.
  • Frequent assessments were scheduled to monitor healing progress and adjust care plans as needed.
  • Ongoing education and emotional support were provided to encourage adherence to treatment regimens.

Conclusion

Young CKD patients with diabetes are at significant risk of early-onset diabetic foot ulcers due to neuropathy, poor circulation, and immune dysfunction. However, early intervention, proper foot care and lifestyle modifications can prevent serious complications. Raising awareness and encouraging regular foot check-ups can significantly reduce the burden of DFUs in young CKD patients, improving their quality of life.

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