As a registered nurse for over 30 years with experience in a variety of settings including: critical care, organ recovery and transplant, cardiac cath lab and wound care I’ve seen and done a lot. One of the irrefutable joys of nursing, no matter the setting, is connecting with people and helping them live a better quality of life. Over the years, I’ve collected many stories, but one really stands out:
This patient was in her 70’s, quite active and loved life. She especially liked to
ballroom dance as she had for many years, with her husband of almost 50 years.
She was a medically complex patient including diabetes, ESRD and was faced with
a transmetatarsal amputation after many unsuccessful attempts to heal her
diabetic foot ulcer (DFU). When her MD discussed her treatment options
(amputation), she replied…
“No thank you, I want to dance.”
People with diabetes fear amputation worse than death. While patients are living longer due to better treatments and technology, they are also living long enough to develop end-stage renal disease (ESRD) making it the most common cause of the chronic disease.
ESRD and diabetes can lead to many complications, one of the most common is diabetic foot ulcer (DFU). Most patients that develop ulcerations in the foot experience diabetic or peripheral neuropathy, the impaired function of the nerves in detecting pain, pressure, or movement sensation that affects the longest nerves first (toes and feet).
Along with the diabetic neuropathy, these patients often experience the same symptoms as uremic neuropathy due to the accumulation of uremia. It is the loss of this protective mechanism that results in undetected trauma or infection that leads to the DFU.
Essential components to wound management and healing are glucose (energy), oxygen, protein, and perfusion. The detrimental effects of diabetes and ESRD impairs wound healing by decreasing the amount of nutrients and oxygen to the wound thus leading to a chronic wound.
- Perfusion is likely to be decreased due to ESRD effects. Neuropathy and microvascular changes are significant risk factors in developing a DFU and impaired wound healing in diabetic patients with ESRD.
- Protein is essential for wound healing as part of an optimal nutrition plan. ESRD patients are at risk for protein energy wasting and malnutrition due to decreased dietary intake, increased inflammation, and metabolic acidosis.
- Dialysis patients have high protein needs without any additional stressors, 1.0-1.2g/kg/day. With the additional stress of wound healing, the protein recommendations will typically increase up to 1.5 – 2.0g/kg/day.
- Patients can benefit from intensive nutrition support in the form of increased dietary protein, oral nutrition supplements, and Intradialytic Parenteral Nutrition (IDPN) for hemodialysis or Intraperitoneal Nutrition (IPN) for peritoneal dialysis.
- Uremia accumulates in the body due to ESRD and has a negative effect on wound healing.
- Hemodialysis is essential for survival in ESRD but also has adverse effects. It’s been observed that a decrease in transcutaneous oxygen (TcPO2) occurs during and after hemodialysis declining for at least four hours after treatment. The drop in oxygen in the lower extremities acquired during dialysis decreases peripheral blood flow depriving the wound of blood, oxygen, and nutrients essential for wound healing.
- Immunosuppression in patients with ESRD is caused not only by hypoproteinemia but also by uremic toxins thus increasing the chance of delayed wound healing through infection.
This patient had a multidisciplinary wound care team that took a comprehensive approach to address her diabetes and ESRD along with other co-morbidities. The main goal was to avoid amputation with limb salvage being in the forefront of our minds.
Medical and surgical interventions were considered as well as the patient’s active lifestyle and motivation to adhere to the comprehensive treatment plan. It was imperative that we addressed as many of these barriers as possible. We wanted to heal her DFU and improve her quality of life. Her treatment plan included relatively new technology that was noninvasive that would hopefully allow her to avoid the transmetatarsal amputation.
Vacuum assisted closure, a noninvasive device that uses vacuum through negative pressure to promote wound healing by removing excess fluid that can impede cell growth and proliferation, improving circulation to the wound bed, reducing bacteria on the wound surface, decreasing local tissue swelling, an increasing rate of cell division and formulation of granulation tissue.
This complicated patient population requires a dedicated multidisciplinary team approach. Barriers to wound healing and an understanding of various causes also need to be considered and monitored carefully. Patient motivation to adhere to the treatment plan was helpful since she allowed time for the wound device to work as well as for her nutritional status to improve.
After six months of a multidisciplinary team approach, she came to clinic and her words that put a smile on my face and warmth in my heart were…
“Thank you, I can dance.”
Thank you to our guest blogger, Andy Araujo, BA, RN, for sharing his expertise and patient experience for this blog post.
To learn more about diabetes in dialysis and how Patient Care America can help support nutrition goals of patients with wounds and other comorbidities, check out these resources:
- Clinician login for patient and clinician handouts
- Blog posts
- Past Presentations
- Nutrition for Wound Healing in the Setting of Chronic Kidney Disease
- Micronutrient Concerns in CKD and ESRD
- Boosting Immune Function in Chronic Kidney Disease
- Evolution in the Assessment of Malnutrition