All-cause mortality among diabetic foot patients and related risk factors in Saudi Arabia

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Abstract

Background

Although Diabetes mellitus is a major public health problem in the Middle East and North Africa (MENA) region with high rates of diabetic foot complications, there are only limited data concerning mortality among such a high risk group. Therefore, the main aim of the current study was to assess all-cause mortality and its related predictors among diabetic patients with and without diabetic foot complications.

Methods

Using data from the Saudi National Diabetes Registry (SNDR), a total of 840 patients with type 1 or type 2 diabetes aged ≥25 years with current or past history of diabetic foot ulcer (DFU) or diabetes related lower extremity amputation (LEA) were recruited in 2007 from active patients’ files and followed up to 2013. These patients were compared with an equal number of age and gender matched diabetic patients without foot complication recruited at the same period. All patients were subjected to living status verification at 31st December 2013.

Results

The all-cause mortality rate among patients with DFU was 42.54 per 1000 person-years and among LEA patients was 86.80 per 1000 person-years among LEA patients for a total of 2280 and 1129 person-years of follow up respectively. The standardized mortality ratio (SMR) (95% CI) was 4.39 (3.55–5.23) and 7.21 (5.70–8.72) for cases with foot ulcer and LEA respectively. The percentage of deceased patients increased by almost twofold (18.5%) among patients with diabetic foot ulcer and more than threefold (32.2%) among patients with LEA compared with patients without diabetic foot complications (10.7%). The worst survival was among patients with LEA at 0.679 and the presence of diabetic nephropathy was the only significant independent risk factor for all-cause mortality among patients with diabetic foot complications. On the other hand, obese patients have demonstrated significantly reduced all-cause mortality rate.

Conclusions

Diabetic patients with diabetic foot complications have an excess mortality rate when compared with diabetic counterparts without foot complications and the general population. Early interventions to prevent foot ulceration and consequent LEA as well as all the measurements for reducing the prevalence of microvascular and macrovascular complications should be considered.

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Most cited references 27

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Diabetic Foot Complications and Their Risk Factors from a Large Retrospective Cohort Study

Khalid Al-Rubeaan, Mohammad Al Derwish, Samir Ouizi … (2015)

Background Foot complications are considered to be a serious consequence of diabetes mellitus, posing a major medical and economical threat. Identifying the extent of this problem and its risk factors will enable health providers to set up better prevention programs. Saudi National Diabetes Registry (SNDR), being a large database source, would be the best tool to evaluate this problem. Methods This is a cross-sectional study of a cohort of 62,681 patients aged ≥25 years from SNDR database, selected for studying foot complications associated with diabetes and related risk factors. Results The overall prevalence of diabetic foot complications was 3.3% with 95% confidence interval (95% CI) of (3.16%–3.44%), whilst the prevalences of foot ulcer, gangrene, and amputations were 2.05% (1.94%–2.16%), 0.19% (0.16%–0.22%), and 1.06% (0.98%–1.14%), respectively. The prevalence of foot complications increased with age and diabetes duration predominantly amongst the male patients. Diabetic foot is more commonly seen among type 2 patients, although it is more prevalent among type 1 diabetic patients. The Univariate analysis showed Charcot joints, peripheral vascular disease (PVD), neuropathy, diabetes duration ≥10 years, insulin use, retinopathy, nephropathy, age ≥45 years, cerebral vascular disease (CVD), poor glycemic control, coronary artery disease (CAD), male gender, smoking, and hypertension to be significant risk factors with odds ratio and 95% CI at 42.53 (18.16–99.62), 14.47 (8.99–23.31), 12.06 (10.54–13.80), 7.22 (6.10–8.55), 4.69 (4.28–5.14), 4.45 (4.05–4.89), 2.88 (2.43–3.40), 2.81 (2.31–3.43), 2.24 (1.98–2.45), 2.02 (1.84–2.22), 1.54 (1.29–1.83), and 1.51 (1.38–1.65), respectively. Conclusions Risk factors for diabetic foot complications are highly prevalent; they have put these complications at a higher rate and warrant primary and secondary prevention programs to minimize morbidity and mortality in addition to economic impact of the complications. Other measurements, such as decompression of lower extremity nerves, should be considered among diabetic patients.

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Smoking in Saudi Arabia.

Medhat M Bassiony (2009)

This article reviewed the literature on the epidemiology, consumption, trade, control, prevention, and treatment of tobacco smoking in Saudi Arabia. The prevalence of current smoking in Saudi Arabia ranges from 2.4-52.3% (median = 17.5%). Among school students, the prevalence of current smoking ranges from 12-29.8% (median = 16.5%), among university students from 2.4-37% (median = 13.5%), and among adults from 11.6-52.3% (median = 22.6%). In elderly people, the prevalence of current smoking is 25%. The prevalence of smoking in males ranges from 13-38% (median = 26.5%), while in females it ranges from 1-16% (median = 9%). To conclude, smoking is prevalent in the Saudi population at different age groups. The prevalence of current smoking is much higher in males than in females at different ages. More research is needed in the area of prevention and treatment of smoking.

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The association of ulceration of the foot with cardiovascular and all-cause mortality in patients with diabetes: a meta-analysis.

Sally R Hinchliffe, Raymond Davey, Matt M. Thompson … (2012)

It is well established that diabetes mellitus increases the risk of cardiovascular disease (CVD) and all-cause mortality. Observational studies suggest that a history of diabetic foot ulceration (DFU) may increase this risk further still. We sought to determine to what extent DFU is associated with excess risk over and above diabetes. We identified studies reporting on associations of DFU with CVD and all-cause mortality. We obtained data on incident events of all-cause mortality, fatal myocardial infarction and fatal stroke. Study-specific estimates were pooled using a random-effects meta-analysis and the statistical heterogeneity of included studies was assessed using the I (2) statistic. The eight studies included reported on 3,619 events of all-cause mortality during 81,116 person-years of follow-up. DFU was associated with an increased risk of all-cause mortality (RR 1.89, 95% CI 1.60, 2.23), fatal myocardial infarction (2.22, 95% CI 1.09, 4.53) and fatal stroke (1.41, 95% CI 0.61, 3.24). CVD mortality accounted for a similar proportion of deaths in DFU and non-DFU patients. Patients with DFU have an excess risk of all-cause mortality, compared with patients with diabetes without a history of DFU. This risk is attributable, in part, to a greater burden of CVD. If this result is validated in other studies, strategies should evaluate the role of further aggressive CVD risk modification and ulcer prevention in those with DFU.

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Author and article information

Contributors

Khalid Al-Rubeaan:

ORCID: http://orcid.org/0000-0003-3615-7192

Role: Data curationRole: Formal analysisRole: InvestigationRole: Writing – original draftRole: Writing – review & editing

Mohammad K. Almashouq: Role: Writing – original draftRole: Writing – review & editing

Amira M. Youssef: Role: Data curationRole: Formal analysisRole: Writing – original draftRole: Writing – review & editing

Hamid Al-Qumaidi: Role: Data curationRole: Writing – original draftRole: Writing – review & editing

Mohammad Al Derwish: Role: Data curationRole: MethodologyRole: Writing – original draftRole: Writing – review & editing

Samir Ouizi: Role: Data curationRole: Writing – original draftRole: Writing – review & editing

Khalid Al-Shehri: Role: Formal analysisRole: Writing – original draftRole: Writing – review & editing

Saba N. Masoodi: Role: Data curationRole: Writing – original draftRole: Writing – review & editing

Rayaz Ahmed Malik: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 27 November 2017

Publication date Collection: 2017

Volume: 12

Issue: 11

Electronic Location Identifier: e0188097

Affiliations

[1 ] University Diabetes Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia

[2 ] College of medicine, King Saud University, Riyadh, Saudi Arabia

[3 ] Registry Department, University Diabetes Center, King Saud University, Riyadh, Saudi Arabia

[4 ] Diabetic Foot Unit, University Diabetes Center, King Saud University, Riyadh, Saudi Arabia

Weill Cornell Medical College in Qatar, QATAR

Author notes

Competing Interests: The authors have declared that no competing interests exist.

* E-mail: krubeaan@ 123456dsrcenter.org

Author information

Khalid Al-Rubeaan http://orcid.org/0000-0003-3615-7192

Article

Publisher ID: PONE-D-17-30243

DOI: 10.1371/journal.pone.0188097

PMC ID: 5703519

PubMed ID: 29176889

SO-VID: d1d4d76a-afc1-4345-b44e-9c3c653df75e

License:

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 30 August 2017

Date accepted : 31 October 2017

Page count

Figures: 2, Tables: 4, Pages: 15

Funding

Funded by: This project was funded by King Abdulaziz city for science and technology (KACST). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Award Recipient :

ORCID: http://orcid.org/0000-0003-3615-7192

Khalid Al-Rubeaan

This project was funded by King Abdulaziz city for science and technology (KACST). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Custom metadata

Data Availability The data contain potentially sensitive patients’ information. The Saudi National Diabetes Registry steering committee has a restriction on sharing the register data. Any queries concerning the data should be addressed to Dr. Al Rubeaan at krubeaan@ 123456dsrcenter.org , or SNDR@ 123456dsrcenter.org However the data access is restricted.

All-cause mortality among diabetic foot patients and related risk factors in Saudi Arabia

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Most cited references 27

Diabetic Foot Complications and Their Risk Factors from a Large Retrospective Cohort Study

Smoking in Saudi Arabia.

The association of ulceration of the foot with cardiovascular and all-cause mortality in patients with diabetes: a meta-analysis.

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