**3.1 Causative disease in patients receiving HD**

Patients receiving HD because of DM (57%) ranged in age from 53 to 74 years (mean, 62.4 ± 7.9 years), and patients receiving HD because of other diseases, including chronic glomerular nephritis (CGN), polycystic kidney, and systemic lupus erythematosus (43%), ranged in age from 52 to 69 years (mean, 61.3 ± 6.0 years) (no significant difference, Wilcoxon rank sum test). All diabetic patients were classified with type 2 diabetes mellitus. Serous calcium level of diabetic patients ranged from 7.1 to 9.3 mg/dl (mean, 8.5 ± 0.7 mg/dl), and that of non-diabetic patients ranged from 8.9 to 10.2 mg/dl (mean, 9.6 ± 0.5 mg/dl). There was no significant difference between the groups (p=0.5, Wilcoxon rank sum test). Inorganic phosphate levels of diabetic patients ranged from 2.4 to 4.2 mg/dl (mean, 3.7 ± 0.6 mg/dl), and that of non-diabetic patients ranged from 2.8 to 4.6 mg/dl (mean, 3.2 ± 0.8 mg/dl). There was no significant difference between the groups (p=0.4, Wilcoxon rank sum test).

Fig. 6. Causative disease in patients receiving HD (N=30)

We investigated differences in the cause of wounds, size of wounds, need for immediate debridement, and interval between the start of HD and wound development, between patients with chronic renal failure due to DM and that due to other diseases (Tables 1, 2). All information was obtained from patients' medical records, examinations, and an interview at the first examination.


DM, diabetes mellitus. CGN, chronic glomerulonephritis. FSG, free skin grafting. SLE, systemic lupus erythematosus. MRSA, methicillin-resistant Staphylococcus aureus. HT, hypertension. ASO, arteriosclerosis obliterans

Table 1. Profiles and clinical status of patients undergoing HD with extremity ulcers due to diabetes mellitus.

126 Technical Problems in Patients on Hemodialysis

Patients receiving HD because of DM (57%) ranged in age from 53 to 74 years (mean, 62.4 ± 7.9 years), and patients receiving HD because of other diseases, including chronic glomerular nephritis (CGN), polycystic kidney, and systemic lupus erythematosus (43%), ranged in age from 52 to 69 years (mean, 61.3 ± 6.0 years) (no significant difference, Wilcoxon rank sum test). All diabetic patients were classified with type 2 diabetes mellitus. Serous calcium level of diabetic patients ranged from 7.1 to 9.3 mg/dl (mean, 8.5 ± 0.7 mg/dl), and that of non-diabetic patients ranged from 8.9 to 10.2 mg/dl (mean, 9.6 ± 0.5 mg/dl). There was no significant difference between the groups (p=0.5, Wilcoxon rank sum test). Inorganic phosphate levels of diabetic patients ranged from 2.4 to 4.2 mg/dl (mean, 3.7 ± 0.6 mg/dl), and that of non-diabetic patients ranged from 2.8 to 4.6 mg/dl (mean, 3.2 ± 0.8 mg/dl). There was no significant difference between the groups (p=0.4,

DM

57%

**3.1 Causative disease in patients receiving HD** 

CGN

SLE

Polycystic kidney 3%

We investigated differences in the cause of wounds, size of wounds, need for immediate debridement, and interval between the start of HD and wound development, between patients with chronic renal failure due to DM and that due to other diseases (Tables 1, 2). All information was obtained from patients' medical records, examinations, and an interview at

3%

37%

Fig. 6. Causative disease in patients receiving HD (N=30)

the first examination.

Wilcoxon rank sum test).


DM, diabetes mellitus. CGN, chronic glomerulonephritis. FSG, free skin grafting. SLE, systemic lupus erythematosus.

MRSA, methicillin-resistant Staphylococcusa complex HT, hypertension. ASO, arteriosclerosis obliterans

Table 2. Profiles and clinical status of patients undergoing HD with extremity ulcers due to diseases other than diabetes mellitus.

Complex Wounds in Patients Receiving Hemodialysis 129

Wounds in patients with CRF due to DM were caused by trauma (burns and pressure ulcers) in 6 cases (35.3%), infection in 6 cases (35.3%), and ischemia in 5 cases (29.4%). Wounds in patients with CRF due to other diseases were associated with trauma in 6 cases

DM+

DM-

Trauma Infection Ischemia

The size of wounds in patients with DM ranged in area from 4 to 450 cm2 (mean, 69.5 ± 120.8 cm2), and that in patients without DM ranged from 3 to 65 cm2 (mean, 617.8 ± 18.9 cm2) (no

DM+ DM-

Wound infection is common and difficult to control, because cutaneous surfaces are without protective barriers, through which patients receiving HD may easily acquire bacterial infection. Our study revealed that bacilli were cultured from 12 of 17 (70.6%) wounds in patients with DM. and 9 of 13 (69.2%) without DM. There was no significant difference in the frequency of bacterial isolation between the two groups (chi-square test). Concerning to

Fig. 8. Differences in size of wounds in CRF due to DM and other diseases.

Fig. 7. Cause of wounds in patients with CRF due to DM or other diseases.

**3.3 Differences in wound size in CRF caused by DM and other diseases** 

significant difference, Wilcoxon rank sum test) (Figure 8).

0

**3.4 Bacterial infection in patients receiving HD** 

100

200

300

400

500

**3.2 Cause of wounds in patients with CRF due to DM or other diseases** 

(46.5%), infection in 3 cases (23.2%), and ischemia in 4 cases (30.3%) (Figure 7).

DM, diabetes mellitus. CGN, chronic glomerulonephritis. FSG, free skin grafting. SLE, systemic lupus

Table 2. Profiles and clinical status of patients undergoing HD with extremity ulcers due to

MRSA, methicillin-resistant Staphylococcusa complex HT, hypertension. ASO, arteriosclerosis

erythematosus.

diseases other than diabetes mellitus.

obliterans

#### **3.2 Cause of wounds in patients with CRF due to DM or other diseases**

Wounds in patients with CRF due to DM were caused by trauma (burns and pressure ulcers) in 6 cases (35.3%), infection in 6 cases (35.3%), and ischemia in 5 cases (29.4%). Wounds in patients with CRF due to other diseases were associated with trauma in 6 cases (46.5%), infection in 3 cases (23.2%), and ischemia in 4 cases (30.3%) (Figure 7).

Fig. 7. Cause of wounds in patients with CRF due to DM or other diseases.

#### **3.3 Differences in wound size in CRF caused by DM and other diseases**

The size of wounds in patients with DM ranged in area from 4 to 450 cm2 (mean, 69.5 ± 120.8 cm2), and that in patients without DM ranged from 3 to 65 cm2 (mean, 617.8 ± 18.9 cm2) (no significant difference, Wilcoxon rank sum test) (Figure 8).

Fig. 8. Differences in size of wounds in CRF due to DM and other diseases.

#### **3.4 Bacterial infection in patients receiving HD**

Wound infection is common and difficult to control, because cutaneous surfaces are without protective barriers, through which patients receiving HD may easily acquire bacterial infection. Our study revealed that bacilli were cultured from 12 of 17 (70.6%) wounds in patients with DM. and 9 of 13 (69.2%) without DM. There was no significant difference in the frequency of bacterial isolation between the two groups (chi-square test). Concerning to

Complex Wounds in Patients Receiving Hemodialysis 131

Extremity ulcers in patients receiving HD are often difficult to heal. Nonetheless, patients with severely ischemic limbs due to maintenance HD are markedly increasing in number 1,2). They often require multiple surgeries because arteriosclerosis obliterans usually progresses,

A B

D

**4. Treatments of complex wounds in patients receiving HD** 

which causes other ischemic ulcers (Figures 2, 11, 12).

**4.1 Immediate debridement and amputation aiming at infection control** 

C

Fig. 11. (A) A patient with an ischemic foot due to maintenance HD developed necrosis of the left 2nd toe. (B) The ulcer was resolved by amputation. (C) However, he developed another site of necrosis with infection (arrow) on the third toe. (D) The patient underwent

immediate debridement and osteotomy. (E)The wounds healed satisfactorily.

E

the seriousness of infection, 13 of 17 wounds required immediate surgery including amputation and debridement in patients with DM, while, only 1 of 13 required immediate surgery in patients without DM. There was a significant difference between the groups (p<0.05, Chi-square test) (Figure 9). These results suggest that patients receiving HD because of diabetes are likely to develop more severe wound infections.

Methicillin-resistant *Staphylococcus aureus* (MRAS) was commonly isolated from these contaminated wounds, being isolated from 9 of 12 (75.0%) in the DM group, and 8 of 9 (88.9%) in the non-DM group.

#### **3.5 Interval between the start of HD and wound development**

The interval between the start of HD and wound development in patients with DM ranged from 1 month to 8 years (mean, 3.2 ± 2.1 years), and that in patients without DM ranged from 2 to 43 years (mean, 12.4± 12.7 years). It was significantly shorter in patients with than in those without diabetes. (p=0.017, Wilcoxon rank sum test) (Figure 10).

Fig. 10. Differences in the interval between the start of HD and wound development in CRF due to DM and other diseases.

the seriousness of infection, 13 of 17 wounds required immediate surgery including amputation and debridement in patients with DM, while, only 1 of 13 required immediate surgery in patients without DM. There was a significant difference between the groups (p<0.05, Chi-square test) (Figure 9). These results suggest that patients receiving HD because

Methicillin-resistant *Staphylococcus aureus* (MRAS) was commonly isolated from these contaminated wounds, being isolated from 9 of 12 (75.0%) in the DM group, and 8 of 9

> DM+ DM-

Immediate debridement+ Immediate debridement-

The interval between the start of HD and wound development in patients with DM ranged from 1 month to 8 years (mean, 3.2 ± 2.1 years), and that in patients without DM ranged from 2 to 43 years (mean, 12.4± 12.7 years). It was significantly shorter in patients with than

DM+ DM-

Fig. 10. Differences in the interval between the start of HD and wound development in CRF

Fig. 9. Need of immediate debridement in patients with CRF due to DM or other diseases.

of diabetes are likely to develop more severe wound infections.

**3.5 Interval between the start of HD and wound development** 

due to DM and other diseases.

(Years)

in those without diabetes. (p=0.017, Wilcoxon rank sum test) (Figure 10).

(88.9%) in the non-DM group.

0

2

4

6

8

10

12

14
