Advanced Chronic Kidney Disease as A Limiting Factor for Conventional Limb Salvage in Neuroischemic Diabetic Foot Syndrome

Abstract

Neuroischemic diabetic foot syndrome in patients with chronic kidney disease is associated with severe peripheral arterial disease, impaired tissue repair, recurrent infectious complications, and high risk of major amputation. Although revascularization remains a cornerstone of limb salvage strategies, the effectiveness of conventional treatment approaches may be substantially limited in patients with advanced renal dysfunction because of restricted feasibility of contrast-enhanced vascular imaging and endovascular correction. To evaluate the effectiveness and limitations of conventional treatment strategies in patients with neuroischemic diabetic foot syndrome and chronic kidney disease depending on the severity of renal dysfunction. This retrospective study included 55 patients with neuroischemic diabetic foot syndrome and chronic kidney disease. Patients were divided into two groups according to renal function severity: Group I included 34 patients with compensated chronic kidney disease (G1-G3a, eGFR ≥45 ml/min/1.73 m²), whereas Group II consisted of 21 patients with decompensated chronic kidney disease (G3b-G5, eGFR <45 ml/min/1.73 m²). Clinical, metabolic, laboratory, vascular, surgical, and postoperative outcomes were analyzed comparatively. Special attention was paid to feasibility of vascular imaging, endovascular treatment, limb preservation, repeated surgical interventions, and mortality. Patients with advanced chronic kidney disease demonstrated more severe ischemic and infectious lesions, higher prevalence of gangrene, larger wound defects, elevated inflammatory markers, anemia, and hypoalbuminemia. Computed tomography angiography was performed significantly less frequently in Group II (28.6% vs 58.8%), while endovascular revascularization procedures were markedly restricted in patients with severe renal dysfunction. Post-angiographic deterioration of renal function occurred in 23.8% of Group II patients compared with 5.9% in Group I. Patients with decompensated chronic kidney disease demonstrated substantially higher rates of repeated surgical procedures, major amputations, reamputations, recurrent necrotic complications, and six-month mortality. Functional limb preservation was achieved in 82.4% of patients in Group I and only 42.9% in Group II. No patients with advanced chronic kidney disease achieved stable long-term “good” treatment outcome. Advanced chronic kidney disease significantly limits the effectiveness of conventional treatment strategies in patients with neuroischemic diabetic foot syndrome. Restricted feasibility of contrast-enhanced vascular imaging and endovascular correction, combined with severe metabolic and inflammatory disturbances, substantially worsens limb salvage outcomes and increases the risk of major amputation and mortality. Development of individualized treatment approaches with reduced nephrotoxic exposure may improve outcomes in this high-risk patient population.