Mortality in Diabetic and Nondiabetic Patients After Amputations Performed From 1990 to 1995 A 5-year follow-up study NICHOLAS TENTOLOURIS, MD SAMEER AL-SABBAGH, MRCP MICHAEL G. WALKER, MD, FRCS ANDREW J.M. BOULTON, MD, FRCP EDWARD B. JUDE, MD, FRCP OBJECTIVE — To compare survival rates after first amputation between patients with and without diabetes. RESEARCH DESIGN AAND METHODS — We performed a retrospective study of all nontraumatic amputations performed at our center in the years 1990 –1995 in patients with (n = 100) and without (n = 151) diabetes. Survival status was assessed from the first amputation until 31 December 2001. RESULTS — Altogether, 61% of the patients with and 54.3% of those without diabetes died 5.2 (4.5–5.8) and 5.3 (4.7–5.9) [mean (95% CI)] years after the first amputation, respectively (P = 0.80). Survival was not different between patients with and without diabetes after control- ling for the level (major versus minor) (P = 0.67) or the cause (ischemia versus infection) of amputation (P = 0.72). No sex differences were found for survival in either study group. Independent predictors of mortality in the diabetic group were duration of diabetes (P = 0.05), history of stroke (P = 0.02), and serum creatinine level (P  0.0001), while in the nondiabetic group independent predictors were history of stroke (P = 0.04), serum creatinine level (P = 0.005), and higher white blood cell count (P = 0.02). The peak incidence of amputations was observed in the decade of 67–76 years of age in both groups. Major amputations were more common among nondiabetic patients in all age-groups. Median hospital stay and postoperative complications were comparable between the two groups. CONCLUSIONS — All-cause mortality is high after an amputation in both diabetic and nondiabetic patients. Mortality rates, hospital stay, and postoperative complications are not different between diabetic and nondiabetic amputees. No modifiable factors, with the exception of nephropathy, were found to improve survival in amputees. Peripheral vascular disease and neuropathy are the main cause of amputations; prevention, therefore, of these complications is warranted to prevent amputations and the subsequent high mortality. Diabetes Care 27:1598 –1604, 2004 D iabetes is the cause of almost 50% of all nontraumatic lower-extremity amputations worldwide (1–5). It is estimated that the lifetime risk for ampu- tation in patients with diabetes is 10 – 15%, 10 –30 times higher in comparison with the general population (2,3). Ampu- tation is associated with a high rate of sub- sequent amputation and considerable health care cost in both patients with and without diabetes (6,7). Most amputations in diabetic patients are due to peripheral vascular disease, peripheral neuropathy, and infection, while in nondiabetic pa- tients peripheral vascular disease is the main cause (2,8). Previous studies have demonstrated an increased mortality fol- lowing an amputation in both diabetic and nondiabetic patients (4,9 –12). How- ever, no recent data exist concerning the comparison in survival after an amputa- tion between diabetic and nondiabetic patients. The primary objective of this study was to look at the outcome of am- putees and compare it between those with and without diabetes to see if there are any modifiable risk factors for increased mortality in the diabetic group. In addi- tion, parameters such as cause and level of amputation, length of hospitalization, and postoperative complications in dia- betic and nondiabetic patients were also examined. RESEARCH DESIGN AND METHODS — We reviewed all non- trauma, nonneoplasm-related amputa- tions (ICD9-CM codes 84.10 – 84.18) (13) performed at the Manchester Royal Infirmary between 1 January 1990 and 31 December 1995. Participants in the dia- betic group (n = 102) were patients who had been diagnosed with diabetes accord- ing to their medical records. In addition, patients with unknown diabetes but with fasting serum glucose values 126 mg/dl measured twice were considered as hav- ing diabetes. Nondiabetic amputees (n = 154) were patients without a history of diabetes and with fasting serum glucose levels 126 mg/dl. Duration of diabetes was from the time of diagnosis until the first event amputation. Presence of dia- betic nephropathy, retinopathy, and his- tory of smoking were noted from the medical records. Nephropathy was de- fined as either serum creatinine values 130 mol/l for both sexes and/or 24-h urine protein 300 mg/dl. The demo- graphic and clinical characteristics of the study patients are shown in Table 1. ●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●● From the University of Manchester, Department of Medicine, Manchester Royal Infirmary, Manchester, U.K. Address correspondence and reprint requests to Dr. E.B. Jude, Diabetes Centre, Tameside General Hos- pital, Fountain Street, Ashton-under-Lyne, OL6 9RW, U.K. E-mail: edward.jude@tgh.nhs.uk. Received for publication 1 February 2004 and accepted in revised form 5 April 2004. Abbreviations: IHD, ischemic heart disease; WBC, white blood cell count. A table elsewhere in this issue shows conventional and Syste `me International (SI) units and conversion factors for many substances. © 2004 by the American Diabetes Association. Epidemiology/Health Services/Psychosocial Research O R I G I N A L A R T I C L E 1598 DIABETES CARE, VOLUME 27, NUMBER 7, JULY 2004