Feckless patient with endstage renal failure

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A 44-year-old woman with type 1 diabetes of 26 years' duration, proliferative retinopathy, profound neuropathy and end-stage renal failure treated by renal transplant had her feet checked at monthly intervals at the renal unit as part of a research protocol. Her foot pulses were palpable. She was educated in foot care, foot inspections and early reporting of any problems. However, during a 3-year period she suffered nine separate episodes of foot trauma, none of which she reported early: they were detected at

Fig. 6.10 This patch of necrosis developed on the apex of the 1st toe of a patient in end-stage renal failure treated by renal transplantation. Her pedal pulses were palpable. The patch of necrosis began as a small crack in the nail sulcus and spread very slowly to involve most of the toe, which was amputated because of severe pain. She smoked 25 cigarettes a day.

Necrosis Toes
Fig. 6.11 This patient in end-stage renal failure treated with renal transplantation dropped an object on her toe and developed dry necrosis. The toe autoamputated after 13 months.

her renal unit appointment. Causes of trauma included blisters from ill-fitting shoes, picking at dry skin, pulling off pieces of nail and being 'trodden on by a baby'. In the last episode she stubbed her toe while walking barefoot, did not report the injury and presented late to the renal unit with spreading cellulitis, wet necrosis and septicaemia. She was resuscitated and treated with intravenous antibiotics and underwent 1st ray amputation to remove the source of her sepsis. Despite this, her septicaemia progressed and became overwhelming and she suffered a cardiac arrest and could not be resuscitated.

Key points

' Diabetic renal patients are susceptible to frequent and repeated traumas

• They often present late

• Infection in the renal transplant patient, in the presence of immunosuppressive treatment, can rapidly become overwhelming.

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