High Burden, Challenging Care and Poor Outcome: the Diabetic Foot Ulcer in Nigeria - data from the MEDFUN Study Group

Ugwu TE1, Adeleye OO2, Gezawa ID3, Okpe IO4, Enamino MI5
Department of medicine; division of endocrinology, diabetes and metabolism:
1Enugu State University of Science and Technology, Enugu, Nigeria
2Lagos State University, Lagos, Nigeria
3Bayero University, Kano, Nigeria
4Ahmadu Bello University, Zaria, Nigeria
5Federal Medical Center, Keffi, Nigeria

Background
Diabetic foot ulceration (DFU) is one of the most disabling complications of diabetes mellitus (DM). It is second to trauma as the commonest cause of lower extremity amputation (LEA) and one of the major causes of DM-related hospital admissions and mortality. Due to a high level of ignorance and poverty, coupled with poor access to qualitative healthcare services, the burden of DFU in developing countries is expected to be enormous. This study sought to evaluate the actual burden and clinical outcome of DFU in a typical developing country - Nigeria, the most populous black nation.

Aim
To prospectively evaluate the profile, ulcer characteristics, associated co-morbidities and outcome of patients with DFU in Nigeria

Methods
The Multi-center Evaluation of Diabetic Foot Ulcer in Nigeria (MEDFUN) was a one year prospective study of all patients admitted for DFU in any of the 6 participating tertiary healthcare institutions in Nigeria, between January 1 and December 31 2016. Demographic characteristics, diabetes-related information and knowledge of proper foot care practices were assessed. Ulcer characteristics including mode of onset, site, size, duration, prior treatment center, Wagner grade and University of Texas (UT) class were documented. Known DFU risk factors including history of previous foot ulcer, bare-foot walking, visual impairment, neuropathy and peripheral arterial disease (PAD) were also evaluated. Investigations included urine protein, HbA1c, full blood count, ESR, blood culture, ulcer specimen culture, lipid profile, plain radiograph of the foot and Doppler ultrasonography of both lower limbs. Associated co-morbidities including hypertension, anemia, shock, hyperglycemic emergency, hypoglycemia, stroke, renal and cardiac failure were explored. All patients received appropriate multi-disciplinary care and were followed up for a maximum of 3 months post discharge or death. Outcome variables of interest included ulcer healing, LEA, duration of hospitalization and mortality.

Results
A total of 336 patients with a male: female ratio of 1:0.8 participated in this study. The mean (±SD) age and mean (±SD) duration of DM were 55.9 ± 12.5 years and 8.5 ± 5.7 years respectively. Majority of the subjects (96.1%) had type 2 diabetes. Only 41 (20.4%) subjects had received foot care education prior to development of ulcer and over half (52.2%) admitted to walking bare feet. Majority of the subjects (66.5%) first indulged in either self medication or unorthodox treatment prior to hospital presentation. The median (IQR) duration of ulcer at presentation was 39 (28 - 54) days. Ulcers were already advanced {Wagner grades ≥ 3) in 79.2% of the participants at the time of admission.  Neuropathic, ischemic and neuro-ischemic  ulcers occurred in 37.2%, 12.5% and 40.2% respectively while 10.1% of ulcers had no identifiable underlying factor. Majority of the ulcers (76.8%) were infected at presentation. Glycemic control was generally poor (mean HbA1c 9.6 ± 1.9%). The commonest co-morbidities were systemic hypertension (56.8%), anemia (53.6%) and hyperglycemic emergencies (36.6%).  Of the 217 subjects who did not undergo LEA, satisfactory ulcer healing occurred in 43.8% prior to discharge and 63.5% at 3 months follow-up. LEA was indicated in 110 (47.8%) while 79 (34.3%) underwent LEA of which 75.6% were major amputations. 35 subjects (10.4%) left against medical advice mainly due to refusal of amputation (48.6%) and poverty (42..9%). The median (IQR) duration of hospitalization was 52.0 (29 - 66) days with mortality rate of 20.9%.  

Conclusion
Results from this study tell a pathetic tale of the devastating impact of DFU in a typical developing country – Nigeria. From poor knowledge of foot care, to a high prevalence of unorthodox treatment and self medications, late hospital presentation with advanced ulceration, prolonged hospitalization, high lower extremity amputation rate and high mortality. An urgent national intervention is desperately needed to stem this ugly tide.

High burden, challenging care and poor outcome: the diabetic foot ulcer in Nigeria: prelim data from the MEDFUN study