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Role of Hemoglobin A1c As Predictor of Foot Ulcer Healing in Diabetes

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Role of Hemoglobin A1c As Predictor of Foot Ulcer Healing in Diabetes Print ISSN: 2321-6379 Online ISSN: 2395-1893 Original Article DOI: 10.17354/SUR/2018/149 Role of Hemoglobin A1c as Predictor of Foot Ulcer Healing in Diabetes H R Manjunath1, Vasudev Murthy Kumar2 1Assistant Professor, Department of General Surgery, Sapthagiri Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India, 2Associate Professor, Department of General Surgery, Akash Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India Abstract Background: Diabetic foot ulcers are associated with substantial morbidity and mortality in diabetic patients. The role of hemoglobin A1c (HbA1c) in assessing the outcome of diabetic ulcer needs to be evaluated. Aim: This study aims to assess the validity and effectiveness of HbA1c to predict foot ulcer healing in diabetic patients. Materials and Methods: This study was conducted in the Department of Surgery, Akash Institute of Medical Sciences and Research Centre, Devanahalli, over 24-month period from February 2015 to February 2017. A descriptive study was carried out in 280 diabetic patients with foot ulcers. The data collection included demographics, medical diagnoses, ulcer healing duration, and HbA1c results. Results: About 50% of patients with controlled HbA1c levels had their wounds healed in 3 months, whereas only 20% of patients with high HbA1c had their wounds healed in same time. 15% of patients with high HbA1c had their wounds persisting even after 1 year. Conclusion: HbA1c levels were strongly associated with the process as well as the duration of foot ulcer healing in the diabetic patients. Elevated HbA1c was associated with poor prognosis in terms of foot ulcer healing. Key words: Diabetic foot ulcers, Hemoglobin A1c, Morbidity, Mortality INTRODUCTION The factors that affect ulcer healing in diabetic patients are generally helpful in optimization of patient management ypically, diabetic foot syndrome is characterized by strategy besides their routine application as predictors Tfoot infection, ulceration, or destruction of deep of the outcome. Some of these predictors are useful in tissues in association with neurological abnormalities early identification of diabetic patients with high risk for and divergent levels of peripheral vascular insufficiency. foot ulcers and hence contribute toward lower rate of Diabetic foot ulcer and infections are associated with extremity amputations. Although prediction of diabetic substantial morbidity and mortality.[1,2] foot ulcer healing may contribute toward optimized and individualized management of the patient, there is no Over 30 million have now diabetes in India. The crude single established and a universally accepted predictor prevalence rate in urban areas of India is thought to be to this end.[4] 9%. In rural areas, the prevalence is approximately 3% of total population.[3] Hemoglobin A1c (HbA1c), an established marker to monitor blood glucose in diabetic patients, is currently Access this article online being investigated for its association with ulcer healing. As an elevated HbA1c predicts poor prognosis for ulcer Month of Submission : 01-2018 healing in patients with diabetes, it has been observed Month of Peer Review : 02-2018 that ulcer healing rate is significantly slower if the HbA1c Month of Acceptance : 03-2018 levels are high. The prime objective of our study was to Month of Publishing : 04-2018 determine the significance of HbA1c level as predictors of www.surgeryijss.com prognosis in patients with diabetic foot ulcers.[5-7] Corresponding Author: Vasudev Murthy Kumar, Department of General Surgery, Akash Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India. E-mail: [email protected] IJSS Journal of Surgery | Mar-Apr 2018 | Volume 4 | Issue 2 71 Manjunath and Kumar: Role of Hemoglobin A1c as Predictor of Foot Ulcer Healing in Diabetes Aims and Objectives [Table 1]. Comparing patients with controlled, highly This study aims to study the role of HbA1c in the elevated HbA1c, only 20% of patients had healed foot management of diabetic foot ulcers. ulcers within 3 months, 30% between 3 and 6 months, and 50% 7 months. MATERIALS AND METHODS While studying the healing process in relation to HbA1c A descriptive study was carried out in diabetic patients levels, we observed that 70% of patients with normal with foot ulceration (n = 280) to determine the role of HbA1c had completely healed foot ulcers, whereas 20% HbA1c affecting the ulcer healing process. The study was showed partial healing and 5% had uncured foot ulcers conducted over 24-month period from February 2015 [Table 2]. The remaining 5% of patients required graft to February 2017. Informed consent was obtained from placement. Among the patients with high HbA1c, 45% the patients. showed complete healing, whereas 35% had partial healing, 5% progressed to grafting process, and 15% had Inclusion Criteria unhealed foot ulcers. A direct comparison of the foot ulcer All patients with foot ulcers, ischemic, neuropathic, or healing time duration [Tables 1], as well as completion neuroischemic ulcers were included in the study. of healing [Table 2], was made with HbA1c. Exclusion Criteria DISCUSSION Patients with non-diabetic foot ulcers were excluded from the study. Typically, diabetic foot syndrome is characterized by foot infection, ulceration, or destruction of deep tissues in The data collection included demographics, medical association with neurological abnormalities and peripheral diagnoses, HbA1c levels, and ulcer healing results. We vascular insufficiency.[13,14] Despite in-depth studies of the employed our standard management protocol in the risk factors associated with diabetic foot ulcer development diabetic center for management of the foot ulcer patients. and the seriousness of the pathological consequences that As a part of this management protocol, all patients may culminate into limb amputation and fatality, there is no underwent a regular wound debridement and dressing standard criterion yet established to predict the prognosis of using normal saline, antiseptic, and hydrocolloid. For diabetic foot ulcer healing. Ours is one of the many studies pressure ulcers and neuropathic ulcers, we aided the that report increased prevalence of problems associated treatment intervention with off-loading strategy which with diabetic foot syndrome and search for a predictor that primarily involved shoe offloading.[8,9] For the assessment would be helpful in predicting the prognosis at the end of the of ulcer healing for each patient, we photographed his ulcer treatment. The main findings of the study are that HbA1c as at the time of presentation followed by photographing an indicator of glycemic control in the body shows significant the healing ulcers at stipulated time points (i.e., 2, 3, 6, association with foot ulcer healing and therefore can be used and 12 months) as a follow-up. The photographs were as reliable predictors of diabetic foot ulcer prognosis.[15,16] then used to compare ulcer size, presence of necrotic tissue, and the granulation tissue formation to ascertain Multiple risk factors have been studied to discriminate the progress of healing.[10-12] between healing and non-healing ulcers by standard therapeutic intervention. Of these, modifiable factor OBSERVATION AND RESULTS [FIGURES 1-4] HbA1c has gained special attention of researchers and has been extensively studied in relation with diabetic foot A total of 280 patients (male n = 196, 70%; female ulcers, gangrene, and limb amputation.[17] It is generally n = 84, 30%) were enrolled in the study. Based on the considered that a persistently elevated glucose level due length of the disease, 45% of the patients had diabetes for to compromised glycemic control in the body results in 10 years, 38.6% for 10–20 years, and 16.4% for 20 years. impaired oxygen and nutrient supply to the ulcer area The average age of the patients included in the study was and a concomitantly compromised immune response 54 years (standard deviation). due to impaired chemotaxis and phagocytosis. Given that glycated HbA1c is a reliable marker of glycemic control 50% of diabetic patients with controlled HbA1c spanning over the previous 2–3 months, it is now being (7 mmol/L) had foot ulcer healing within 3 months, 40% recommended by the American Diabetes Association had healing in 3–6 months, and 10% took 7 months for and World Health Organization as a reliable marker for complete healing of the foot ulcers. On the other hand, diagnosis of diabetes. A validated relationship has also in patients with uncontrolled diabetes indicated by been established between HbA1c levels and various highly elevated HbA1c (10 mmol/L), a significant delay pathological complications in diabetic patients such as in foot ulcers was observed in majority of the patients diabetic retinopathy and foot ulcers.[18,19] However, there 72 IJSS Journal of Surgery | Mar-Apr 2018 | Volume 4 | Issue 2 Manjunath and Kumar: Role of Hemoglobin A1c as Predictor of Foot Ulcer Healing in Diabetes Figure 1: Complete healing percentage Figure 2: Partial healing percentage Table 1: Association of HbA1c and healing time duration HbA1c Duration to achieve healed foot ulcers n (%) Total <3 months 3–6 months 7 months–1 year 1–2 years >2 years HbA1c Controlled 26 (50) 20 (40) 4 (10) 50 Mildly elevated 35 (40) 35 (40) 12 (20) 82 Highly elevated 45 (20) 47 (30) 42 (25) 148 Total 106 (37.8) 102 (36.42) 58 (20.71) 12 (4.28) 2 (0.71) 280 HbA1c: Hemoglobin A1c Table 2: Association between HbA1c levels and the process of diabetic foot ulcer healing HbA1c Healing process (n %) Total Complete healing Partial healing No healing Healing with graft HbA1c Controlled 35 (70) 10 (20) 2 (5) 3 (6) 50 Mildly elevated 42 (50) 30 (40) 1 (5) 9 (10.97) 82 Highly elevated 70 (45) 51 (35) 20 (15) 7 (4.72) 148 Total 147 (52.5) 91 (32.5) 23 (8.21) 19 (6.78) 280 HbA1c: Hemoglobin A1c IJSS Journal of Surgery | Mar-Apr 2018 | Volume 4 | Issue 2 73 Manjunath and Kumar: Role of Hemoglobin A1c as Predictor of Foot Ulcer Healing in Diabetes CONCLUSION Our study results show that HbA1c shows good association with the process of healing as well as time required for healing process to complete.
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