Foot problems in patients with diabetes and chronic kidney disease.

There is a much higher incidence of diabetic foot disease in those with concurrent renal disease and outcomes, including amputation and mortality, are generally poorer. The risk factors contributing to the higher incidence of foot disease in those with both diabetes and renal disease are outlined, and the evidence explored demonstrating higher incidence of foot disease across categories of renal disease, including impaired renal function (chronic kidney disease stages 3 and 4), haemodialysis, continuous ambulatory peritoneal dialysis, renal transplantation and simultaneous pancreas and kidney transplantation. Three major pathological aspects of diabetic foot disease in which concurrent renal disease either contributes to a higher incidence, or modifies the clinical manifestations and outcomes, are described: ulceration; Charcot neuroarthropathy and necrotic toes. Pathophysiology, clinical features and management strategies for these three conditions are described. Finally, the evidence for preventative strategies for foot disease is explored, and the important role of speed of access to specialist multi-disciplinary diabetic foot services discussed.