Upper Limb Amputations in End-Stage Renal Failure Patients: A Single Institution's Prospective Cohort Study on Risk...

Background: Patients with end-stage renal failure (ESRF) are prone to vascular complications that may result in limb ischaemia and gangrene. While lower limb amputation (LLA) outcomes in this population are well-documented, data on upper limb involvement remain limited. This study aimed to characterise the types of hand conditions leading to hand specialist referrals amongst ESRF patients, identify risk factors associated with upper limb amputation (ULA) and assess post-amputation survival outcomes. Methods: ESRF patients referred to a single hand surgery unit were recruited over 5 years. Data on demographics, comorbidities, referral diagnosis and treatment were obtained. Univariate analysis and Kaplan-Meier survival analysis were performed using STATA. Results: Of the 76 included patients, 50% were referred for infection and the rest for trauma, digit ischaemia and gout in decreasing order of incidence. A total of 22 patients, accounting for 29% of the cohort, required ULA. All but one patient (96%) underwent a ULA due to an infection. Significant risk factors identified are having an ipsilateral arteriovenous fistula (p = 0.024), peripheral neuropathy (p = 0.031), peripheral arterial disease (PAD; p = 0.00010), hyperlipidaemia (p = 0.013), the history of previous surgery for a soft tissue infection (p < 0.0001) and previous amputation in any limb (p = 0.013). Survival rates at 1, 2 and 5 years post-ULA were 82%, 59% and 14%, respectively. The time to mortality after index amputation was 2.42 years. Conclusions: Infections were the most common referral diagnosis and the primary indication for ULA in ESRF patients. Identified risk factors - including PAD, previous soft tissue infection, prior LLA and the presence of an ipsilateral AV fistula - put patients at increased risk for ULA. Post-amputation survival was poor, with high mortality within 5 years. Level of Evidence: Level IV (Therapeutic).