Predictors of gangrenous complications in diabetic foot ulcers: A cross-sectional study from Indonesia 10.55131/jphd/2026/240222
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Abstract
Type 2 diabetes mellitus (T2DM) is highly prevalent in Indonesia, where diabetic foot ulcer (DFU) affects 26% of patients, far above the global average. DFU, especially when complicated by gangrene, leads to severe morbidity and mortality, yet evidence related to its predictors remains limited. This study therefore aims to assess the prevalence of gangrene and the factors associated with a history of previous diabetic foot ulcers, insulin treatment and the development of gangrene. The analytical cross-sectional study involved T2DM patients with DFU admitted to the Margono Hospital in Central Java, Indonesia, from 2018 to 2024. Generalized linear mixed models (GLMM) employing a logistic regression model and adjusted odds ratio (AOR) with 95% CI were provided. Out of 859 patients with DFU, 30.97% (95%CI:27.96-34.15) were diagnosed with gangrene during the study period, which was higher in those with a history of DFU (AOR:3.59; 95%CI:1.28-10.08); those using insulin therapy (AOR:3.35; 95%CI:2.25-4.98); those diagnosed with renal disease (AOR:2.22; 95%CI:1.34-3.67); and those with normal weight or underweight of body mass index (BMI) (AOR:1.87; 95%CI:1.24-3.67). However, hypertensive patients with DFU (AOR:1.68; 95%CI:1.12-2.53) were more likely to develop gangrene. Nearly one-third of the DFU patients are diagnosed with gangrene in Indonesia. A previous history of DFU, insulin therapy, renal disease, and lower body mass index (normal or underweight) were significant predictors of gangrene, while hypertension appeared to have a protective association. The findings underscore the importance of early screening and management of comorbidities, particularly renal disease, nutritional status, and blood pressure control to reduce the risk of gangrenous complications among DFU patients.
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References
Abdul, M. et al. Epidemiology of type 2 diabetes – Global burden of disease and forecasted trends. J Epidemiol Glob Health 10, 107–111 (2020).
IDF. International Diabetes Federation Diabetes Atlas 10th Edition. International Diabetes Federation vol. 10th editi (2021).
Soeatmadji DW, Rosandi R, Saraswati MR, Sibarani RP, Tarigan WO. Clinicodemographic profile and outcomes of type 2 diabetes mellitus in the Indonesian cohort of DISCOVER: A 3-year prospective cohort study. Journal of the ASEAN Federation of Endocrine Societies. 2023 Jan 25;38(1):68.
Onyango, E. M. & Onyango, B. M. The rise of noncommunicable diseases in Kenya: An examination of the time trends and contribution of the changes in diet and physical inactivity. J Epidemiol Glob Health 8, 1–7 (2018).
Khan, Y., M. Khan, M. & Raza Farooqui, M. Diabetic foot ulcers: a review of current management. Int J Res Med Sci 5, 4683 (2017).
Zhang, P. et al. Global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis†. Ann Med 49, 106–116 (2017).
Yusuf, S. et al. Prevalence and Risk Factor of Diabetic Foot Ulcers in a Regional Hospital, Eastern Indonesia. Open J Nurs 06, 1–10 (2016).
Pengzi Zhang et al. Global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis. Ann Med 49, 106–116 (2017).
Byrnes, J. et al. Health-related quality of life in people with different diabetes-related foot ulcer health states: A cross-sectional study of healed, non-infected, infected, hospitalised and amputated ulcer states. Diabetes Res Clin Pract 207, (2024).
Akkus, G. & Sert, M. Diabetic foot ulcers: A devastating complication of diabetes mellitus continues non-stop in spite of new medical treatment modalities. World J Diabetes 13, 1106–1121 (2022).
Jalilian, M., Sarbarzeh, P. A. & Oubari, S. Factors related to severity of diabetic foot ulcer: A systematic review. Diabetes, Metabolic Syndrome and Obesity 13, 1835–1842 (2020).
Brennan, M. B. et al. Diabetic foot ulcer severity predicts mortality among veterans with type 2 diabetes. J Diabetes Complications 31, 556–561 (2017).
Marzoq, A., Shiaa, N., Zaboon, R., Baghlany, Q. & Alabbood, M. H. Assessment of the Outcome of Diabetic Foot Ulcers in Basrah, Southern Iraq: A Cohort Study. Dubai Diabetes and Endocrinology Journal 25, 33–38 (2019).
Fournier, C., Singbo, N., Morissette, N. & Thibeault, M. M. Outcomes of Diabetic Foot Ulcers in a Tertiary Referral Interdisciplinary Clinic: A Retrospective Canadian Study. Can J Diabetes 45, 255–260 (2021).
Guo, Q. et al. Influencing factors for the recurrence of diabetic foot ulcers: A meta-analysis. International Wound Journal vol. 20 1762–1775 Preprint at https://doi.org/10.1111/iwj.14017 (2023).
Tola, A., Regassa, L. D. & Ayele, Y. Prevalence and associated factors of diabetic foot ulcers among type 2 diabetic patients attending chronic follow-up clinics at governmental hospitals of Harari Region, Eastern Ethiopia: A 5-year (2013–2017) retrospective study. SAGE Open Med 9, (2021).
Vanderpant, N., Ward, E., Farrell, E. & Theodoraki, A. Insulin for people with type 2 diabetes mellitus. BMJ Preprint at https://doi.org/10.1136/bmj-2023-078015 (2024).
Gallo, G. & Savoia, C. New Insights into Endothelial Dysfunction in Cardiometabolic Diseases: Potential Mechanisms and Clinical Implications. International Journal of Molecular Sciences vol. 25 Preprint at https://doi.org/10.3390/ijms25052973 (2024).
D, M. B., Arvind, S. G. & Professor, A. Diabetic foot disease-clinical presentations, Glycaemic status and limb vascularity on radiological imaging and treatment modalities. CME Journal of Geriatric Medicine 108, (2024).
Barakat, A. M. et al. Predictors of diabetic foot ulcer severity among patients attending Menoufia University Hospital, Egypt. Menoufia Medical Journal 35, 32 (2022).
Wang, X., Yuan, C.-X., Xu, B. & Yu, Z. Diabetic foot ulcers: Classification, risk factors and management. World J Diabetes 13, 1049–1065 (2022).
World Health Organization. International Association for the Study of Obesity and International Obesity Task Forc. (2000).
Khawaja, N. Understanding the renal threshold for glucose: Implications for diabetes management. African Journal of Diabetes Medicine 32, (2024).
Gonzales, G. F. et al. Correcting the cut-off point of hemoglobin at high altitude favors misclassification of anemia, erythrocytosis and excessive erythrocytosis. American Journal of Hematology vol. 93 E12–E16 Preprint at https://doi.org/10.1002/ajh.24932 (2018).
Hosmer, D. & Lemeshow, S. Applied logistic regression, 2nd Edition edn. New York: Willey. Preprint at (2000).
Yunir, E., Hidayah, C. D., Harimurti, K. & Kshanti, I. A. M. Three Years Survival and Factor Predicting Amputation or Mortality in Patients with High Risk for Diabetic Foot Ulcer in Fatmawati General Hospital, Jakarta. J Prim Care Community Health 13, 1–7 (2022).
Syamsul S, Usman S, Saputra I, Maulana T, Ismail I. Risk Factor Analysis for Gangrene in Diabetes Mellitus Patients AT Hafidh Clinic Aceh Besar District in 2023. International Journal of Medical Science and Dental Health.;10(05):1-9.
Yunir, E. et al. Non-vascular contributing factors of diabetic foot ulcer severity in national referral hospital of Indonesia. J Diabetes Metab Disord 20, 805–813 (2021).
Vanherwegen, A. S. et al. Sex differences in diabetic foot ulcer severity and outcome in Belgium. PLoS One 18, (2023).
Vanherwegen, A. S. et al. Sex differences in diabetic foot ulcer severity and outcome in Belgium. PLoS One 18, (2023).
Jarl, G., Alnemo, J., Tranberg, R. & Lundqvist, L. O. Gender differences in attitudes and attributes of people using therapeutic shoes for diabetic foot complications. J Foot Ankle Res 12, (2019).
Hariftyani, A. S., Novida, H. & Edward, M. Profile of Diabetic Foot Ulcer Patients at Tertiary Care Hospital in Surabaya, Indonesia. Jurnal Berkala Epidemiologi 9, 293 (2021).
Bhargava, A., Mahakalkar, C., Kshirsagar, S. & Dhole, S. Assessing the Prevalence Rate of Gangrene Among Patients With Peripheral Vascular Disease in a Tertiary Care Hospital in Central India. Cureus https://doi.org/10.7759/cureus.57038 (2024) doi:10.7759/cureus.57038.
Mahmoudvand, G., Karimi Rouzbahani, A., Razavi, Z. S., Mahjoor, M. & Afkhami, H. Mesenchymal stem cell therapy for non-healing diabetic foot ulcer infection: New insight. Frontiers in Bioengineering and Biotechnology vol. 11 Preprint at https://doi.org/ 10.3389/fbioe.2023.1158484 (2023).
Littig, J. P. B., Moellmer, R., Estes, A. M., Agrawal, D. K. & Rai, V. Increased Population of CD40+ Fibroblasts Is Associated with Impaired Wound Healing and Chronic Inflammation in Diabetic Foot Ulcers. J Clin Med 11, (2022).
Ansari, P. et al. Hyperglycaemia-Linked Diabetic Foot Complications and Their Management Using Conventional and Alternative Therapies. Applied Sciences (Switzerland) vol. 12 Preprint at https://doi.org/10.3390/app122211777 (2022).
Lee, B.-W. et al. Insulin Therapy for Adult Patients with Type 2 Diabetes Mellitus: A Position Statement of the Korean Diabetes Association, 2017. Diabetes Metab J 41, 367 (2017).
Insulin Therapy in Type 2 Diabetes Mellitus. Singapore Fam Physician 47, (2021).
Demidova, T. Y. & Titova, V. V. Insulin therapy is a personalized approach to glycemic management in diabetes. Ter Arkh 92, 201–206 (2021).
Zerovnik, S., Kos, M. & Locatelli, I. Initiation of insulin therapy in patients with type 2 diabetes: An observational study. Acta Pharmaceutica 72, 147–157 (2022).
Schmidt, S. K. Interactive and sculptural printmaking in the renaissance. Brill’s Studies in Intellectual History vol. 270/21 1–467 Preprint at https://doi.org/10.6084/ m9.figshare (2018).
Rahman, Md. A. & Islam, S. The complications of long time treatment of insulin therapy in type-2 diabetes patients: A Review. Molecular Mechanism Research 2, 6172 (2024).
Vatankhah, N., Jahangiri, Y., Landry, G. J., Moneta, G. L. & Azarbal, A. F. Effect of systemic insulin treatment on diabetic wound healing. Wound Repair and Regeneration 25, 288–291 (2017).
Margolis, D. J., Hofstad, O. & Feldman, H. I. Association between renal failure and foot ulcer or lower-extremity amputation in patients with diabetes. Diabetes Care 31, 1331–1336 (2008).
Mancin, S. et al. Diabetes, Chronic Kidney Disease, and Vascular Ulcers: Prevention Strategies and Clinical Implications. Diabetology vol. 6 Preprint at https://doi.org/10.3390/ diabetology6020010 (2025).
Bonnet, J. B. & Sultan, A. Narrative Review of the Relationship Between CKD and Diabetic Foot Ulcer. Kidney International Reports vol. 7 381–388 Preprint at https://doi.org/10.1016/ j.ekir.2021.12.018 (2022).
Hahn, H. M., Jeong, K. S., Park, D. H., Park, M. C. & Lee, I. J. Analysis of prognostic factors affecting poor outcomes in 41 cases of Fournier gangrene. Ann Surg Treat Res 95, 324–332 (2018).
Salim, M. Clinical outcomes among patients with chronic kidney disease hospitalized with diabetic foot disorders: A nationwide retrospective study. Endocrinol Diabetes Metab 4, (2021).
Voordeckers, M., Noels, J., Brognet, M., Salaouatchi, M. T. & Mesquita, M. Localized Fournier’s Gangrene in ‘end-Stage’ Renal Failure: Multidisciplinary Approach and Integration of Palliative Care. Case Rep Nephrol 2020, (2020).
Chen, F., Wang, X., Pan, Y., Ni, B. & Wu, J. The paradox of obesity in pressure ulcers of critically ill patients. Int Wound J 20, 2753–2763 (2023).
Abuhay, H. W., Yenit, M. K. & Wolde, H. F. Incidence and predictor of diabetic foot ulcer and its association with change in fasting blood sugar among diabetes mellitus patients at referral hospitals in Northwest Ethiopia, 2021. PLoS One 17, (2022).
Stańkowska, M. et al. Microbiological, Clinical and Radiological Aspects of Diabetic Foot Ulcers Infected with Methicillin-Resistant and-Sensitive Staphylococcus aureus. Pathogens 11, (2022).
Yang, D. R., Wang, M. Y., Zhang, C. L. & Wang, Y. Endothelial dysfunction in vascular complications of diabetes: a comprehensive review of mechanisms and implications. Frontiers in Endocrinology vol. 15 Preprint at https://doi.org/10.3389/ fendo.2024.1359255 (2024).
Wang, X. et al. The awareness and determinants of diabetic foot ulcer prevention among diabetic patients: Insights from NHANES (2011–2018). Prev Med Rep 36, (2023).
