신경병증연구회 4 th clinical recommendation of diabetic neuropathy 2018-05-03 Diagnosis & management of diabetic foot 부산성모병원내분비내과 이창원 Division of Endocrinology, Internal Medicine, Busan St. Mary s Hospital Chang Won Lee
Conflict of interest disclosure None Committee of Scientific Affairs Committee of Scientific Affairs
Diabetic foot 당뇨병성족부질환 당뇨병성족부질환 - 정의 (definition), 분류 발생기전및위험인자 역학 : 유병율, 예후 발검사 발관찰, 포괄적인발검사 치료, 예방 발관리교육 당뇨병성신경병증진료지침 - 족부질환
당뇨병성족부질환 - 정의 혈당이잘조절되지않는당뇨병환자에서발생하게되어 입원, 의료비용, 장애및사망의상당수를차지하게되는 당뇨병의주요한합병증중의하나이다 족부궤양 ( 상처 ) + 하지절단 Lee JH. J Kor Diabetes 2011; 69-71
The University of Texas (UT) classification of diabetic ulcers 족부궤양은과거 Maggitt Wagner 분류법을사용하다가감염과허혈이동반된경우를포함하여분류하는텍사스대학분류법사용 Stage Grade 0 1 2 3 A 완전상피화된상처 표재성상처 힘줄이나캡슐을침범한상처 뼈나관절을침범한상처 B + 감염 + 감염 + 감염 + 감염 C + 허혈 + 허혈 + 허혈 + 허혈 D + 감염과허혈 + 감염과허혈 + 감염과허혈 + 감염과허혈 Boulton AJM. The foot in diabetes. 4th ed. Chichester: John Wiley & Sons, Ltd.; 2006. p92-107 Lee JH. J Kor Diabetes 2011; 69-71 Microvascular Complications and Foot Care: Standards of Medical Care in Diabetesd 2018 Diabetes Care 2018, 41(Suppl. 1) S105-S118
F/65 T2DM - 7 years CC : skin ulcer on left great toe for 6 month 8 개월전검사결과 Monofilament 10/10 Ankle jerk ++/++ Tuning folk : normal Pin-prick : normal Thermal sensation : normal 굳은살, 발톱무좀, 건조 TTS : 1.0 DICAN : 2..0 ABI : 1.02/1.05 A1c : 7.4 day 1 day 17
당뇨병성족부질환 - 역학조사의어려움 일생동안당뇨병성족부질환발생의역학자료를조사하는일은전향적인코호트연구를통해서나가능 현재보고된연구자료들은보고자마다당뇨병성족부질환의진단기준, 분류기준이상이보고되는궤양정도, 절단율등이매우상이직접비교하는데는문제가있다 Ahn KJ. J Kor Diabetes 2011; 72-74
당뇨병성족부질환 - 발생률 대규모연구결과 과거외국의역학연구 당뇨병환자의족부궤양의발생률은약 2~7% 당뇨병환자가사는동안족부궤양을앓을가능성은약 15% - 약 3% 는하지절단을경험 Boulton AJM: Textbook of Diabetes Vol 2. 58:1-20, 1997 당뇨병환자의족부궤양 - 발생률 4 ~ 10% - Lifetime incidence may be as high as 25% Singh N, JAMA, 2005, 293:217 28
Comparison between the Incidences of the Foot Disorders in Diabetic and Non-diabetic Patients 1994 ~ 2002 년당뇨병상병으로건강보험심사평가원에 1 회이상청구된환자중 2003 년도당뇨병성족부질환의발생률과의료비용확인 - 사망자와기존유병자를제외 우리나라당뇨병성족부질환의현황 : 건강보험자료분석결과 Chung CH. J Korean Diabetes Assoc 2006;30:372-6.
Incidences of foot amputation in diabetic and nondiabetic patients according to age (per population 100,000) 우리나라당뇨병성족부질환의현황 : 건강보험자료분석결과 Chung CH. J Korean Diabetes Assoc 2006;30:372-6.
Comparison between Annual Total Medical Costs and Hospital Stay in Diabetic and Non-diabetic Patients 우리나라당뇨병성족부질환의현황 : 건강보험자료분석결과 Chung CH. J Korean Diabetes Assoc 2006;30:372-6.
Crude prevalence of type 2 diabetes-related chronic complications The Korean National Diabetes Program (KNDP) cohort study between June 2006 and September 2009 at 13 university hospitals Variable Male (n=2,142) Female (n=1,653) Cardiovascular disease Cerebrovascular disease Total (n=3,795) 129 (6.0) 79 (4.8) 208 (5.5) 100 (4.7) 90 (5.4) 190 (5.0) PAD 16 (0.7) 12 (0.7) 28 (0.7) Amputation 3 (0.1) 0 (0.0) 3 (0.1) Foot ulcer 5 (0.2) 6 (0.4) 11 (0.3) Peripheral : Total 24 (1.1) 18 (1.1) 42 (1.1) Rhee SY. Diabetes Metab J 2011: 35;504-512
당뇨병성족부질환의발생률 ( 한국 ) Rhee SY. Diabetes Metab J 2011: 35;504-512
당뇨병성족부질환의발생기전 DM Kim J Kor Diabetes 2011; 80-82
당뇨병성족부질환고위험군 혈당조절불량 보호감각소실을동반한말초신경병증 흡연 족부기형 궤양전상태의굳은살또는티눈 말초동맥질환 족부궤양의병력 족부절단 시각장애 당뇨병성신증 ( 특히투석중인환자 ) Microvascular Complications and Foot Care: Standards of Medical Care in Diabetesd 2018 Diabetes Care 2018, 41(Suppl. 1) S105-S118 Diabetes Care 2017;40(Suppl. 1): S88 S98
당뇨병성족부질환 - 위험인자 당뇨병환자의약 1/3 은족부궤양의주된위험인자 인말초신경병증및혈관질환을가지고있다 Lee JH. J Kor Diabetes 2011; 69-71 TTS 2, % 28.3 36.8 Ha BK, Lee CW. Diabetes Metab J 2012;36:443-451
3-year risk of foot ulcer and amputation Ahn YB. J Kor Diabetes 2011; 76-79
당뇨병성족부질환 - 예후 족부궤양 : 치명률 2배증가하지절단가능성 10 ~ 15배증가 5년생존율 50% 이하 < 대장암환자의 5년생존율 족부절단 : 3 년생존율약 50% 5 년이내반대쪽절단 약 50% Lee JH. J Kor Diabetes 2011; 69-71
당뇨병성족부질환 - 예후 족부절단환자에서사망률이높은이유 대부분고령 광범위한혈관질환 다른당뇨병성만성합병증동반 Ahn KJ. J Kor Diabetes 2011; 72-74
M/54 T2DM - 28 years CC : multiple skin ulcer /c infection at left stump Monofilament 10/- Ankle jerk ++/ Tuning folk : normal Pin-prick : normal Thermal sensation : normal TTS : 0 DICAN : 3.0 ABI : 1.17 A1c : 10.0
포괄적인발검사 - 매년 당뇨병성족부질환위험인자에대한병력수집 궤양, 절단, 흡연, 망막병증, 신장질환, 발관리 신경병증 ( 통증, 화끈거림, 무감각 ) 과혈관질환 ( 다리피로, 파행 ) 에대한증상확인 발관찰 피부상태, 근골격계기형 매방문시 신경학적평가 (10 그램모노필라멘트검사 + 핀찌르기검사, 128-Hz 튜닝포크검사, 온도감각또는발목반사중적어도한가지 ) - 초기신경병증보다는보호감각의소실을확인 Microvascular Complications and Foot Care: Standards of Medical Care in Diabetesd 2018 Diabetes Care 2018, 41(Suppl. 1) S105-S118 Diabetes Care 2017;40(Suppl. 1): S88 S98
포괄적인발검사 - 매년 다리와발의맥박을포함한혈관평가 발목-상완지수검사 ( 발목위팔지수, ankle-brachial index, ABI) 걷는속도감소, 다리피로증상 파행, 족부맥박소실 필요시추가적인혈관검사를시행 (ABI <0.9) 50 세이상의당뇨병환자 다른말초동맥질환의위험인자 ( 예, 흡연, 고혈압, 고지혈증또는당뇨병유병기간 10 년이상 ) Microvascular Complications and Foot Care: Standards of Medical Care in Diabetesd 2018 Diabetes Care 2018, 41(Suppl. 1) S105-S118 Diabetes Care 2017;40(Suppl. 1): S88 S98
위험인자에따른포괄적인발검사 고위험군 : 무감각발 ± 족부기형, 말초동맥질환, 족부궤양또는절단의병력 고위험군환자는더자주포괄적인발검사를받아야필요가있다
M/34 T2DM 3 years CC : rapid decreased egfr Monofilament 10/10 Ankle jerk ++/++ Tuning folk : normal Pin-prick : normal Thermal sensation : abnormal TTS : 1.0 DICAN : 3.0 ABI : 1.06/1.04 A1c : 7.2 NCV : sensory motor polyneuropathy
당뇨병성족부궤양의치료 고전적인치료 : debridement, 드레싱, total contact cast, mechanical offloading devices 최근소개되는치료 : negative pressure wound therapy, 고압산소요법, larval therapy, 성장인자, Living tissue engineered products, Stem cells 최근치료기술의발달로인해족부질환으로인한사망이감소하는추세에있다 Lee JH. J Kor Diabetes 2011; 69-71
당뇨병성족부궤양의치료 족부궤양의감염 - polymicrobial - aerobic gram-positive cocci (staphylococci, streptococci) 연부조직이나뼈를침범하지않은상처 항생제가필요하지않다 Empiric antibiotic therapy - 급성감염 gram-positive cocci에효과적인항생제 - 항생제내성균주의심, 만성, 재발성, 심한감염 광범위항생제 Microvascular Complications and Foot Care: Standards of Medical Care in Diabetesd 2018 Diabetes Care 2018, 41(Suppl. 1) S105-S118 Diabetes Care 2017;40(Suppl. 1): S88 S98
당뇨병성족부질환예방하기 엄격한혈당조절 환자에대한교육 발관리교육 일차진료의사에대한교육 포괄적인발검사 연화제사용 다양한 protective gear의사용 ( 보조기, 보호용신발, 양말, insole) Ahn KJ. J Kor Diabetes 2011; 72-74
당뇨병환자를위한발관리교육 당뇨병합병증예방과관리 발관찰 - 매일 - 상처, 물집, 굳은살, 발톱의문제, 발적등을관찰 발위생과피부관리 양말 신발 - 잘맞는보행용신발이나운동화 볼이넓거나속이깊은신발 치료용신발 혈액순환 - 발마사지, 발운동 발관련증상이있을경우병원을방문하도록교육 시력, 신체활동의제한, 인지장애가있는환자 가족등다른사람들의도움이필요 HJ Cha. J Korean Diabetes 2018;19:41-45
당뇨병성족부질환예방하기 환자및의료진들에대한교육, 검진및적극적인치료 하지절단율을 49~85% 감소 International Working Group on the Diabetic Foot(IWGDF) 당뇨병성족부질환예방을위해 정기검진, 고위험환자선별, 환자와가족및의료진의교육, 적절한신발의선택, 비궤양성병변치료 정기적인발검진과발관리교육 BK Apelqvist J. Diabetes Metab Res Rev 2012;28 Suppl 1:225-31 HJ Cha. J Korean Diabetes 2018;19:41-45
발검진의어려움 Diabetes in Korea 2007 - 발검진률을 10% 이하로보고 인력부족, 제한된진료시간및교육시간, 당뇨병교육실의부재등현실적인여러가지요인들로인해가이드라인에따라발검진을하기에는어려움이따른다 의료시스템의개선, 정부의지원 의료진 ( 또는교육자 ) 이적극적인접근과지속적인관심필요 Task Force Team for Basic Statistical Study of Korean Diabetes Mellitus of Korean Diabetes Association, Park IeB. Diabetes Metab J 2013;37:233-9. HJ Cha. J Korean Diabetes 2018;19:41-45
당뇨병성신경병증진료지침 - 당뇨병성족부질환 당뇨병성족부질환 ( 궤양및절단 ) 은당뇨병의합병증으로발생하는족부의손상으로서 예방을위하여면밀한진단과적극적인발관리가필요하다 (E) 당뇨병성족부질환은여러위험인자들이서로상호작용하여발생하며, 특히말초신경병증, 말초동맥질환, 그리고외상이주요한역할을한다 (B) 말초동맥질환은상처회복지연과하지절단에대해서독립적인위험인자이다 (B)
당뇨병성신경병증진료지침 - 당뇨병성족부질환 족부질환에대한위험요소를확인하기위해적어도매년포괄적인발평가를해야한다 (B) 모든당뇨병환자는매방문때마다발관찰을해야한다 (E) 위험인자 ( 궤양, 절단, Charcot 발, 혈관성형술또는혈관수술, 흡연, 망막병증, 신질환 ) 에대한병력을수집해야하며 신경병증 ( 통증, 화끈거림, 무감각 ) 과혈관질환 ( 다리피로, 파행 ) 에대한증상을확인해야한다 (B)
당뇨병성신경병증진료지침 - 당뇨병성족부질환 피부관찰, 발기형평가, 신경학적평가 (10 그램모노필라멘트검사와함께핀찌르기검사, 온도감각또는발목반사중적어도한가지 ) 및다리와발의맥박을포함한혈관평가를시행해야한다 (B) 족부질환으로심각한파행이있거나발목팔지수가비정상 (0.9 이하 ) 인경우추가적인혈관검사를시행하고운동, 약물치료와수술을고려할수있다 (E)
FOOT CARE Recommendations A multidisciplinary approach is recommended for individuals with foot ulcers and high-risk feet (e.g., dialysis patients and those with Charcot foot, prior ulcers, or amputation) (B) Refer patients who smoke or who have histories of prior lower-extremity complications, loss of protective sensation, structural abnormalities, or peripheral arterial disease to foot care specialists for ongoing preventive care and life-long surveillance (C) Microvascular Complications and Foot Care: Standards of Medical Care in Diabetesd 2018 Diabetes Care 2018, 41(Suppl. 1) S105-S118
FOOT CARE Recommendations 족부궤양및고위험발 ( 예 : 투석환자및 Charcot 발, 이전의궤양또는절단병력이있는환자 ) 을가진환자는다학제적접근이권장된다 (B) 흡연자와이전의하지합병증, 보호감각상실, 족부기형또는말초동맥질환의병력이있는환자들은지속적인예방요법과평생동안의감시를위해발관리전문가에게의뢰해야한다 (C) Microvascular Complications and Foot Care: Standards of Medical Care in Diabetesd 2018 Diabetes Care 2018, 41(Suppl. 1) S105-S118
FOOT CARE Recommendations Provide general preventive foot self-care education to all patients with diabetes (B) The use of specialized therapeutic footwear is recommended for high risk patients with diabetes including those with severe neuropathy, foot deformities, or history of amputation (B) Microvascular Complications and Foot Care: Standards of Medical Care in Diabetesd 2018 Diabetes Care 2018, 41(Suppl. 1) S105-S118
FOOT CARE Recommendations 모든당뇨병환자에게일반적인예방적자가발관리교육을제공해야한다 (B) 중증신경병증, 발기형또는절단병력이있는고위험당뇨병환자에게전문화된치료신발을사용을권고한다 (B) Microvascular Complications and Foot Care: Standards of Medical Care in Diabetesd 2018 Diabetes Care 2018, 41(Suppl. 1) S105-S118
요약 족부궤양 하지절단위험 재발의위험 사망위험증가 통합적인합병증관리 : 위험인자관리, 포괄적인발검사, 발관리교육 족부궤양감소 족부궤양에대한평가 ( 분류 ) 와최신치료 절단감소 당뇨병성신경병증진료지침활용
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