Charcot neuroarthropathy after simultaneous pancreas-kidney transplantation: risk factors, prevalence, and outcome

Does Improvement of Glycemic Control Cause Acute Charcot Foot in Patients with Diabetes?

Recent studies have suggested that improved glycemic control in patients with diabetes may cause acute Charcot foot. To conduct a narrative review of studies investigating whether improved glycemic control in patients with diabetes causes acute Charcot foot.Publications found by searching PubMed, EMBASE, and Cochrane Library as well as reference lists of identified publications were reviewed.Very few publications were found, primarily consisting of case reports and case studies without control groups, documenting instances where cases of acute Charcot foot had been preceded by improved glycemic control. Recent large multicenter randomized placebo-controlled clinical trials of anti-hyperglycemic agents in patients with diabetes, where significant improvement of glycemic control occurred, have not reported incidences of acute Charcot foot.There is so far no solid evidence to suggest that improvement of glycemic control in patients with diabetes causes acute Charcot foot.

Real-world treatment patterns and diagnosis of charcot foot in franco-belgian diabetic foot expert centers (The EPiChar Study)

AIM

To evaluate the real-life diagnosis and therapeutic means of Charcot Neuroosteoarthropathy (CN) in French-Belgian diabetic foot expert centers.

METHODS

We collected clinical characteristics, results of exams and therapeutic pathways of consecutive adult patients with diabetic osteoarthropathy seen in consultation or hospitalization from January 1 to December 31, 2019 in 31 diabetic foot expert centers. The primary outcome was to describe the diagnostic and management methods for CN according to patient clinical characteristics, the clinical-radiological characteristics of acute and chronic CN and discharge means.

RESULTS

467 patients were included: 364 with chronic CN and 103 in the acute phase. 101 patients had bilateral chronic CN. Most patients were male (73.4%), treated with insulin (73.3%), and with multicomplicated diabetes. In the acute phase, edema and increased foot temperature were present in 75% and 58.3% of cases, respectively. Diagnosis confirmation was usually by MRI and the mode of discharge was variable. In the chronic phase, orthopedic shoes were prescribed in 81.5% of cases.

CONCLUSIONS

This observational study highlights the diagnostic and therapeutic practices in 31 diabetic foot centers. Our results highlight that the use of MRI and the modalities of offloading, an essential treatment in the acute phase, need to be better standardized. Centers were highly encouraging about creating a patient registry.

Impact of Intensive Glycemic Treatment on Diabetes Complications-A Systematic Review

Diabetes complications can be related to the long duration of the disease or chronic hyperglycemia. The follow-up of diabetic patients is based on the control of chronic hyperglycemia, although this correction, if obtained rapidly in people living with severe chronic hyperglycemia, can paradoxically interfere with the disease or even induce complications. We reviewed the literature describing the impact of the rapid and intense treatment of hyperglycemia on diabetic complications. The literature review showed that worsening complications occurred significantly in diabetic microangiopathy with the onset of specific neuropathy induced by the correction of diabetes. The results for macroangiopathy were somewhat mixed with the intensive and rapid correction of chronic hyperglycemia having a neutral impact on stroke and myocardial infarction but a significant increase in cardiovascular mortality. The management of diabetes has now entered a new era with new therapeutic molecules, such as gliflozin for patients living with type 2 diabetes, or hybrid insulin delivery systems for patients with insulin-treated diabetes. Our manuscript provides evidence in support of these personalized and progressive algorithms for the control of chronic hyperglycemia.

The Charcot Foot Reflects a Response to Injury That Is Critically Distorted by Preexisting Nerve Damage: An Imperfect Storm

It has been recognized since comprehensive descriptions by Jean-Martin Charcot in 1868 and 1883 that development of what is usually known as neuropathic osteoarthropathy (or the Charcot foot) requires the coincidence of neuropathy and inflammation. Despite this, detailed understanding of the causes has remained remarkably limited in the succeeding century and a half. The aim of this descriptive account is to draw particular attention to the processes involved in both the onset and resolution of the inflammation that is an essential component of active disease. The principal observation is that while neuropathy is common in people with diabetes, the inflammation and secondary skeletal damage that characterize neuropathic osteoarthropathy are observed in only a small minority of people with diabetes and with neuropathy. We therefore argue that the key to understanding the causes of the Charcot foot is to focus equally on those who have active disease as well as those who do not. Although neuropathy is essential for development of the disorder, neuropathy also has an adverse impact on the mechanisms involved in the onset of inflammation, and these may be critically affected in the majority of those who are susceptible. The Charcot foot is uncommon in people with diabetes (or any other cause of neuropathy) because the large majority of those with neuropathy may have also lost the capacity to mount the specific inflammatory reaction that is essential for its development.

Why the Risk of Developing Neuroarthropathy Is Higher After Simultaneous Kidney and Pancreatic Transplantation Compared to Kidney Transplantation Only: The Role of Euglycemia

Charcot’s neuroarthropathy is a destructive complication of the joint, which is often found in patients living with diabetes. Despite the fact that its description was published almost 100 years ago, its pathophysiology, diagnosis, and treatment remain areas that need to be updated. Its prevalence is low in patients living with diabetes, but this increases in particular situations such as peripheral neuropathy, as well as after simultaneous kidney-pancreas transplantation (SPKT) in patients living with type 1 diabetes. We suggest that the development of neuroarthropathy after SPK in not only due to glucocorticoid therapy, as described, but also to the rapid passage into euglycemia. The reduced prevalence of neuroarthropathy after only kidney transplantation compared to SPK seems to validate our hypothesis.

Rapid glycemic regulation in poorly controlled patients living with diabetes, a new associated factor in the pathophysiology of Charcot's acute neuroarthropathy

Objective

Aggressive antidiabetic therapy and rapid glycemic control are associated with diabetic neuropathy. Here we investigated if this is also the case for Charcot neuroarthropathy.

Research design and methods

HbA1c levels and other relevant data were extracted from medical databases of 44 cases of acute Charcot neuroarthropathy.

Results

HbA1c levels significantly declined from 8.25% (67mmol/mol) [7.1%–9.4%](54-79mmol/mol), at -6 months (M-6), to 7.40%(54mmol/mol) [6.70%–8.03%] (50–64 mmol/mol) during the six months preceding the diagnosis of Charcot neuroarthropathy (P <0.001).

Conclusions

HbA1c levels significantly declined during the six months preceding the onset of Charcot neuroarthropathy. This decline seems to be a associated factor with the appearance of an active phase of Charcot neuroarthropathy in poorly controlled patients with diabetic sensitive neuropathy.

BILATERAL NEUROARTHROPATHY 11 YEARS AFTER SIMULTANEOUS PANCREAS-KIDNEY TRANSPLANT FOR TYPE 1 DIABETES MELLITUS

Objective

To report a case of a man who developed bilateral Charcot arthropathic feet 11 years after a simultaneous pancreas-kidney transplant (SPKT) for type 1 diabetes mellitus (DM). The patient had remained normoglycemic after surgery.

Methods

We present a retrospective review of the case notes and serial imaging.

Results

The patient developed dense peripheral diabetic neuropathy due to poor glycemic control. His biochemical markers of DM all normalized following SPKT, and he was discharged by his primary and secondary care diabetes services. Eleven years later, he developed Charcot arthropathy in one foot and, within a month, the other foot as well.

Conclusion

Individuals with DM who had preoperative end organ diabetes-related damage who went into biochemical remission after SPKT may be at risk for future complications. They should not be discharged from specialist diabetes services, and they need continued education about foot care.

Multifocal (tarsus and knee) activation of neuroarthropathy following rapid glycaemic correction

OBJECTIVE

To report a case of neuroarthropathy in the tarsus and knee following rapid glycaemic normalisation in a female patient with type I diabetes.

METHODS

A retrospective review of case notes.

RESULTS

We describe the case of a female patient with type I diabetes who had developed a multifocal neuroarthropathy in only six months, probably due to a rapid glycaemic normalisation. The onset of this neuroarthropathy was not only fast but mostly multifocal affecting two levels of joints.

CONCLUSION

The link between the onset of multifocal neuroarthropathy and the rapid correction of chronic hyperglycaemia is probably proven in our case. Patients with chronic hyperglycaemia with sensitive neuropathy should benefit from a gradual correction of their glycaemic imbalance in order to avoid the apparition of neuroarthropathy.

Pathogenesis and potential relative risk factors of diabetic neuropathic osteoarthropathy

Diabetic neuropathic osteoarthropathy (DNOAP) is an uncommon, but with considerable morbidity and mortality rates, complication of diabetes. The real pathogenesis is still unclear. The two popular theories are the neuro-vascular theory and neuro-traumatic theory. Most theories and pathways focused on the uncontrolled inflammations that resulted in the final common pathway, receptor activator of nuclear factor κβ ligand (RANKL)/osteoprotegerin (OPG) axis, for the decreased bone density in DNOAP with an osteoclast and osteoblast imbalance. However, the RANKL/OPG pathway does not explain all the changes, other pathways and factors also play roles. A lot of DNOAP potential relative risk factors were evaluated and reported in the literature, including age, gender, weight, duration and type of diabetes, bone mineral density, peripheral neuropathy and arterial disease, trauma history, and some others. However, most of them are still in debates. Future studies focus on the pathogenesis of DNOAP are still needed, especially for the genetic factors. And, the relationship between DNOAP and those potential relative risk factors are still need to further clarify.

Diabetic Foot Complications Despite Successful Pancreas Transplantation

BACKGROUND

It is known that successful pancreas transplantation enables patients with diabetes to maintain a normal glucose level without insulin and reduces diabetes-related complications. However, we have little information about the foot-specific morbidity in patients who have undergone successful pancreas transplantation. The purpose of this study was to investigate the prevalence and predisposing factors for foot complications after successful pancreas transplantation.

METHODS

This retrospective study included 218 patients (91 males, 127 females) who had undergone pancreas transplantation for diabetes. The mean age was 40.7 (range, 15-76) years. Diabetes type, transplantation type, body mass index, and diabetes duration before transplantation were confirmed. After pancreas transplantation, the occurrence and duration of foot and ankle complications were assessed.

RESULTS

Twenty-two patients (10.1%) had diabetic foot complications. Fifteen patients (6.9%) had diabetic foot ulcer and 7 patients (3.2%) had Charcot arthropathy. Three patients had both diabetic foot ulcer and Charcot arthropathy. Three insufficiency fractures (1.4%) were included. Mean time of complications after transplantation was 18.5 (range, 2-77) months. Creatinine level 1 year after surgery was higher in the complication group rather than the noncomplication group ( P = .02).

CONCLUSION

Complications of the foot and ankle still occurred following pancreas transplantation in patients with diabetes.

LEVEL OF EVIDENCE

Level III, comparative study.