Diabetes rarely affects a single organ in isolation. When kidney disease and foot disease occur together — as they frequently do — the combination is far more dangerous than either condition alone. People with diabetes and chronic kidney disease (CKD), and particularly those receiving dialysis, face a substantially higher risk of foot ulceration, infection, and amputation, and their wounds are notoriously slow to heal. Understanding why kidney function shapes foot outcomes helps patients, caregivers, and clinicians recognise a high-risk situation early and respond to it appropriately.
How Often Do Kidney Disease and Foot Disease Overlap?
The overlap is common. In a narrative review of the relationship between CKD and the diabetic foot, Bonnet and Sultan (2022) noted that up to 40% of people with diabetes are expected to develop CKD, and that between 19% and 34% will experience a diabetic foot ulcer at some point in their lives. These two complications are not independent. The review found that the incidence of foot ulceration — and the likelihood of a poor outcome — tends to rise in step with the stage of CKD, reaching its peak in people with end-stage kidney disease.
Dialysis appears to mark a particularly sharp threshold. Research has consistently identified dialysis treatment itself as an independent risk factor for foot ulceration, beyond the separate contributions of diabetes, nerve damage, and circulation problems.
Why Kidney Disease Makes Foot Wounds Harder to Heal
Vascular calcification and reduced perfusion
As kidney function declines, disturbances in calcium and phosphate metabolism and the accumulation of uremic toxins promote calcification of the artery walls in the lower limb. Stiff, calcified vessels deliver less oxygen-rich blood to the foot, and they can also make standard circulation tests, such as ankle pressure measurements, falsely reassuring. In their 2025 review of the “renal foot,” Rastogi and colleagues describe how this impaired perfusion compounds the effects of peripheral arterial disease, leaving healing tissue starved of the blood supply it needs.
A wound-healing environment under strain
Advanced kidney disease creates a state of chronic inflammation, impaired immune defence, and poor nutrition. Protein loss, anemia, and deficiencies of vitamins and minerals reduce collagen production and slow the orderly repair of damaged tissue. Uremia can also worsen nerve function, adding to the diabetic neuropathy that allows minor injuries to go unnoticed until they become serious. The dialysis process itself adds further pressure through long hours of relative immobility, fluid shifts, and repeated handling of the feet during treatment sessions.
The Outcomes: Ulcers, Amputation, and Survival
The clinical consequences are stark. A systematic review and meta-analysis by Kaminski and colleagues (2015), pooling 30 studies of adults on dialysis, identified previous foot ulceration, peripheral arterial disease, peripheral neuropathy, and diabetes as the strongest risk factors for both ulceration and amputation. Previous ulceration carried an especially high odds ratio for subsequent amputation, underscoring how a healed wound in this population should never be regarded as a closed chapter.
Hospital data reinforce the concern. In a nationwide analysis of more than 120,000 admissions for diabetic foot disorders, Salim (2021) found that patients with dialysis-dependent CKD had significantly higher odds of major amputation, in-hospital death, and sepsis, along with longer hospital stays, than patients without kidney disease. Amputation rates among people with diabetes and end-stage kidney disease are several times those of the wider diabetic population, and survival after a major amputation is poor.
Reducing the Risk: Screening and Shared Care
Because the risk is so concentrated, prevention centres on early detection and coordinated care. The dialysis unit offers a practical advantage: patients attend regularly, often three times a week, which creates natural and repeated opportunities for foot inspection. International guidance, including the IWGDF 2023 practical guidelines, places people with diabetes and significant comorbidity such as kidney disease toward the higher-risk end of foot-risk stratification and recommends frequent, structured screening of sensation, circulation, deformity, and skin integrity.
Practical measures include protecting the feet during dialysis sessions, relieving pressure on the heels of patients who are immobile for long periods, arranging prompt review of any new wound, and maintaining close communication among nephrology, podiatry, vascular, and diabetes teams. Where ulcers do develop, the established principles of diabetic foot care — pressure offloading, infection control, debridement, and careful assessment of blood supply — still apply, but with a lower threshold for specialist involvement.
Key Takeaways
Kidney disease and diabetic foot disease are deeply interconnected. Declining kidney function, and dialysis in particular, raises the risk of foot ulceration, slows healing through vascular calcification, chronic inflammation, and poor nutrition, and increases the likelihood of amputation and death once a wound develops. Recognising the person with diabetes and CKD as a high-risk patient, and building regular foot surveillance into routine kidney care, are among the most effective ways to change that trajectory.
References
Kaminski MR, Raspovic A, McMahon LP, et al. Risk factors for foot ulceration and lower extremity amputation in adults with end-stage renal disease on dialysis: a systematic review and meta-analysis. Nephrology Dialysis Transplantation. 2015;30(10):1747–1766.
Bonnet JB, Sultan A. Narrative review of the relationship between CKD and diabetic foot ulcer. Kidney International Reports. 2022;7(3):381–388.
Salim M. Clinical outcomes among patients with chronic kidney disease hospitalized with diabetic foot disorders: a nationwide retrospective study. Endocrinology, Diabetes & Metabolism. 2021;4(3):e00277.
Rastogi A, Gupta R, Ghosh J, Jude EB. Renal foot in diabetes: implications for wound healing and solutions. Advances in Wound Care. 2025.
Schaper NC, van Netten JJ, Apelqvist J, et al. Practical guidelines on the prevention and management of diabetes-related foot disease (IWGDF 2023 update). Diabetes/Metabolism Research and Reviews. 2024;40(3):e3657.
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