Diabetes-related foot disease and diabetic kidney disease are usually managed by different specialists, in different clinics, on different schedules. The literature of the past decade suggests they should be thought of together. Declining kidney function is one of the strongest and most consistently reported predictors of foot ulceration, poor healing, and lower-extremity amputation in people with diabetes — and the risk escalates sharply once dialysis begins.
Why Kidney Disease Changes the Foot
A narrative review by Bonnet and Sultan in Kidney International Reports (2021) mapped the overlap between the two complications. Up to 40% of people with diabetes are expected to develop chronic kidney disease (CKD), and 19% to 34% will experience a diabetic foot ulcer (DFU) in their lifetime. The two conditions share pathophysiology rather than simply co-occurring: peripheral arterial disease (PAD) is common to both, and CKD adds medial arterial calcification, uremic neuropathy layered onto diabetic peripheral neuropathy, impaired nutritional status, and altered wound-healing biology. Importantly, the authors found that the severity of podiatric risk tracks with CKD stage, with the worst outcomes concentrated in end-stage renal disease (ESRD).
Neuropathy and Perfusion
Because neuropathy is the anchor of most foot risk-stratification systems, including the International Working Group on the Diabetic Foot (IWGDF) framework, a CKD-related increase in neuropathy severity directly moves a patient into a higher risk category. Reduced perfusion compounds the problem: calcified, non-compressible vessels make ankle-brachial index measurement unreliable in dialysis patients, which can mask significant ischemia at exactly the point where detection matters most.
Ulceration Risk Rises With Declining Kidney Function
Cohort data support the gradient. In the Fukuoka Diabetes Registry, Iwase and colleagues followed 4,870 patients with type 2 diabetes for a median of 5.3 years and reported a DFU incidence of 2.9 per 1,000 person-years. An estimated glomerular filtration rate below 60 mL/min/1.73 m² was an independent risk factor for developing a new ulcer, alongside prior ulcer history, poor glycemic control, and depressive symptoms (Diabetes Research and Clinical Practice, 2018).
In the Atherosclerosis Risk in Communities study, Fang and colleagues followed 1,428 participants with diabetes for more than two decades and found a cumulative incidence of diabetic foot disease of 33.3%. Chronic kidney disease was among the identified risk factors, and the consequences of an incident foot lesion were substantial: 5-year cumulative incidence after a first episode was 38.9% for death and 14.5% for non-traumatic lower-extremity amputation (Diabetes Research and Clinical Practice, 2023).
A focused comparison by Özdemir and Nural in Wounds (2023) examined 160 patients with renal failure, with and without diabetes, receiving or not receiving hemodialysis. Patients with both diabetes and hemodialysis had the highest ulceration rate and, more strikingly, 72.5% were classified as high risk for foot ulceration — significantly more than any other group. Advanced (stage 4 or 5) CKD, hemodialysis, prior ulceration or amputation, foot deformity, nail and skin pathology, neuropathy, and vascular insufficiency all clustered in this population.
Outcomes After Ulceration and Amputation
Once a wound develops, kidney status shapes what happens next. Using the U.S. National Inpatient Sample, Salim and colleagues analyzed 121,815 hospitalizations for diabetic foot ulcers or infections, of which 8.4% involved dialysis-dependent CKD. Compared with patients without CKD, the dialysis group had significantly higher adjusted odds of major amputation (aOR 1.74), in-hospital mortality (aOR 3.77), and sepsis (aOR 1.83), along with longer stays and higher costs (Endocrinology, Diabetes & Metabolism, 2021).
Surgical series echo this. Wukich and colleagues reviewed 102 patients with diabetes undergoing transtibial amputation and found that those with ESRD on dialysis were significantly more likely to die during follow-up (52.4% vs. 23.5%) and significantly less likely to ambulate with a prosthesis (42.9% vs. 67.9%). Notably, the ability to walk after amputation was itself associated with a 62% reduction in mortality risk (Foot & Ankle International, 2017).
Surveillance Before Dialysis Begins
The encouraging finding in this literature is that the trajectory is not fixed. Bonnet and Sultan noted that targeted programs for dialysis populations have reduced major amputation rates in that group by more than half. A 2025 study by Behme, Girgis, and Schmidt in The International Journal of Lower Extremity Wounds examined patients with stage 3a–3b CKD and a foot ulcer and reported that every major amputation in their cohort occurred in patients who had not established podiatric care before starting hemodialysis. The study was small and hypothesis-generating rather than definitive, and the authors also flagged a possible disparity in access, with African American patients less likely to be connected to podiatry before dialysis initiation.
This aligns with the IWGDF 2023 practical guidelines, which structure prevention around risk stratification, screening frequency matched to risk category, protective footwear, structured education, and integrated multidisciplinary care.
Clinical Summary
Kidney function is a marker of foot risk, not merely a comorbidity. Ulcer incidence rises as eGFR falls; dialysis marks a step change in the likelihood of major amputation, sepsis, and death; and post-amputation function and survival are measurably worse in ESRD. The available evidence indicates that risk stratification and foot surveillance are most valuable when they begin in the pre-dialysis stages of CKD rather than after renal replacement therapy has started.
References
- Bonnet JB, Sultan A. Narrative Review of the Relationship Between CKD and Diabetic Foot Ulcer. Kidney International Reports. 2022;7(3):381–388.
- Iwase M, Fujii H, Nakamura U, et al. Incidence of diabetic foot ulcer in Japanese patients with type 2 diabetes mellitus: The Fukuoka Diabetes Registry. Diabetes Research and Clinical Practice. 2018;137:183–189.
- Fang M, Hu J, Jeon Y, Matsushita K, Selvin E, Hicks CW. Diabetic foot disease and the risk of major clinical outcomes. Diabetes Research and Clinical Practice. 2023;202:110778.
- Özdemir VA, Nural N. Evaluation of risk factors for foot ulceration in individuals with chronic kidney disease. Wounds. 2023;35(10):E319–E328.
- 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.
- Wukich DK, Ahn J, Raspovic KM, Gottschalk FA, La Fontaine J, Lavery LA. Comparison of Transtibial Amputations in Diabetic Patients With and Without End-Stage Renal Disease. Foot & Ankle International. 2017;38(4):388–396.
- Behme S, Girgis C, Schmidt BM. Impact of Podiatric Surveillance on Amputation Rates in Patients with Diabetes and Chronic Kidney Disease. The International Journal of Lower Extremity Wounds. 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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