Diabetic foot disease is usually discussed in terms of wounds, infection and limb loss. Yet the clinical story does not end at the foot. Over the past decade, large cohort studies and meta-analyses have shown that a diabetic foot ulcer (DFU) or amputation marks a person at substantially elevated risk of death. Understanding the size and drivers of that risk is essential for clinicians, caregivers and people living with diabetes.
How High Is Mortality After a Diabetic Foot Ulcer?
A 2023 systematic review and meta-analysis by Chen and colleagues (Diabetes, Obesity and Metabolism) pooled 34 observational studies comprising 124,376 participants from 16 countries. Pooled survival after DFU was approximately 87% at one year, 67% at three years, 51% at five years and 23% at ten years. In other words, roughly half of people with a DFU in these studies had died within five years.
Figures differ between healthcare settings and populations. Armstrong and colleagues (Journal of Foot and Ankle Research, 2020) reported five-year mortality of 30.5% for people with a DFU, 29.0% for Charcot neuroarthropathy, 46.2% after minor amputation and 56.6% after major amputation. For context, the same analysis cited a pooled five-year mortality of 31.0% for all cancers combined, with wide variation between types (about 9% for breast cancer and about 80% for lung cancer). The authors argued that the outcomes of diabetic foot complications are comparable to many malignancies, and that this is rarely appreciated.
What Causes These Deaths?
The foot ulcer itself is seldom the direct cause of death. In the Chen meta-analysis, cardiovascular disease accounted for about 46.6% of deaths and infection for about 24.8%. Peripheral artery disease, chronic kidney disease (including end-stage renal disease) and a history of cardiovascular disease were associated with higher mortality risk.
This pattern fits a broader interpretation: a DFU is a visible marker of advanced systemic disease. The same processes that damage the foot, including long-standing hyperglycemia, microvascular and macrovascular disease, neuropathy and renal impairment, also damage the heart, brain and kidneys. Frailty, reduced mobility after ulceration, and the physiological burden of recurrent infection may add further risk.
Amputation as a Marker of Risk
Amputation carries the highest mortality in the available data. The Chen meta-analysis identified amputation as a significant mortality risk factor (hazard ratio about 2.4). The Armstrong 2020 analysis showed a clear gradient from ulcer to minor amputation to major amputation, with major amputation associated with a five-year mortality above 50%. Because amputation often follows infection or advanced ischemia, it is difficult to separate the effect of the procedure from the severity of the underlying disease. Both likely contribute.
Recurrence Compounds the Problem
Healing an ulcer does not end the risk. Armstrong, Boulton and Bus (New England Journal of Medicine, 2017) summarized evidence that about 40% of people have a recurrent ulcer within one year of healing and about 65% within five years. Each recurrence represents another episode of tissue loss, infection risk and potential hospitalization. The authors framed the healed ulcer as a state of remission rather than cure, which calls for ongoing surveillance.
Implications for Care
The 2023 JAMA review by Armstrong, Tan, Boulton and Bus describes evidence-based management built on several elements: regular foot examination and risk stratification, effective offloading, treatment of infection, assessment and treatment of peripheral artery disease, and coordinated multidisciplinary care. Given the mortality data, these elements are best seen as part of overall cardiovascular and metabolic care. Cardiovascular risk assessment, renal monitoring and management of glycemia, blood pressure and lipids are directly relevant to survival in people with foot disease.
Key Takeaways
Pooled data suggest that about half of people with a DFU die within five years, although estimates vary by population and setting. Mortality rises further after minor and major amputation. Cardiovascular disease and infection are the leading causes of death, and recurrence is common after healing. A diabetic foot ulcer is therefore best understood as a marker of systemic disease with prognostic importance comparable to many cancers.
References
- Chen L, Sun S, Gao Y, Ran X. Global mortality of diabetic foot ulcer: a systematic review and meta-analysis of observational studies. Diabetes, Obesity and Metabolism. 2023;25(1):36-45.
- Armstrong DG, Swerdlow MA, Armstrong AA, Conte MS, Padula WV, Bus SA. Five year mortality and direct costs of care for people with diabetic foot complications are comparable to cancer. Journal of Foot and Ankle Research. 2020;13:16.
- Armstrong DG, Boulton AJM, Bus SA. Diabetic foot ulcers and their recurrence. New England Journal of Medicine. 2017;376(24):2367-2375.
- Armstrong DG, Tan TW, Boulton AJM, Bus SA. Diabetic foot ulcers: a review. JAMA. 2023;330(1):62-75.
Comments
