Lower limb amputation in incident dialysis patients in England: incidence, outcomes, and inter-centre variation from a national registry study

Abstract Background Lower limb amputation (LLA) is a devastating complication in dialysis patients, often related to diabetes and peripheral vascular disease. National data on LLA incidence, variation, and outcomes in England are limited. Methods A retrospective cohort study conducted using linked data from the UK Renal Registry (UKRR) and Hospital Episode Statistics (HES) for incident dialysis patients in England (2003–2017). Cumulative incidence plots assessed LLA rates across three patient subgroups- Primary renal disease (PRD) Diabetes, Diabetes as comorbidity and no-diabetes. Fine-Gray competing risk models identified independent risk factors for LLA. One-year mortality following LLA was presented as Kaplan-Meier curves and analysed using age- and sex-adjusted standardised mortality rates (SMR). Results Among 69 701 incident dialysis patients, 9.1% with PRD diabetes underwent LLA within three years, versus 2.6% with diabetes as comorbidity and 0.6% without diabetes. Risk factors for LLA included diabetes (sHR 9.3 for PRD diabetes, sHR 3.6 for diabetes as comorbidity), peripheral vascular disease (sHR 2.11), prior amputation (sHR 2.19), ischaemic heart disease and white ethnicity. Major amputation rates declined over time, while minor amputation rates remained stable. Significant inter-centre variation was observed after adjustment. One-year mortality after LLA exceeded 40% in all subgroups. SMRs were highest in the PRD diabetes group compared to the general population (34.7), but highest in the diabetes as comorbidity group compared to the dialysis population (5.31). Conclusion Incident dialysis patients, particularly with PRD diabetes, face high LLA risk and very poor survival after amputation. Persistent inter-centre variation suggests scope for national audit, standardised foot care, and preventive strategies.