Foot Care and your Transplant. Shawn M Sanicola DPM FACFAS 2835 N Grandview Blvd #300 Pewaukee, WI

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1 Foot Care and your Transplant Shawn M Sanicola DPM FACFAS 2835 N Grandview Blvd #300 Pewaukee, WI

2 Post Transplant: It is good to have a more experienced friend when wading into uncharted waters!

3 Objectives 1. Understand the importance of foot care after your transplant 2. Discuss the role your post transplant medications play in your foot care 3. Dealing with Post Transplant Diabetes Mellitus

4 Diabetes and your transplant 15-25% of people develop new onset diabetes post transplant Elevated blood glucose levels affect small blood vessels, peripheral nerves, and can cause foot deformities. These three things in combination are the reason why diabetics are the leading population for ulcerations and lower extremity amputations.

5 The effect of elevated blood glucose Glucose is our energy and is designed to be sequestered in our muscles Insulin from the pancreas is meant to recognize and push excess glucose into muscle If there is too much glucose floating around in our blood stream it sticks to things and makes them not work correctly

6 The effect of elevated blood glucose Nerves begin to swell and loose there myelin sheath Swollen nerves get pinched or compressed at tight areas of the body Below the knee and the ankle are common areas Neuropathy occurs in a stocking and glove distribution Loose balance, then discriminate touch, and then pressure sensation

7 Peripheral Nerve

8 Peripheral Neuropathy

9 Peripheral Neuropathy

10 The effect of elevated blood glucose Excess blood sugars cause inflammation of the blood vessel walls This shuts down the small blood vessels (especially in the feet and organs) This hardens the medium size blood vessels (garden hose into a hard pipe) Increases the rate of CAD (coronary artery disease) Can lead to blockages in blood vessels

11 The effect of elevated blood glucose Excess glucose sticks to tendons Tendons become tighter leading to foot deformities Hammertoes, bunions, and ankle equinus

12 Foot Deformities Hammertoe Hammertoe-simple deformity causing 3 major pressure problems

13 Hammertoe and Ulcer

14 Hammertoe and Ulcer

15 Equines

16 What Causes PTDM? Weight gain Inactivity Diet Genetics Post Transplant Anti Rejection Medication!!!!

17 Anti rejection medication Steroids, tacrolimus, and sirolimus increase blood glucose levels Affect normal insulin production Inhibit the immune system by design to protect the grafted organ from rejection This is done by halting the inflammatory response This also affects healing and the ability to fight infection Weakens bones Leads to increase fractures (especially the foot)

18 Anti rejection medication Loss of bone strength combined with loss of balance Diabetics are the largest population of hip and wrist fractures Insensate foot can lead to Charcot deformity Neuropathy and deformity can lead to ulcers Ulcers difficult to heal with inhibition of inflammation

19 Charcot

20 Charcot

21 Charcot Ankle

22 Charcot Ankle

23 Vascular Disease Control high blood pressure (HTN) Control High cholesterol/triglycerides (dyslipidemia) Both of these leads to peripheral and cardio vascular disease Circulation in the feet and legs can be affected first (small vessels) Small vessels also dominate in the organs You could be putting your new organ and your feet at risk.

24 Why is this important? Amputations! The combination of Peripheral Neuropathy, Peripheral Vascular Disease, and Foot Deformity can lead to Foot Ulcerations Foot Ulcerations can lead to infections and amputations. It takes 60% more cardiac output to walk with a Below Knee Prosthesis With the combination of Cardiac disease and neuropathy most people can not balance with a prosthesis Most people die within 3-5 years after a Below Knee Amputation from Congestive Heart Failure (CHF)

25 Prevention! Prevention! Prevention! This can be avoided! Need a multidisciplinary approach Transplant team, Nephrologist/Endocrinologist, Podiatrist, Cardiologist, Nutritionist, Nursing Aggressive blood glucose control from the beginning! Aggressive blood pressure control! Aggressive lipid control!

26 Prevention! Prevention! Prevention! Diet, exercise, weight loss all play big roles Needs to be done within the parameters set by your transplant team Your Podiatrist can help with prevention with regular risk assessments I would rather see you every 3 months or sooner if needed then perform amputations!

27 Conclusion Aggressive control of your health is essential to survival post transplant Prevention and/or aggressive management of diabetes can dramatically decrease amputations If you are diabetic YOU NEED A PODIATRIST! Multidisciplinary approach works the best.

28 The End Or The Beginning

29 Thanks Shawn M Sanicola DPM, FACFAS 2835 N Grandview Blvd #300 Waukesha, WI