Foot ulceration and its association with mortality in diabetes mellitus: a meta‐analysis

Background Diabetic foot ulcers portend an almost twofold increase in all‐cause mortality compared with diabetes on its own. Aim To investigate the association between diabetic foot ulcers and risk of death. Methods We performed a meta‐analysis of all observational studies investigating the association between diabetic foot ulcers and all‐cause mortality. Risk ratios and risk differences were pooled in a random‐effects model. The I2 statistic was used to quantify heterogeneity between studies. Results Altogether, we identified 11 studies that reported 84 131 deaths from any cause in 446 916 participants with diabetes during a total of 643 499 person‐years of follow‐up. The crude event rate for all‐cause mortality in individuals with diabetes who did not develop foot ulceration was 22% lower at 181.5 deaths (per 1000 person‐years) than in those who developed foot ulcers (230.8 per 1000 person‐years). Diabetic foot ulceration was associated with an increased risk of all‐cause mortality (pooled relative risk 2.45, 95% CI 1.85–2.85). We did not observe any tangible differences in risk of all‐cause mortality from diagnosis in studies reporting a mean duration of follow‐up of ≤3 years (relative risk 2.43, 95% CI 2.27–2.61) or >3 years (relative risk 2.26, 95% CI 2.13–2.40) years. Funnel plot inspection revealed no significant publication bias among studies included in this meta‐analysis. Conclusions Our study shows an excess rate of all‐cause mortality in people with diabetic foot ulceration when compared to those without foot ulceration. It is imperative that early interventions to prevent foot ulceration and modify cardiovascular disease risk factors are put in place to reduce excess mortality. What's new? Diabetes mellitus increases the risk of cardiovascular disease and all‐cause mortality. There is clear evidence that diabetic foot ulceration, a common problem in long‐standing diabetes increases risk of death further still. In this systematic review we have updated the meta‐analysis by Brownrigg et al. (2012), including almost half a million participants. We pooled study‐specific estimates using random‐effects meta‐analysis to ascertain risk of death in people with diabetes who developed foot ulceration vs those who did not. We conclude that, in the presence of diabetes, people with ulcers have an excess rate of all‐cause mortality as compared to those without any foot complications. The presence of diabetic foot ulceration should be viewed as a major red f