Diabetes is one of the most frequent reasons of end-stage renal failure and a well-established cause of the development of foot lesions . Almost 25% of patients with diabetes have been stated to develop foot ulceration as a complication during their lifetime . Furthermore, independent of diabetes, renal failure has been reported to markedly increase the risk of diabetic foot ulceration and amputation [3, 12]. Hence the coexistence of these two conditions, there is a double threat for development of foot lesions which impair the patient’s quality of life, increase health care costs, and, for patients who require surgical interventions, there is a higher mortality compared with patients without renal disease .
Given that any significant wound leads to a hyper-metabolic and catabolic state, wound healing is a complex chain of biochemical events during which nutritional needs are significantly increased . It is a well-known fact that protein and amino acid support accelerates the wound healing. In this retrospective study, it was determined that the nutrition support combination consisting of beta-hydroxy-beta-methylbutyrate, arginine and glutamine would be useful for the treatment of foot ulcers, which are encountered as an important problem in diabetic dialysis patients.
Due to its rapid metabolism, the wound needs high amounts of nutritional elements while protein-calorie malnutrition extends the phase of inflammation with negative effects on the fibroplasia, proteoglycans and collagen synthesis. Essential amino acids play a significant role in wound healing by increasing the production of inflammation and fibroblast products . Beta-hydroxy-beta-methylbutyrate is a leucine metabolite. It decreases the proteolysis, increases the protein synthesis, decreases the apoptosis and increases the cell proliferation. HMB is generally used safely as support in patients with malnutrition, cancer, chronic disease, sepsis and HIV . Being a product of the ornithine metabolism, arginine is required for the cell proliferation, regeneration and collagen synthesis . Glutamine is not essential for the body; however, it is the most intense amino acid in the body that regulates the cell functions, coordinates the immune parameters, displays an anti-oxidant effect and regulates the adjuvant T-cell functions . In a study by Arana et al. evaluation of the effect of arginine treatment on healing of foot ulcer in 11 diabetic patients revealed that the recovery was complete for 8 patients and considerable for 3 patients . Costa et al. indicated that glutamine support significantly improved the laceration strength of wound and increased the percentage of mature collagen area . Likewise, HMB is known to have positive effects on wound healing.
Abound is a special formula that is consisted of beta-hydroxy-beta-methylbutyrate, arginine and glutamine that supports the wound healing and enables the structuring of lean body mass. This combination is potentially used among patients with cancer, sarcopenia, trauma, chronic diseases, chronic obstructive lung disease and HIV [17, 18]. However, the studies previously conducted have concluded that this product also accelerates the wound healing. In their study that was performed on 18 healthy adults older than 70 years of age, Williams et al. indicated that the Abound support increased the collagen synthesis and accelerated the wound healing . The period of ulcer healing was also shown to be significantly shortened with by Tatti et al. in retrospective evaluation of 12 patients with diabetic foot who were receiving the Abound treatment . Likewise, our findings also indicated that the healing was observed on wound depth score of 7 patients and on wound appearance score of 8 patients out of 11. While the wound depth score of 4 cases and wound appearance score of 3 cases remained the same, no deterioration was observed on any cases throughout the follow-up. In line with no negative side effect associated with the Abound treatment in the literature, none of our patients experienced a negative effect throughout the treatment.
The major limitation of the present study is its retrospective design as an uncontrolled series of diabetic haemodialysis patients besides the small sample size. Nevertheless, given that malnutrition is a common and well-known deleterious outcome in dialysis patients which delays wound healing, our findings indicating that beta-hydroxy-beta methylbutyrate, arginine and glutamine may be very beneficial in these patients by not only improving wound healing seem notable.