Objective:
Microvascular free tissue transfer is critical to the success of the reconstruction of diabetic foot. Patients with diabetes mellitus (DM) usually have diabetic nephropathy necessitating hemodialysis. Several studies reported renal disease is a risk factor for free flap failure and limb amputation. Limb salvage in DM patients with hemodialysis remains a subject of debate.

Material and Methods:
A retrospective study of diabetic mellitus patients underwent free flap reconstruction of diabetic foot at the Hualien Tzu Chi General Hospital for a 12-year period between January 2005 to June 2017 was conducted. Patients were classified into DM undergoing hemodialysis (DM-HD) and those without hemodialysis (DM alone).

Results:
A total of 60 patients were included in the study. DM-HD patients (n=13) had higher rate of cardiovascular disease, ASA score and Charlson comorbidity index. Greater severity of peripheral arterial disease was noted in DM-HD group and bypass surgery was conducted in half of the patients. Total flap failure rate in DM-HD group (4/13, 30.8%) was significantly higher than that of the DM alone (2/47, 4.3%, p=0.017). The result showed hemodialysis is an independent factor of total flap loss (odds ratio=6.94, p=0.047).

Conclusions:
Our results show that free flap reconstruction is achievable in patient with diabetic foot and end-stage renal disease on hemodialysis. Although with a higher total flap failure rate, the rate of long-term limb salvage is still reasonably good.

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