Diyabetik Ayak: Etiyoloji
Özet
Diyabetik ayak yaralarının etiyolojisinde nöropati, iskemi (periferik arter hastalığı) ve infeksiyon ana rolü oynamaktadır. Distal simetrik sensoriyel nöropati, ağrı ve ısı hissi kaybına yol açarak travmaların fark edilmesini engeller; otonom nöropati ise cilt kuruluğu ve bası odaklı nasır oluşumuyla yara riskini artırır. Motor nöropati ayak şekil bozukluklarına sebep olurken, propriosepsiyon kaybı denge sorunları ve düşmelere zemin hazırlar. İskemi ise yaraların iyileşmesini önler; diyabetiklerde daha diffüz seyreden periferik arter hastalığı, ampütasyon riskini yükseltir. Nöropatik yaralar genellikle ayak tabanında mekanik bası alanlarında çıkarken, iskemik yaralar parmak uçlarında ve ayak kenarlarında gözlenir. Charcot nöroartropatisi (Charcot ayağı), ileri nöropatili hastalarda inflamasyon, kemik destrüksiyonu ve "beşik ayak" deformitesine yol açan nadir fakat ciddi bir tablodur. İyileşen ayak yaralarının bir yıl içinde %40, beş yıl içinde %65 oranında nüks etmesi, bu vakaların iyileşmiş değil remisyonda kabul edilmesini gerektirir. Ayrıca yaraların %50-60'ı infekte olmakta ve orta-ileri derece infeksiyonların %20'si ampütasyonla sonuçlanmaktadır. Özellikle diyalize giren hastalar için ayak yaraları yüksek mortalite ile seyreden bağımsız bir risk faktörüdür.
Neuropathy, ischemia (peripheral arterial disease), and infection play a major role in the etiology of diabetic foot ulcers. Distal symmetric sensory neuropathy causes loss of pain and temperature sensation, preventing the awareness of traumas, while autonomic neuropathy increases ulcer risk through skin dryness and callus formation under pressure areas. Motor neuropathy leads to foot deformities, and the loss of proprioception causes balance issues and falls. Ischemia prevents wounds from healing, and peripheral arterial disease, which follows a more diffuse course in diabetic patients, increases the risk of amputation. Neuropathic ulcers usually occur in high mechanical pressure areas on the sole of the foot, whereas ischemic ulcers are observed on the tips of the toes and edges of the foot. Charcot neuroarthropathy (Charcot foot) is a rare but severe condition that causes inflammation, bone destruction, and "rocker bottom" deformity in patients with advanced neuropathy. The fact that healed foot ulcers recur at a rate of 40% within one year and 65% within five years requires these cases to be considered in remission rather than cured. Furthermore, 50-60% of ulcers become infected, and 20% of moderate-to-severe infections result in amputation. Especially for patients undergoing dialysis, foot ulcers are an independent risk factor associated with high mortality.
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