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Original Article The Severity of Diabetes and the Risk of Diabetic Foot Amputation: A National Cohort Study
Jin Yu1*orcid , Ji-Hyun Kim1*orcid , Bongseong Kim2, Kyungdo Han2, Seung Hwan Lee1, Mee Kyoung Kim3orcid

DOI: https://doi.org/10.3803/EnM.2024.2266 [Epub ahead of print]
Published online: April 15, 2025
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1Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
2Department of Statistics and Actuarial Science, Soongsil University, Seoul, Korea
3Division of Endocrinology and Metabolism, Department of Internal Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
Corresponding author:  Mee Kyoung Kim, Tel: +82-2-2030-4435, Fax: +82-2-780-3132, 
Email: makung@catholic.ac.kr
*These authors contributed equally to this work.
Received: 28 November 2024   • Revised: 17 January 2025   • Accepted: 4 February 2025
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Abstract

Background
This study aimed to assess whether markers of diabetes severity could serve as predictors for foot amputation risk among patients with type 2 diabetes mellitus.
Methods
We analyzed data from the nationally representative Korean National Health Insurance System database, tracking 2,544,077 patients with type 2 diabetes mellitus who participated in routine health check-ups between 2009 and 2012, with followup extending through the end of 2018. The parameters used to define the diabetes severity score encompassed diabetes duration, insulin usage, the number of oral glucose-lowering medications, the presence of chronic kidney disease, diabetic retinopathy, and cardiovascular disease. Each factor was assigned one point, yielding a cumulative severity score ranging from 0 to 6.
Results
The risk of diabetic foot amputation was predominantly predicted by insulin therapy, diabetic retinopathy, and a prolonged duration of diabetes. The hazard ratios for foot amputation increased with the severity score as follows: 2.31 (95% confidence interval [CI], 2.15 to 2.47) for a score of 1, 4.73 (95% CI, 4.42 to 5.07) for a score of 2, 8.86 (95% CI, 8.24 to 9.53) for a score of 3, 16.95 (95% CI, 15.60 to 18.4) for a score of 4, 23.98 (95% CI, 21.25 to 27.05) for a score of 5, and 37.87 (95% CI, 28.93 to 49.57) for a score of 6.
Conclusion
Specific markers of advanced diabetes effectively identified patients at an elevated risk for diabetic foot amputation.

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