Careful! Diabetes leading cause of amputations

Amputated left toes of Beatrice Ikamba Runji. [Christopher Kipsang, Standard]

Beatrice Ikamba Runji, a house help, felt tired and decided to rest her then 51-year-old body in 2015.

As she removed socks to take a nap on the couch in Kanganangu village, Mbeere sub-County, she felt her right foot caked in blood- she had a prick, the foot was badly hurt and oozing blood.

“I did not know my foot was hurting because I had lost sensation. I soaked it in water, but the bleeding did not stop,” recalled Runji.

Runji went to Kiritiri Hospital where she was diagnosed with diabetes Type 2. By the time she was referred to Chogoria PCEA Hospital for specialised care, the infection could not be stopped. Part of her foot had to be amputated.

“I was shocked to realise I had diabetes and required amputation,” says the mother of seven who was put on physiotherapy and insulin to manage her glucose levels after the surgery.

Runji receives free insulin from Médecins Sans Frontières (MSF) which educates residents on Non-Communicable Diseases, but whenever there’s a supply hitch, she spends her own money on insulin monthly.

Runji also has visual challenges and is yet to go for a check-up due to financial constraints. She earns Sh500 weekly as a househelp.

“I am worried of losing my sight. I am praying to God to keep me healthy because the little earnings are not enough to help manage my condition and seek quality healthcare,” she said, adding she now gets tired fast.

Dr Daniel Katambo, a diabetic specialist based in Nairobi explained that even with amputation, patients have to continue observing their sugar levels as defaulting can still cause bilateral amputation of the other leg.

“When patients default, sugar levels go up, and can lead to other diabetes complications like kidney failure, blindness, stroke and eventually death,” said Dr Katambo.

What leads to a leg getting amputated?

Dr Katambo attributes it to poor disease management leading to decreased nerve sensation or lack of sensation especially on the legs and “damage to nerves and blood vessels leads to poor blood circulation in the legs or the affected limb.”

He adds that “once a patient develops an ulcer and it’s not treated, or does not heal, due to poor blood circulation, it may progress to affect the bone leading to the death of the body tissues (Necrosis) and Osteomyelitis or infection of the bone. This is what leads to amputation.”

But before amputation, diabetic patients undergo thorough evaluation including tests like CT-Angiogram of the affected limb to detect viability of the blood vessels and guide on where to cut besides the quality of blood on the leg.

The procedure entails putting patients on block anesthesia depending on the area to be amputated, for example above the knee, below the knee or below the ankle.

After amputation, patients go through physiotherapy before being encouraged to have a prosthesis, which only about 20 to 30 per cent of patients can afford, according to studies.

It takes time to get used to artificial legs. Phyllis Thenya, 72, from Koma village also in Mbere sub-County, felt numbness on her left foot and a fever. She developed a wound on the foot and was diagnosed with diabetes type 2 at Gategi Hospital which is a few kilometres from her home.

Deteriorating and requiring specialised care, Thenya was referred to Embu Level Five Hospital, then Gurumbani Hospital where she did not object the doctor’s decision to amputate her leg “as it felt like a massive cloud that was hanging on my head had been lifted. The pain on my foot was unbearable. But life as an amputee is not a joke.”

The amputation cost Sh180,000 after which she has fitted with a temporary artificial leg four years ago, but is yet to get used to it.

She has had to learn to use a walker to move around and “my normal home operations have since been grounded. Even with the artificial leg, I cannot walk smoothly,” says the mother of seven who stopped farming and now depends on her children.

Amputation is not the end of diabetes care- as Thenya uses insulin to manage her glucose levels. While amputation relieved her of chronic pain, it turned the tables of her life. “I cannot work, nor travel. I miss meeting friends and more so, attending church service,” narrates the granny who also has to deal with stigma.

Thenya covers her prosthesis with socks and “nobody can tell I have prosthesis when they see me in socks. I put socks on to avoid lots of stares from children and the elderly.”

The two are among hundreds of patients who have had an amputation due to diabetes, the leading cause of amputation in Kenya, according to data.

Stephen Njiru, a clinician and NCD coordinator in Embu said diabetes and hypertension are common NCDs in the county but are also “nationally worrying and might have complications on health financing. We need to revamp prevention measures.”

Health & Science visited Gategi Health Centre where about 1,200 patients are managed at NCD clinic where Samson Mutunga, a community health volunteer says patients ‘feels it is a burden to take drugs for long and give up.”

This means cases of defaulting are linked to misinformation about diabetes management and the results can be grave such as diabetic getting diabetic retinopathy(eye disease), diabetic foot and chronic kidney disease.

Patients also succumb to strokes and other heart conditions and to illustrate, just consider that there were at least 8, 700 diabetes-related deaths in Kenya in 2015.

According to Dr Katambo, insulin is a major drug in managing diabetes, more so type 1 diabetes, while type 2 diabetes, management can be achieved with oral drugs in the first few years of diagnosis, but progresses to insulin but remission is the best option for managing type 2 diabetes, and related complications.

“Every individual with type 2 diabetes has to know that we can actually prevent the disease, by putting it into remission, if their lifestyle is well controlled,” said Dr Katambo adding that “with recent studies, remission can be achieved through lifestyle change. This is giving hope to patients living with type 2 diabetes, and hence averting complications like amputations.”

He adds: “Nobody should wait to get amputated, let us go for regular annual medical check-ups, as diabetes is a silent disease. Early diagnosis helps in its proper management.”

Martha Mundi, a clinical officer mentor, with MSF noted most patients were also defaulting on medication, due to lack of knowledge on the disease, and care was only offered at Embu level Five Hospital-where prior to the sensitization, 50 per cent of inpatients were due to NCDs.

Healthcare workers have also been trained on screening, diagnosis, and treatment of the disease, but myths don’t help matters considering a majority of communities in larger Embu County associate diabetes with curses.

But Mundi is hopeful that “the training have equipped patients, medics and health volunteers with knowledge and cases management of diabetes.”

Edi Atte, MSF head of mission and medical coordinator reckons that “patients engagement and integration of NCDs diagnosis, care and treatment into primary health care, MSF and Embu County department of health demonstrated the feasibility of managing stable patients… and with sufficient investment, this is an approach duplicable in other facilities countrywide.”

MSF also integrated diabetes, among other NCD care at Level 2, 3 and 4 hospitals for easier access by patients.

Through integration, at least level hospitals across the county, namely Muchagori, Machanga, Kiritiri, Kigumo, Kibugu, Kiambere, Karau, Kanja, Kairuri, Kabuguri and Gategi are adequately equipped to take care of the estimated 6,802 patients with NCD in Embu County of which over 1000 are diabetics, according to MSF-whose health partner projects in the county have come to an end, but a community revolving pharmacy will see insulin supplied at subsidized rates via Missions for Essential Drugs and Supplies (Meds).