Correlation of HDL cholesterol serum and Wagner’s severity level of diabetic foot ulcers

Tommy Kartono, Muhammad Nuralim Mallapasi, Mulawardi Mulawardi, Sachraswaty R. Laidding, Meiliati Aminyoto, Prihantono Prihantono


Background: Diabetic foot ulcers are one of the leading causes of amputation in non-traumatic patients. This research aimed to investigate the correlation between the level of HDL cholesterol and the severity level of diabetic foot ulcer based on Wagner classification. The study conducted at Wahidin Sudirohusodo Hospital, Makassar, Indonesia.

Methods: This is an observational study with the cross-sectional design. The data collected before and after the treatment. The change of the levels of HDL cholesterol and the severity level of the diabetic foot ulcer based on Wagner classification during the treatment were analyzed. Data analyzed using Spearman Correlation test, the paired t-test to assess the change in the levels of HDL cholesterol and the levels of severity of diabetic foot ulcer based on Wagner classification at the time admission and after the treatment.  ANOVA test was used to observe the reduction significance of the severity of diabetic foot ulcer based on Wagner classification, and it was categorized as significant if p<0.05.

Results: The results indicated that there is a correlation between the level of HDL cholesterol and the severity level of diabetic foot ulcer based on Wagner classification either at the early treatment with p-value = 0.003 (r = - 0.448) and the end of the treatment with p-value = 0.001(r = - 0.477).  The lower of the level of cholesterol HDL, the higher was the severity level of the diabetic foot ulcer. Meanwhile, the correlation between the increase of the level of HDL cholesterol and the reduction of Wagner classification during the treatment was statistically insignificant with p-value = 0.100 (r = - 0.215).

Conclusions: there was a correlation between elevated HDL cholesterol levels during treatment with Wagner classification decrease during treatment, the higher the HDL change, the higher the Wagner classification, but this was weak correlation and statistically insignificant.


HDL cholesterol, Ulcers, Wagner classification

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Zubair M, Malik A, Ahmad J. Diabetic foot ulcer: a review. Am J Internal Med. 2015;3(2):28-49.

Rudianto A, Soewondo P, Waspadji S, Yunir E, Purnamasari D. The Indonesian society of endocrinology’s summary article of diabetes mellitus national clinical practice guidelines. J ASEAN Fed Endoc Soci. 2014;26(1):17.

Fauci A, Braunwald E, Kasper D. Diabetes Mellitus. Harrison’s Manual of Medicine. 2009;7:942-7.

Ahmeti I, Bogoev M, Petrovski G, Milenkovic T, Krstevska B, Taravari A. Influence of metabolic dysregulation in pre ulcerative phase of diabetic foot. J Diab Foot Complications. 2012;4(1):6-12.

Pei E, Li J, Lu C, Xu J, Tang T, Ye M, Zhang X, Li M. Effects of lipids and lipoproteins on diabetic foot in people with type 2 diabetes mellitus: A meta-analysis. J Diab Complications. 2014 Aug 31;28(4):559-64.

Jong WD, Sjamsuhidajat. Diabetic Gangrene. In: Textbook of Surgical Science. 2013:579-580.

Ikura K, Hanai K, Shinjyo T, Uchigata Y. HDL cholesterol as a predictor for the incidence of lower extremity amputation and wound-related death in patients with diabetic foot ulcers. Atherosclerosis. 2015 Apr 30;239(2):465-9.

Kumar A, Joshi S. Diabetic Foot Classifications: Review of Literature. J Med Sci. 2013;2(3):715-21.

Manda V, Sreedharan J, Muttappallymyalil J, Das R, Hisamatsu E. Foot ulcers and risk factors among diabetic patients visiting Surgery Department in a University Teaching Hospital in Ajman, UAE. Int J Medicine Public Health. 2012;2(3).

Mendes JJ, Neves J. Diabetic foot infections: current diagnosis and treatment. J Diabetic Foot Complications. 2012;4(2):26-42.

Singh S, Pai DR, Yuhhui C. Diabetic foot ulcer–diagnosis and management. Clin Res Foot Ankle. 2013 Nov 7;1(3):120.

Cimmino G, Ciccarelli G, Morello A, Ciccarelli M, Golino P. High-density lipoprotein cholesterol increasing therapy: The Unmet Cardiovascular Need. Transl Med UniSa. 2015 May-Aug; 12: 29-40.

Spieker LE, Sudano I, Hürlimann D, Lerch PG, Lang MG, Binggeli C, Corti R, Ruschitzka F, Lüscher TF, Noll G. High-density lipoprotein restores endothelial function in hypercholesterolemic men. Circulation. 2002 Mar 26;105(12):1399-402.

Lüscher TF, Landmesser U, von Eckardstein A, Fogelman AM. High-density lipoprotein vascular protective effects, dysfunction and potential as therapeutic target. Circ Res. 2014 Jan 3;114(1):171-82.

Mineo C, Shaul PW. Novel biological functions of HDL cholesterol. Circ Res 2012;111(8):1079-90.

Guo L, Ai J, Zheng Z, Howatt DA, Daugherty A, Huang B, Li XA. High density lipoprotein protects against polymicrobe-induced sepsis in mice. J Biol Chem. 2013 Jun 21;288(25):17947-53.

Assmann G, Gotto AM Jr. HDL Cholesterol and protective factors in atherosclerosis. Circulation. 2004 Jun 15;109(23 Suppl 1):III8-14.

Jellinger PS, Smith DA, Mehta AE, Ganda O, Handelsman Y, Rodbard HW, Shepherd MD, Seibel JA. American Association of Clinical Endocrinologists' guidelines for management of dyslipidemia and prevention of atherosclerosis. Endocr Pract. 2012 Mar;18(Suppl 1):1-78.

Graversen JH, Castro G, Kandoussi A, Nielsen H, Christensen EI, Norden A, Moestrup SK. A pivotal role of the human kidney in catabolism of HDL protein components apolipoprotein AI and A-IV but not of A-II. Lipids. 2008 May 1;43(5):467-70.

Vollenweider P, von Eckardstein A, Widmann C. HDLs, diabetes, and metabolic syndrome. InHigh Density Lipoproteins Springer International Publishing; 2015:405-21.