Most studies identified in this review aimed to both prevent and manage foot and lower limb health complications (n = 153, 72%). A common example were studies which investigated surgical management for PAD but also aimed to prevent amputation. This aligns with our finding that more than one foot or lower limb health outcome (PAD, foot ulceration, amputation, related infection, and associated hospital admission) was reported in 67% of identified studies (n = 141). As noted previously, often more than one foot or lower limb health complication is experienced by adults undergoing dialysis [4] and these complications are frequently interrelated [3]. As such, an interdisciplinary approach to both research and care is essential. It is positive that guidelines which promote interdisciplinary care for foot and lower limb health are acknowledging dialysis patients as a particularly high risk group [10, 11]. Of note, foot and lower limb health guidelines are primarily targeted to patients with diabetes [10, 11], however, in practice these guidelines are often applied to patients without diabetes who experience the same or similar complications. As dialysis patients without diabetes also experience foot and lower limb health complications [1], it is encouraging that patients without diabetes were included in 54% of studies (n = 114) identified in this review.

The outcome results (positive, negative, or neutral) identified in this review were variable. For example, one study aimed to manage major amputation via rehabilitation and reported an ambulatory rate of 74% for patients with below knee amputation, however, most patients experienced difficulties with prosthetic fit [12]. This required an average length of stay of 74 days, and during rehabilitation 43% of patients (n = 13) required transfer to an acute hospital unit [12], identifying results which were clinically positive, neutral and negative. A different study which also aimed to manage major amputation via rehabilitation reported that on discharge 26% of patients were independent, 26% achieved partial independence and 47% were dependent, requiring complete assistance [13], again demonstrating clinically variable results. These variable results related in part to the broad inclusion criteria employed in the current scoping review, including various foot and lower limb health outcomes (PAD, foot ulceration, etc.), interventions, overall management goals (prevention and/or management), and reported outcomes (arterial patency, foot ulcer healing rates, etc.). We believe that the benefits of completing this broad review (due to foot and lower limb health being complex and interrelated for dialysis patients) outweigh this limitation. Of note, some positive results were identified, such as reduced rates of major amputation with the introduction of routine foot screening (17% reduction for rate of major amputation, p = 0.003) [14].

Most studies identified in this review were observational (n = 199, 94%). The limitations of observational research are well known, particularly the risk of bias [15]. However, the benefits of observational research are also acknowledged, such as feasibility for longer follow-up [16], which aligned with the results of this review (78% of studies involved intervention or follow-up for one year or more). While dialysis patients are sadly known to experience high mortality rates in general, appropriate time for follow up among this cohort remains relevant. For example, one study included in this review also tracked mortality and reported that following transtibial amputation, survival was 48% after approximately 2 years [17], identifying that long term outcomes are relevant for a large portion of dialysis patients who experience foot and lower limb health complications. Also, assessing bias was not a goal of this review, related to the extent and variability of included studies. However, assessing bias for existing experimental studies would be a beneficial next step in guiding future experimental research.

Only a small number of studies were identified which reported some of the outcomes of interest investigated in this review, including the management of foot and lower limb infection (n = 7, 3%) and associated hospital admission (n = 26, 12%). Furthermore, no studies were found to support evidence for interventions primarily related to exercise, offloading or education. As such, these may be areas for future research to guide foot and lower limb health management for dialysis patients. However, the overall health and capacity of dialysis patients must also be considered when planning interventions. Health and capacity factors of note may include the common occurrence of comorbidities, which one study reported impacting 82% of investigated ESRD patients in South Taiwan [18], and mental health challenges, which another study reported impacting 28% of ESRD patients in South Korea [19]. Also for consideration, given the high risk nature of foot and lower limb health for dialysis patients in combination with the body of evidence summarised in this review, future interventions should ideally be compared with standard care through randomised trials.

Studies identified in this review were conducted in various clinical settings. Clinical setting is important from a feasibility perspective as dialysis patients often struggle with severe fatigue and have to manage their available energy, juggling factors such as other medical appointments and travel time [20]. Although not captured in this review (related to this variable not being generally reported), the timing of intervention is also important for dialysis patients. Cognitive function for haemodialysis patients declines during dialysis, and is best immediately before or the day after dialysis [21]. Additionally, in practice we recognise that patients who attend dialysis units (hospital or satellite) are generally very eager to begin and finish dialysis promptly, which should be considered as it may impact feasibility if studies aim to work with patients during this time. Overall, clinical setting and timing are examples of variables which should be reported routinely in research regarding interventions for dialysis patients.

Of interest, 55% of the studies captured in this review (n = 117) included a population where dialysis patients made up less than 75% of the total study population. In many of these publications we noticed a trend where dialysis patients were mentioned only briefly in the abstract, hence full text review was required to determine eligibility, which led to high numbers of full text review (1032). Had these steps not been taken a large amount of evidence would have been missed. This should be considered when planning future related reviews and the importance of an appropriate search strategy is similarly emphasised [22].

Results from this review have limitations, some of which have already been acknowledged. For additional consideration, the broad inclusion criteria employed also at times made distinguishing whether studies met the inclusion criteria difficult and discussion between reviewers was employed. Also, no systematic search can capture all potentially relevant evidence. For example, more social support for dialysis patients is associated with less hospital admissions [23], however, this evidence was not captured in the current review as it has not been investigated specifically in relation to foot and lower limb health. Additionally, some dialysis patients are recognised as being more likely to experience health complications compared with others. For example, one study in Australia identified that Indigenous background was associated with amputation among dialysis patients (OR 3.39, 95% CI 1.38-8.33, p 0.01) [24]. However, analysis of subgroups was not an aim of the current review and hence none were conducted. Future investigation of distinct subgroups of dialysis patients should be approached collaboratively to support the achievement of goals which are meaningful to that group of dialysis patients, such as when working toward improved outcomes for Indigenous people [25].