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Jornal Vascular Brasileiro

Print version ISSN 1677-5449

J. vasc. bras. vol.10 no.4 Porto Alegre Dec. 2011 



Impact of socioeconomic markers in severity of lower extremity lymphedema



Aquiles Tadashi Ywata de CarvalhoI; Maria Clara Sampaio Barretto PereiraII; Aleksandro de Jesus SantosIII; Giselle da Fonseca GalonIV; Antônio Urbano Ferreira FilhoIII; Vinicius Dias CambuíV; Roberto Pastor RubeizIII; Roberto Augusto CaffaroVI

IMaster and Doctor degrees in Medicine at the Faculdade de Ciências Médicas da Santa Casa de São Paulo - São Paulo (SP), Brazil; Preceptor, Vascular Surgery Residency Program, Hospital Geral Roberto Santos - Salvador (BA), Brazil
IIMedical Student at the Faculdade de Tecnologia e Ciências - Salvador (BA), Brazil
IIIPreceptor, Vascular Surgery Residency Program, Hospital Geral Roberto Santos - Salvador (BA), Brazil
IVMedical Student at the Universidade Federal do Espírito Santo - Vitória (ES), Brazil
VEx-Resident of Vascular Surgery, Hospital Geral Roberto Santos - Salvador (BA), Brazil
VIDoctor Professor; Chief of Vascular Surgery Discipline at Santa Casa de São Paulo - São Paulo (SP), Brazil





In Brazil, the incidence of lymphedema is poorly known, and there is little scientific documentation reporting the association of lymphedema with the social and economic factors in our region. The objective was to analyze the impact of socioeconomic markers on the severity of lymphedema of the lower extremities according to the classification of Mowlem in the metropolitan region of Salvador (BA), Brazil. Of the 324 patients studied, 200 (62%) were female. The age ranged between 14 and 69 years, median 48 years. Comparatively analyzing the varying severity of lymphedema versus education level and severity versus family income, it showed that 93.8% of patients classified as Mowlem III were included in the group of patients without education and/or with income up to three minimum wages. There was no record of advanced disease in patients with family incomes greater than seven minimum wages and/or graduate.

Keywords: lymphedema; classification; severity of illness index; educational status.




The main function of the lymphatic system is to reabsorb macromolecules and interstitial fluid, keeping stable the extracellular composition. In addition, lymph nodes are important sites of the immune system, where phagocytosis, antigen presentation to macrophages and lymphoplasmacytic proliferation occur. Lymphopathy, which causes reduced lymphatic function and consequent deficit of interstitial drainage, leads to lymphedema, characterized by increased volume and weight of the affected region, reduced function and cosmetic alterations, that may result in fibrosis along the disease course1,2. Complications such as cellulitis, erysipela, chronic ulcers, fibroedema and lymphangiosarcoma, may aggravate the initial condition3.

Regarding its etiology, it can be classified as primary and secondary, according to the classification of Kinmonth et al.4. Primary lymphedema results from congenital alterations of lymphatic vessels, whereas secondary lymphedema results from acquired alterations that occur after infections, trauma, operations, radiotherapy, chronic venous insufficiency, among other causes4,5.

The exact prevalence of lymphatic disorders has not been well defined in the literature, due to the scarcity of epidemiological data, although its occurrence is largely underestimated in clinical practice. The estimated prevalence is around 450 million people with lymphatic disorders, i.e., 15%, of the world population6. In Brazil, the incidence and distribution of lymphedema are little known. Likewise, there is little scientific information on the association of lymphedema with social and economic factors in our region6,7.

The objective of this study was to analyze the impact of socioeconomic markers (education level and family income) on the severity of lower extremity lymphedema, according to Mowlem's classification, in the metropolitan region of Salvador (BA), Brazil.



The study analyzed consecutively 324 patients with lower extremity lymphedema that came to the Service of Vascular Surgery at Hospital Geral Roberto Santos (HGRS), between November 2005 and May 2010. The patients had access to the Service through spontaneous demand to the outpatient clinic and therefore, this is a non-probabilistic sample.

The patients were examined using a preset clinical protocol that included personal data, such as age, sex, comorbidities, socioeconomic level and lymphedema etiology and severity, according to Mowlem's classification8,9 (Chart 1), with the agreement of more than one examiner (two Vascular Surgery specialists, HGRS). In cases of bilateral lymphedema, only the limb with higher severity was included in the study. The patients were then stratified by education level (no education, basic, intermediate and higher levels) and by family income (less than 1 minimum wage, 1-3, 3-5, 5-7 and above 7 minimum wages), which were the analyzed variables.



Logistic regression technique10 was used to analyze the relation between variables and lymphedema severity, with the adoption of p value below 0.05 for statistically significant factors.

Due to the observational and descriptive nature of the study, the patients' treatment was not influenced by the study. All participants in this study were asked to sign the informed consent form.

The study was approved by the HGRS Ethics Committee and was conducted following the ethical principles of the Declaration of Helsinki and local and international standards of good clinical practices in clinical research.

Out of the 324 patients studied, 200 (62%) were female and 124 (38%) were male. The age ranged from 14 to 69 years, with median value of 48 years.

Regarding associated diseases, most patients (77%) had obesity, followed by arterial hypertension (49%) and diabetes mellitus (47%).

Regarding the severity, 81 (25%) patients presented with lymphedema Mowlem I, 146 (45%) had Mowlem II and 97 (30%) had Mowlem III.



Tables 1 and 2 show the frequency distribution of patients by education level and disease severity and family income and disease severity, respectively, according to Mowlem's classification.





When comparatively analyzing the variables: lymphedema severity versus education level and lymphedema severity versus family income, 93.8% of the patients classified as Mowlem III were in the group with no formal education and/or family income up to three minimum wages. No case of the disease in its most advanced stage was reported in patients with income family above seven minimum wages and/or with complete higher education level. These relations were statistically significant, with p value below 0.05 (Figures 1 and 2).






Lymphedema is a chronic disease characterized by the retention of high protein interstitial fluid, resulting from insufficient lymphatic drainage caused by congenital and/or acquired anomalies of the lymphatic system5,11 In the beginning, the edema is mild, soft and depressible at compression, but as the disease progresses, it becomes hard and non-depressible6,12 Chronically, this increased limb size can cause significant deformities, disability and, in extreme cases, elephantiasis. Besides that, it can undergo malignant transformation6. It can affect one or both lower extremities6.

The diagnosis is basically clinical and imaging exams, such as computed tomography and lymphoscintigraphy, are used to confirm the suspected diagnosis, to detect sites of lymphatic malformation and neoplasias and to exclude other causes of increased limb size8,13-15.

The frequency of lymphatic disease is much lower than the frequency of arterial and venous disease8. Lymphedema, however, it is not an uncommon disease. It is essential to know the prevalence and methods of treatment, in order to take early action. When not properly addressed, lymphedema may result in serious sequelae, limiting the patient's quality of life.

In this study, the incidence of women with lymphedema was high (62%). Such prevalence was also observed by Kefeijan-Haddad et al.6 and agrees with data found in world literature8,16.

A higher prevalence of secondary lymphedema was observed, when compared to primary lymphedema (93% versus 7%). In the cohort, infection (post-erysipela) was the most frequent cause of secondary lymphedema, corresponding to 83% of the patients. Such data agree with the results obtained in other studies conducted in Brazil2,8. In contrast, in Europe, the bacterial and fungal infections represent less frequent etiological factors, as demonstrated by Smith, Spittell and Schirger16 and Milroy17. Post-operative lymphedema corresponded to 10% of the secondary lymphedema causes, as demonstrated by Guedes Neto8.

Regarding the severity of lymphedema, only 25% of patients were Mowlem I, while 45% were Mowlem II and 30% were Mowlem III. We observed that most patients with the disease in its most advanced stages (Mowlem II and III) were individuals with no education and/or low economic level. We reported that the social and economic level was inversely proportional to the lymphedema severity. This finding can be explained by the fact of having more difficult access to medical care, inadequate treatment and lack of instruction on lymphedema prevention after the initial episode of limb infection. It should be emphasized that, after the onset of lymphatic injury and lymphedema, the scarcity of specialized services in complex physical therapy offered by the Public Health Service (Sistema Único de Saúde) in Salvador may have contributed to such findings. On the other hand, there was no record of advanced disease in patients with family incomes greater than seven minimum wages and/or complete higher education, which confirmed the study results. A stronger awareness of the need for diagnosis and early treatment of lymphedema may help improve these patients' quality of life.



The severity of lower extremity lymphedema, according to Mowlem's classification, was directly related to socioeconomic markers, such as low education level and low family income. Further studies on occurrence and severity of lymphedema are required for a better understanding of the related factors and prevention of this disorder in our region.



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Aquiles Tadashi Ywata de Carvalho
Clínica de Cirurgia Galon Ywata
Av. Antônio Carlos Magalhães, 3.244 - sala 1.416 - Caminho das Árvores
CEP: 41820-000 - Salvador (BA), Brazil
E mail:

Submitted on: 04.11.11.
Accepted on: 09.06.11.



Author's contributions
Conception and design: ATYC, MCSBP, VDC
Analysis and interpretation: ATYC, MCSBP, VDC
Data collection: ATYC, MCSBP, AJS, VDC
Writing the article: ATYC, GFG, MCSBP
Critical revision of the article: AUFF, RPR, RAC
Final approval of the article*: ATYC, MCSBP, VDC, GFG, AJS, AUFF, RPR, RAC
Statistical analysis: ATYC, AUFF
Overall responsibility: ATYC
Obtained funding: ATYC
*All authors have read and approved the final version submitted at the J Vasc Bras.
Study carried out at the Hospital Geral Roberto Santos - Salvador (BA), Brazil.

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