|Year : 2016 | Volume
| Issue : 1 | Page : 39-43
Diabetic nephropathy among diabetic patients attending El Mahalla General Hospital
Mostafa M Elnajjar1, Alaa El Dien Dawood1, Mahmud Abu Salem2, Zeinab A Kasemy2, Ola T Nohman3
1 Department of Internal Medicine, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Public Health and Community Medicine, Faculty of Medicine, Menoufia University, Menoufia, Egypt
3 Department of Internal Medicine, El Mahalla General Hospital, El Mahalla, Egypt
|Date of Submission||01-Feb-2015|
|Date of Acceptance||19-Apr-2015|
|Date of Web Publication||22-Mar-2016|
Ola T Nohman
MSc, Department of Internal Medicine, El Mahalla General Hospital, El Mahalla
Source of Support: None, Conflict of Interest: None
The aim of this study was to study the prevalence of diabetic nephropathy (DN) and the related risk factors among diabetic patients attending El Mahalla General Hospital.
DN is the leading cause of chronic kidney disease and end-stage renal disease in developing countries. Early detection and risk-reduction measures can prevent DN. In Egypt, the prevalence of DN as a cause of end-stage renal disease increased from 8.9% of patients in 1996 to 14.5% in 2002. Studies in patients who have or do not have clinically evident DN have identified a number of factors to be associated with an increased risk of renal involvement.
Participants and methods
This study was carried out on 100 diabetic patients who attended El Mahalla. All the participants studied were subjected to a full assessment of history, a general clinical examination, and laboratory investigations including determination of glycated hemoglobin (HbA1c), serum creatinine, estimated glomerular filtration rate, and the urinary albumin to creatinine ratio.
The results showed that 78% of all the patients studied had DN. There were statistically significant relationships between nephrogenic diabetes and duration of diabetes (P = 0.008), higher systemic blood pressures (P = 0.003), an evident decrease in the glomerular filtration rate through the course of disease (P = 0.038), poor glycemic control (P = 0.036), obesity (P = 0.002), and a family history of diabetes (P = 0.006). There were no statistically significant relationships between nephrogenic diabetes and age, sex of the patient, use of oral contraceptive pills, and smoking.
Screening for microalbuminuria will enable early identification of patients with DN. Duration of diabetes mellitus and hypertension were strong predictors associated with the development of DN in the patients studied.
Keywords: Microalbuminuria, prevalence, risk factors
|How to cite this article:|
Elnajjar MM, Dawood AE, Salem MA, Kasemy ZA, Nohman OT. Diabetic nephropathy among diabetic patients attending El Mahalla General Hospital. J Egypt Soc Nephrol Transplant 2016;16:39-43
|How to cite this URL:|
Elnajjar MM, Dawood AE, Salem MA, Kasemy ZA, Nohman OT. Diabetic nephropathy among diabetic patients attending El Mahalla General Hospital. J Egypt Soc Nephrol Transplant [serial online] 2016 [cited 2017 Dec 17];16:39-43. Available from: http://www.jesnt.eg.net/text.asp?2016/16/1/39/179214
| Introduction|| |
Diabetic nephropathy (DN) is by far the most common cause of end-stage renal disease (ESRD) . Approximately one-third of individuals with diabetes develop DN, with a high likelihood of progression to ESRD. In addition, DN is associated with considerably increased cardiovascular disease risk and mortality. Thus, the public health burden from DN is enormous. Current evidence suggests that both genetic and environmental factors determine susceptibility to development of DN and the risk for and rate of progression of DN .
Epidemiologic studies have shown that DN is strongly clustered in families and that race has a major effect on DN susceptibility and rate of progression, firmly establishing the importance of genetic risk factors in the development of DN .
| Aim|| |
The aim of this work was to study the prevalence of DN and the related risk factors among diabetic patients attending the El Mahalla General Hospital.
| Participants and methods|| |
This study was carried out on 100 individuals who attended the El Mahalla General Hospital clinic [68 patients had type 2 diabetes mellitus (DM) and 32 patients had type 1 DM] (73 male patients and 27 female patients).
All participants were subjected to the following: a full assessment of history, a thorough clinical examination, and laboratory investigations including:
- Random urine samples were collected for determination of creatinine and microalbumin in urine to calculate the albumin/creatinine ratio.
- A blood sample was placed in an EDTA tube for quantitative colorimetric determination of HbA1c.
- A blood sample was placed in a plain tube for the measurement of serum creatinine.
DNP was determined on the basis of questionnaires, medical files, and laboratory data. DNP was diagnosed clinically when the patient had albuminuria with an albumin/creatinine ratio of more than 300 μg/mg in the absence of hematuria or infection. Written informed consent was obtained from all the participants in accordance with the principles of the Ethical Committee of Menoufia Faculty of Medicine.
The results were collected, tabulated, and statistically analyzed using an IBM personal computer statistical package SPSS version 20 (Chicago, Ill, USA). Student's t-test was used for normally distributed quantitative variables. The Mann-Whitney test was used for non-normally distributed quantitative variables. χ2 -Test was used for qualitative variables. Fisher's exact test was used when the count of any of the expected cells was less than 5. Pearson's correlation analysis was used to determine the strength and direction of the association between two quantitative variables. Odds ratios (ORs) described the probability that individuals who were exposed to a certain factor would have a disease compared with individuals who were not exposed to the factor. A P value less than 0.05 was considered statistically significant.
| Results|| |
The result showed that 78% of the patients developed DN. Their mean age was 51.38 ± 10.84 years. The mean duration of diabetes in these patients was 10.57 ± 6.95 years. In all, 50% of the patients studied had hypertension (HTN). A total of 44.4% of the female patients studied took oral contraceptive pills. In all, 69% of the patients had a family history of diabetes. Eleven percent of the patients were smokers. Sixty-eight percent of the patients were obese [Table 1].
|Table 1: Number and percent distributions of the participants studied in terms of their history|
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The duration of DM was significantly higher among the group with DN (10.63 ± 6.24) than the group without DN (7.50 ± 3.85) (P = 0.046). HbA1c was significantly higher among the group with DN (8.49 ± 1.86) than the group without DN (7.37 ± 1.16) (P = 0.009). Glomerular filtration rate was significantly lower among the group with DN (138.26 ± 45.36) than the group without DN (161.24 ± 45.36) (P = 0.038) [Table 2]. In terms of the duration of DM, 59% of the patients in the DN group had DM for more than 10 years in contrast to 27.3% of the patients in the group without nephropathy (P = 0.008). In all, 57.7% of the patients in the nephropathy group had HTN in contrast to 22.7% of the patients in the non-nephropathy group (P = 0.003). In all, 75.6% of the patients in the nephropathy group had a family history in contrast to 45.5% of the patients in the non-nephropathy group (P = 0.006). A total of 75.6% of the patients in the nephropathy group were obese in contrast to 40.9% of the patients in the non-nephropathy group (P = 0.006) [Table 3]. The study found no statistically significant difference among age, smoking, use of oral contraceptive pills, and sex. Regressive analysis of the studied risk factors indicated that the duration of DM and HTN were strong predictors for the development of DN (P = 0.001) [Table 4].
|Table 2: Distribution of the nephropathy groups studied in terms of age, duration of diabetes mellitus, and lab investigations|
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|Table 3: Number and percent distribution of the nephropathy groups studied in terms of the risk factors|
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| Discussion|| |
The diabetes control and complications trial showed the association of long duration of diabetes with the development of DN. A significant correlation between increasing duration of diabetes and the development of microproteinuria was documented by Kathryn et al. . The present study confirmed and extended the frequent occurrence of microproteinuria with increasing duration of diabetes; there were statistically significant relationships between duration of diabetes and nephrogenic diabetes. It was significantly higher among the group of patients with diabetes for more than 10 years [OR 3.83, 95% confidence interval (CI) 1.35-10.86] (P = 0.008). Similar results were observed in the studies of Nelson and colleagues ,,.
In the present study, there were statistically significant relationships between nephrogenic diabetes and poor glycemic control. HbA1c was significantly higher among the patients in the group with DN than the patients in the group without DN (OR 2.80, 95% CI 1.05-7.46) (P = 0.036). These results are in agreement with ADVANCE Collaborative Group . However, the Veteran's Affairs Diabetes Trial (VADT) yielded conflicting results; here, intensive therapy did not lead to a reduction in retinopathy or major nephropathy outcomes compared with standard therapy, but this study has limited numbers of patients and follow-up duration .
The association between HTN and DN has been established by most related studies [10-12] and also the present study. Our study showed that the risk of DN was 4.64 times higher in the hypertensive group than the normotensive one (OR 4.64, 95% CI 1.55-13.84) (P = 0.003). The study by Abdulhakeem et al.  yielded a conflicting result; the possible explanation for the conflicting findings could be that HTN was considered if the patient was classified in the file as hypertensive. Blood pressure of the patients classified as nonhypertensive was not rechecked. It is transfered from its source (Abdulhakieem et al.) of these patients may have had HTN with nephropathy, but this was not detected .
The present study showed a significant association between a positive family history of DN and the development of DN. The risk of DN was 3.73 times higher in the group with a family history of DN compared with the other group without a family history of DN (OR 3.73, 95% CI 1.39-9.99) (P = 0.006); this is in agreement with many related studies [14,15]. The likelihood of developing DN was markedly increased in patients with a diabetic sibling or parent who had DN; these observations were made in patients with type 1 and type 2 diabetes ,.
According to our evaluation, the prevalence of nephropathy was clearly and significantly related to BMI. The risk of DN was 4.49 times higher in the obese group than in the nonobese one (OR 4.49, 95% CI 1.66-12.13) (P = 0.002). Other studies also support a correlation between obesity and diabetic microvascular complications in patients with type 2 diabetes [18,19]; some of these results and conclusions are different and contradictory, likely because microvascular and neuropathic complications in diabetes are not necessarily a direct result of obesity, but a consequence of a multiplicity of other risk factors.
In the present study, in terms of renal function by assessment of estimated glomerular filtration rate, it was found that there was a significant negative correlation between albumin/creatinine ratio (ACR) and glomerular filtration rate (P = 0.002). Nassi and Vijayalakshmy  showed that serum creatinine and blood urea levels increased with the duration of diabetes. In contrast, Azar et al.  found no change in the kidney functions in normoalbuminuric diabetic patients.
The present study showed that age was not associated with DN (OR 2.57, 95% CI 0.75-8.87) (P = 0.152). This result was in agreement with that of many other studies ,. It seems that age is not an important factor; however, the duration of diabetes is an important factor. The multivariate analysis showed that the duration of diabetes is an independent risk factor for DN and this is in agreement with most other related studies ,.
Smoking was not a risk factor for progression to DN in the present study (OR 0.44, 95% CI 0.11-1.68) (P = 0.223). In contrast ,, smoking was identified as an important and graded risk factor for the development and progression of microalbuminuria. Recently, in a prospective follow-up study of 301 type 1 diabetic patients with overt DN, smoking was not an independent predictor for progression in diabetic kidney disease . Long-term studies on the effect of smoking on decline in kidney function in DN are lacking.
Our study showed no statistically significant relationships between nephrogenic diabetes and oral contraceptive pills (OR 2.0, 95% CI 0.38-10.58) (P = 0.682). However, in the study by Ahmed et al. , there were strong associations of oral contraceptives (OC) use with angiotensin-dependent control of the renal circulation and the development of macroalbuminuria, suggesting that the use of OC may be a risk factor for DN. Large prospective studies are required to further investigate this relationship.
Our study showed no statistically significant relationships between nephrogenic diabetes and sex (OR 2.31, 95% CI 0.85-6.27) (P = 0.096). However, other studies showed strong association between male gender and diabetic nephropathy ,.
| Conclusion|| |
Screening for microalbuminuria will enable early identification of patients with DN. Duration of DM and HTN were strong predictors associated with the development of DN in the patients studied.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Collins AJ, Kasiske B, Herzog C, Chavers B, Foley R, Gilbertson D. Excerpts from the United States Renal Data System 2004 complications of type 2 diabetes (UKPDS 36): prospective observational study 2005. BMJ 2000; 321
Jones CA, Krolewski AS, Rogus J, Xue JL, Collins A, Warram JH. Epidemic of end-stage renal disease in people with diabetes in the United States population: do we know the cause? Kidney Int 2005; 67
Ng DP, Krolewski AS. Molecular genetic approaches for studying the etiology of diabetic nephropathy. Curr Mol Med 2005; 5
Kathryn AK, McClellan WM, Ziemer DC, Kleinbacim DG, Bori JR. Risk factors for microalbuminuria in black Americans with newly diagnosed type 2 diabetes. Am J Kidney Dis 2000: 36
Nelson RG, Knowler WC, Pettitt DJ, Saad MD, Bennett PH. Diabetic kidney disease in Pima Indians. Diabetes Care 1993; 16
Dasmahapatra A, Bale A, Raghuwanshi MP, Reddi A, Byrne W. Incipient and overt diabetic nephropathy in African-American with NIDDM. Diabetes Care 1994; 17
Prashant P, Sulaiman KJ, Kadaha G, Bazarjani N, Bakir S. Prevalence and risk factors for albuminuria among type 2 diabetes mellitus patients: a Middle-East perspective. Diabet Res Clin Pract 2010; doi:10.1016/j.diabres.2010.02.004.
ADVANCE Collaborative Group, Patel A, MacMahon S. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 2008; 358
Duckworth W, Abraira C, Moritz T, et al
. Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med 2009; 360
Schrier RW, Estacio RO, Esler A, Mehler P. Effects of aggressive blood pressure control in normotensive type 2 diabetic patients on albuminuria, retinopathy and strokes. Kidney Int 2002; 61
Adler AI, Stevens RJ, Manley SE, Bilous RW, Cull CA, Holman RR. Development and progression of nephropathy in type 2 diabetes: the United Kingdom Prospective Diabetes Study (UKPDS 64). Kidney Int 2003; 63
Retnakaran R, Cull CA, Thorne KI, Adler AI. Holman RRUKPDS Study Group. Risk factors for renal dysfunction in type2 diabetes: U.K. Prospective Diabetes Study 74. Diabetes 2006; 55:1832-1839.
Abdulhakeem HA, Rizvi SGV, Al-Riyami D. Prevalence and Risk Factors of Diabetic Nephropathy in Omani Type 2 Diabetics in Al-Dakhiliyah Region. Oman Med J 2012; 27
Adler S. Diabetic nephropathy: linking histology, cell biology, and genetics. Kidney Int 2004; 66
Cooper ME. Pathogenesis prevention and treatment of diabetic nephropathy. Lancet 1998; 352
Satko SG, Langefeld CD, Daeihagh P, Bowden DW, Rich SS, Freedman BI. Nephropathy in siblings of African Americans with overt type 2 diabetic nephropathy. Am J Kidney Dis 2002; 40
Trevisan R, Viberti G. Genetic factors in the development of diabetic nephropathy. J Lab Clin Med 1995; 126
Klein R, Klein BEK, Moss SE. Is obesity related to microvascular and macrovascular complications in diabetes - The Wisconsin Epidemiologic Study of Diabetic Retinopathy. Arch Intern Med 1997; 157
Haupt E, Benecke A, Haupt A, Herrmann R, Vogel H, Walter C. The KID Study VI: Diabetic complications and associated diseases in younger type 2 diabetics still performing a profession. Prevalence and correlation with duration of diabetic state, BMI and C-peptide. Endocrinol Diabetes 1999; 107
Nassi J, Vijayalakshmy R. Role of duration of diabetes in the development of nephropathy in type 2 diabetic patients. Natl J Med Res 2013; 3
Azar ST, Salti I, Zantout MS, Major S. Alterations in plasma transforming growth factor-β in normoalbuminuric type 1 and type 2 diabetic patients. J Clin Endocrinol Metab 2000; 85
Modarresi M, Amirchaghmaghi M. Prevalence of microalbuminuria and its risk factors in type 2 diabetic patients. Indian J Nephrol 2008; 18
Shekiba M, Afkhami-Ardekani MOrafa AM. The prevalence of micro and macroalbuminuria in diabetic patients referring to diabetes research center. J Shahid Sadoughi Univ Med Sci Health Services 2003; 10
Rema M, Pradeepa R, Deepa M, Shanthirani CS, Deepa R. American Diabetic Association Prevalence and risk factors of diabetic nephropathy in an urban South Indian population: the Chennai Urban Rural Epidemiology Study (CURES 45). Diabetes Care 2007; 30
Modebe O, Masoomi MA. Microalbuminuria and associated factors in Bahraini patients with type 2 diabetes mellitus. Ann Saudi Med 2000; 20
Biesenbach G, Grafinger P, Janko O. Influence of cigarette smoking on the progression of clinical diabetic nephropathy in type 2 diabetic patients. Clin Nephrol 1997; 48
Gambaro G, Bax G, Fusaro M. Cigarette smoking is a risk factor for nephropathy and its progression in type 2 diabetes mellitus. Diabetes Nutr Metab 2001; 14
Hovind P, Rossing P, Tarnow L. Smoking and progression of diabetic nephropathy in type1 diabetes. Diabetes Care 2003; 26
Ahmed SB, Hovind P, Parving HH. Oral contraceptives, angiotensin-dependent renal vasoconstriction, and risk of diabetic nephropathy. Diabetes Care 2005; 28
Modebe O, Masoomi MA. Microalbuminuria and associated factors in Bahraini patients with type 2 diabetes mellitus. Ann Saudi Med 2000; 20
Varghese A, Deepa R, Rema M, Mohan V. Prevalence of microalbuminuria in type 2 diabetes mellitus at a diabetes centre in southern India. Postgrad Med J 2001; 77
[Table 1], [Table 2], [Table 3], [Table 4]