MICROALBUMINURIA AND ITS CORRELATION WITH GLYCEMIC CONTROL IN TYPE 2 DIABETIC PATIENTS.
Objective: To find out the frequency of microalbuminuria and its correlation with glycemic control in type 2 diabetic patients presenting to a teaching hospital.
Methodology: This descriptive study was carried out from March 2011 to April 2012, in the Department of Medicine, Lady Reading Hospital, Peshawar. The study included 121 type 2 diabetic patients of both genders above 30 years of age. Frequency of microalbuminuria was detected among these patients. Demographic and clinical details were recorded regarding microalbuminuria, duration of diabetes, glycated hemoglobin (HbA1c), blood glucose, gender and age. For data entry and analysis, SPSS version 21.0 was utilized. Chi-square test and boxplots were used for comparison of data and determining the relationship of microalbuminuria with glycemic control.
Results: There were 47 (38.8%) males and 74 (61.2%) females in the present study. Mean age of study patients was 54.21 +-10.27 years (range 30-80 years). Microalbuminuria was present in 73 (60.3%) patients. Average duration of diabetes was 5.809 +-3.55 years and average HbA1c was 8.55 +-1.24%. There was significantly increased frequency of microalbuminuria in poorly controlled diabetics (83.56%) compared to diabetics with good glycemic control (16.44%), p value 0.015.
Conclusion: Microalbuminuria was found with increased frequency in type 2 diabetic patients. The relationship of microalbuminuria with glycemic control and duration of diabetes mellitus was statistically significant.
KeyWords: Microalbuminuria, Glycated hemoglobin, Diabetes mellitus, HbA1c.
Type 2 diabetics are at risk of developing several serious complications including diabetic nephropathy. Microalbuminuria is considered an independent predictor of nephropathy as well as cardiovascular disease1. It progresses at a rate of 5-10% per year to overt nephropathy and with continued decline in glomerular filtration rate will end up in end stage renal disease. Endothelial damage is proposed as the likely mechanism for appearance of albumin in urine. If the renal glomerulus had high permeability for albumin, it will be leaked into the urine. When this excretion of urinary albumin is 30-300 mg/24 hours or 20-200 ug/min, it is known as microalbuminuria2. In type 2 diabetic patients, the reported prevalence of microalbuminuria varies from 19.7% to 28.5% in India3. However, in Pakistan, as high as 72% frequency of microalbuminuria has been shown which may reflect a very poor glycemic control in our country4. Good glycemic control is shown to significantly reduce renal damage5.
On the other hand, increased prevalence and severity of microalbuminuria are linked to poor glycemic control. Glycated hemoglobin or HbA1c gained popularity as the preferred test for glycemic control assessment in diabetics because no special preparation (fasting or post-prandial) is required and it gives an estimate of glycemic control over the preceding 8-12 weeks period6. Diabetes mellitus is a major health issue in Pakistan with a prevalence of 3-14%7. Though microalbuminuria is linked to adverse renal and cardiovascular complications, still its regular screening in type 2 diabetics is not a common clinical practice8-9. The current study was designed with the following objectives: (i) to find out the frequency of microalbuminuria in type 2 diabetics presenting to a teaching hospital; (ii) to compare it with glycemic state in poor and well controlled diabetics; and (ii) to find out the relationship between duration of diabetes and microalbuminuria.
If found to be significantly high in type 2 diabetics and in those with poor controlof diabetes, routine screening for microalbuminuria and measures for glycemic control will be suggested in diabetic patients. Early detection of diabetic nephropathy is important so that progression to end stage renal disease could be prevented and thus help in reducing the associated morbidity and mortality.
This descriptive study was carried out from March 2011 to April 2012, in the Department of Medicine, Lady Reading Hospital, Peshawar. The study included 121 type 2 diabetic patients of both genders above 30 years of age. The patients were enrolled in the study by consecutive sampling technique. Calculated sample size was 121; using WHO sample size calculations and keeping 19% prevalence of microalbuminuria in diabetic patients3, at 95% confidence interval and 7% margin of error. Ethical approval of hospital ethical review board was taken. An informed consent was obtained from the enrolled patients. Confidentiality of all information was assured to them. Patients with urinary tract infection, hypertension, congestive cardiac failure, smoking, obesity, pregnant ladies, bed ridden patients for more than one month and chronic NSAIDs users were excluded. As anemic patients could affect HbA1c levels, they were also excluded. These were excluded clinically and by relevant investigations, as needed.
Relevant laboratory tests were carried out in the laboratory of Lady Reading Hospital, Peshawar. Demographic and clinical details were recorded regarding microalbuminuria, duration of diabetes, glycated hemoglobin, blood glucose, gender and age. Venous blood samples were collected and analyzed for blood glucose, HbA1c and serum creatinine. Mid-stream urine samples from the patients were collected after explaining the procedure and necessary instructions regarding the collection of urine samples. Microalbuminuria was estimated by immersing the strip in urine for five seconds. Operational definitions of key terms included: diabetes mellitus (random blood sugar >200 mg/dl, fasting blood sugar level of >126 mg/dl or patient was taking anti-diabetic medications); microalbuminuria (20-200 ug/min in spot urine, according to the change of color in the strip); and diabetes control (well controlled if HbA1c 7%).
All the above mentioned information was recorded in a pre-designed proforma. All the data were entered and analyzed by SPSS version 21.0. For quantitative variables (HbA1c levels, duration of diabetes and age) mean and SD were calculated; while for qualitative variables (frequency of microalbuminuria, glycemic control and gender) frequency and percentages were calculated. Microalbuminuria was stratified according to age and gender to see the effect modifications. Chi-square test and boxplots were used for comparison of data and determining the relationship of microalbuminuria with glycemic control. Statistical significance was considered at p value 70###2###1.7
Quantitative Variables###Minimum###Maximum###Mean +- SD
Glycated Hemoglobin###6.0###10.9###8.555 +- 1.24
Blood Sugar Level###101###472###224.36 +-69.29
Duration of Diabetes###.25###16.00###5.8091 +- 3.55
Table 2: Albuminuria and control of diabetes (n=121)
Albuminuria###Control of Diabetes###Total###Significance
No###17###31###48###p value= .015
In the present study, there were 74 (61.2%) females. Mean age of study patients was 54.21 +-10.27 years. Baseline demographic details are shown in Table 1. Microalbuminuria, when cross tabulated with different age groups, was found statistically insignificant (p=0.795). Microalbuminuria was present in 73 (60.3%) patients. Among these, 28 (38.36%) were males and 45 (61.64%) females, p value= 1.000. Average duration of diabetes was 5.809 +-3.55 years. Figure 1 shows that microalbuminuria was significantly related with duration of diabetes mellitus. There was significantly increased frequency of microalbuminuria in poorly controlled diabetics (83.56%) compared to diabetics with good glycemic control (16.44%) with p value 0.015, as shown in Table 2. Average HbA1c was 8.55 +-1.24%. Figure 2 shows that microalbuminuria was significantly high in patients with higher HbA1c levels.
Our study showed higher frequency (60.3%) of microalbuminuria in type 2 diabetics as compared to reported prevalence in different studies (19.7-28.5%3 and 25-30%10-12). The possible reasons for this difference could be the increased number of patients with poor glycemic control (76.03%) and relatively smaller sample size in our study. Similarly, ethnic susceptibility to develop nephropathy and laboratory method of estimation of microalbuminuria have also been shown as likely possibilities regarding frequency differences in various studies13. There were more females as compared to males (61.64% vs. 38.36%, respectively) who had microalbuminuria. However, the difference was statistically insignificant (p value= 1.000). Similar results have also been shown by other studies14,15. On the contrary, another study reported increased prevalence of microalbuminuria in males as compared to females (53.7% vs. 46.3%, respectively) and the adjusted OR was 1.89, p value= 0.192)16.
Similarly, Amini et al17 observed an association between microalbuminuria and male gender. Severity of microalbuminuria was also recorded more in males as compared to females18. The differene in results of these studies might be due to diffrence in sample selection and size. In our study, majority of patients with microalbuminuria were young i.e. 44.6% were <50 years of age. However, microalbuminuria, when cross tabulated with different age groups, was found to be statistically insignificant (p=0.795). Our results were in accordance with other studies12,19. This might be explained on the basis of increased prevalence of diabetes in patients between 40-50 years of age13. The risk of chronic complications increases with the duration of hyperglycemia20. The average duration of diabetes mellitus was 5.809 +-3.55 years in our patients; and duration of diabetes was found to be significantly related with microalbuminuria.
Hyperglycemia-induced advanced glycosylation end products may be responsible for increased frequency of microalbuminuria with increased duration of diabetes. Moreover, there is augmented degree of microalbuminuria with increased duration of diabetes, which necessitates early detection and timely taken measures to retard the progression of renal damage and prevent overt nephropathy2,8. The degree of microalbuminuria was shown to be significantly associated (p 15 years. In our study, average HbA1c was 8.55 +-1.24% and microalbuminuria was significantly high in patients with higher HbA1c levels.
There was significantly increased frequency of microalbuminuria in poorly controlled diabetics (83.56%) compared to diabetics with good glycemic control (16.44%) with p value 0.015. Our results were consistent with findings of previous studies14,21,22,24-26. Other studies have shown that the levels of microalbumin were linearly correlated with HbA1c16,27,28. The prevalence as well as progression of microalbuminuria can be decreased by achievement of good glycemic control22,25,29. Lowering of HbA1c by 0.9% has been shown in the UKPDS to result in 30% decreased development of microalbuminuria30.
Our research was hospital based and was a non-randomized study with small samples size but it does validate the findings of other studies that are available in the literature, which have shown association of microalbuminuria with poor glycemic control.
Microalbuminuria was found with increased frequency in patients with type 2 diabetes mellitus. The relationship of microalbuminuria with glycemic control and duration of diabetes was statistically significant.
All type 2 diabetic patients need to be screened for microalbuminuria. Its early detection and timely taken measures are recommended to retard the progression of renal damage and prevent overt nephropathy.
1. Pan CY, Ho LT, Soegondo S, Prodjosudjadi W, Suwanwalaikorn S, Lim SC et al. Prevalence of albuminuria and cardiovascular risk profile in a referred cohort of patients with type 2 diabetes: an Asian perspective. Diabetes Technol Ther 2008; 10:397-403.
2. Molitch ME, DeFronzo RA, Franz MJ, Keane WF, Moqensen CE, Parving HH, American Diabetes Association. Diabetic Nephropathy. Diabetes Care 2003; 26:S94-8.
3. Bouhanick B, Berrut G, Chameau AM, Hallar M, Bled F, Chevet B et al. Predictive value of testing random urine sample to detect micro albuminuria in diabetic subjects during outpatient visit. Diabete Metab 1992; 18:54-8.
4. Shaukat A, Arain TM, Shahid A. Microalbuminuria: Incidence in patients of diabetes mellitus at Bahawalpur. Pak J Pathol 2005; 16:17-21.
5. Ghafoor F, Bano KA, Malik T, Mahmood S, Khan MA. Microalbuminuria as an indicator of kidneyfunction among Diabetics. J Coll physicians Surg Pak 2004; 14: 670-2.
6. Jesudason DR, Dunstan K, Leong D, Wittert GA. Macrovascular Risk and Diagnostic Criteria for Type 2 Diabetes: implications for the use of FPG and HbA (1c) for cost-effective screening. Diabetes Care 2003; 26:485-90.
7. Shera AS, Jawad F, Maqsood A. Prevalence of diabetes in Pakistan. Diab Res Clin Pract 2007; 76:219-22.
8. Kundu D, Roy A, Mandal T, Bandyopadhyay U, Ghosh E, Ray D. Relation of microalbuminuria to glycosylated hemoglobinand duration of type 2 diabetes. Niger J Clin Pract 2013; 16:216-20.
9. Morrish NJ, Wang SL, Stevens LK, Fuller JH, Keen H. Mortality and causes of death in the WHO multinational study of vascular disease in diabetes. Diabetologia 2001; 44:S14-21.
10. Rathore JA, Abid R, Saleem M. Microalbuminuria in Diabetes Mellitus Type 2: Association with Age, Sex, and Body Mass Index: A Cross Sectional Study. Med Forum Month 2015; 26:21-3.
11. Venugopal S, Iyer UM. Risk factors analysis and prevalence of microalbuminuria among type 2 diabetes mellitus subjects: the need for screening and monitoring microalbuminuria. Asian J Exp Bio Sci 2010; 1:652-9.
12. Naz S, Sadruddin A, Khanum A, Osmani R. Frequency of microalbuminuria in diabetic patients of Islamabad and Rawalpindi. Pak J Med Res 2007; 46:70-4.
13. Khan P, Khan M, Ahmad A, Ahad A, Khan W. Relationship of glycemic control with prevalence of microalbuminuria in diabetic patients. Gomal J Med Sci 2012; 10:201-4.
14. Sigdel M, Rajbhandari N, Basnet S, Nagila A, Basnet P, Tamrakar BK. Microalbuminuria among type 2 diabetes mellitus patients in Pokhara, Nepal. Nepal Med Coll J 2008; 10:242-5.
15. Pruijm MT, Madeleine G, Rieson WF, Burnier M, Bovet P. Prevalence of microalbuminuria in the general population of Seychelles and strong association with diabetes and hypertension independent of renal markers. J Hypertens 2008; 26:871-7.
16. Showail AA, Ghoraba M. The Association Between Glycemic Control and Microalbuminuria in Type 2 Diabetes. Saudi J Kidney Dis Transpl 2016; 27:473-9.
17. Amini M, Safaei H, Aminorroaya A. The incidence of microalbuminuria and its associatedrisk factors in type 2 diabetic patients in Isfahan, Iran. Rev Diabet Stud 2007; 4:242-8.
18. Varghese A, Deepa R, Rema M, Mohan V. Prevalence of microalbuminuria in type 2 diabetes mellitus at a diabetes center in southern India. Postgrad Med J 2001; 77:399-402.
19. Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for the year 2000 and projection for 2030. Diabetes care 2004; 27: 1047-53.
20. Selvin E, Marinopoulos S, Berkenblit G, Rami T, Brancati FL, Powe NR et al. Meta-analysis: Glycosylated hemoglobin and cardiovascular disease in diabetes mellitus. Ann Intern Med 2004; 141:421-31.
21. Young BA, Katon WJ, Korff MV, Simon GE, Lin EHB, Ciechanowski PS et al. Racial and ethnic differences in microalbuminuria prevalence in a diabetes population: The Pathways Study. J Am Soc Nephrol 2005; 16: 219-28.
22. Sheikh SA, Baig JA, Iqbal T, Kazmi T, Baig M, Husain SS. Prevalence of microalbuminuria with relation to glycemic control in type-2 diabetic patients in Karachi. J Ayub Med Coll Abbotabad 2009; 21:83-6.
23. Ramanathan RS. Correlation of duration, hypertension and glycemic control with microvascular complications of diabetes mellitus at a tertiary care hospital. J Neurol Exp Neural Sci 2016; 2017:1-5.
24. Patel A, MacMahon S, Chalmers J, Neal B, Billot L, Woodward M et al. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 2008; 358:2560-72.
25. Ismail-Beigi F, Craven T, Banerji MA, Basile J, Calles J, Cohen RM et al. Effect of intensive treatment of hyperglycaemiaon microvascular outcomes in type 2 diabetes: An analysis of the ACCORD randomised trial. Lancet 2010; 376:419-30.
26. Duckworth W, Abraira C, Moritz T, Reda D, Emanuele N, Reaven PD et al. Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med 2009; 360:129-39.
27. Mandal GK, Jyothrimayi D. Comparative study of microalbuminuria and glycated hemoglobin levels in type 2 diabetic complications. Asian J Pharm Clin Res 2016; 9:356-60.
28. Huraib S, Abu-Aisha H, Sulimani RA, Famuyiwa FO, Al-Wakeel J, Askar A et al. The pattern of diabetic nephropathy among Saudi patients with noninsulin-dependent diabetes mellitus. Ann Saudi Med 1995; 15:120-4.
29. Jerums G, Macisaac RJ. Treatment of microalbuminuria in patients with type 2 diabetes mellitus. Treat Endocrinol 2002; 1:163-73.
30. Fioretto P, Bruseghin M, Berto I, Gallina P, Manzato E, Mussap M. Renal protection in diabetes,role of glycemic control. J Am Soc Nephrol 2006; 17:S86-9.
|Printer friendly Cite/link Email Feedback|
|Author:||Muhammad, Riaz; Afridi, Muhammad Abdur Rahman; Ali, Zafar; Rahman, Syed Kashif Ur; Hussain Lal; Alam|
|Publication:||Journal of Postgraduate Medical Institute|
|Date:||Sep 30, 2018|
|Previous Article:||FREQUENCY OF ATRIAL FIBRILLATION IN PATIENTS WITH ACUTE ISCHEMIC STROKE PRESENTING TO A TERTIARY CARE HOSPITAL.|
|Next Article:||EFFECTIVE HANDOVER: A TOOL FOR PATIENT'S SAFETY.|