| Abstract|| |
Diabetes is the main cause of end-stage renal disease (ESRD) in the developed countries and its prevalence and incidence have been constantly increasing over the years. To determine the prevalence and profile of diabetic nephropathy in our ESRD population, we retrospectively studied 564 hemodialysis patients in ten dialysis units in Casablanca. The mean age was 49 ±16.2 years. The diabetic nephropathy came at the third rank with a prevalence of 13.5% behind chronic glomerulonephritis (21.8%) and hypertensive nephropathy (14.7%). Almost 74% of our diabetics were type 2. From the time of diagnosis the type 2 diabetics reached the ESRD earlier than the type 1 diabetics with a mean period of 15.1 ± 7 years and 18.8 ± 5 years, respectively; however, the difference was not statistically significant. There was at least another microangiopathic complication in 95.4% of the patients and macroangiopathic complication in 82%. The median hemoglobin A1C in all patients was higher than normal value. We conclude that ESRD is a serious complication of diabetes, which is constantly increasing. The appropriate management of diabetes and a multidisciplinary approach are necessary to avoid it or at least delay its occurrence.
Keywords: Diabetic nephropathy, End-stage renal disease, Prevalence, Angiopathic, Hemodialysis.
|How to cite this article:|
Khanfri N, Medkouri G, Aghai R, Hachim K, Benghanem M G, Ramdani B, Zaid D. Diabetic Nephropathy in Hemodialysis Patients in Casablanca. Saudi J Kidney Dis Transpl 2005;16:89-92
|How to cite this URL:|
Khanfri N, Medkouri G, Aghai R, Hachim K, Benghanem M G, Ramdani B, Zaid D. Diabetic Nephropathy in Hemodialysis Patients in Casablanca. Saudi J Kidney Dis Transpl [serial online] 2005 [cited 2016 Dec 4];16:89-92. Available from: http://www.sjkdt.org/text.asp?2005/16/1/89/32955
| Introduction|| |
Diabetes mellitus is the most common cause of end-stage renal disease (ESRD) in the developed countries. ,,,, The incidence and prevalence of ESRD attributed to diabetic nephropathy have increased over the years as reported in the regional and national registries.
The aim of this study was to determine the prevalence of diabetic nephropathy in the ESRD population and its profile in the hemodialysis units of Casablanca, the economic capital of Morocco.
| Patients and Methods|| |
We retrospectively studied all the chronic hemodialysis patients treated in ten of the 22 dialysis units in Casablanca (4 public and 6 private units) from September to December 2002. We used two questionnaires; the first one for all the hemodialysis patients which contained queries about the identity and cause of nephropathy, and the second was only for the diabetic patients. The latter contained questions about clinical history, type of diabetes, date of diagnosis, date of initiation of hemodialysis, glycemic and lipid profiles and complications. The data was analyzed using the software "Epi info" (version 6.04 Fr.).
| Results|| |
We screened 564 patients; 292 women (51.8 %) and 272 men (48.2 %) with mean age of 49.5 ± 16.2 years. There were 76 diabetic patients. Accordingly, diabetic nephropathy (DN) was the third most prevalent cause (13.5 %) after chronic glomerulonephritis (21.8%) and hypertensive nephropathy (14.7%). There were 41 men (54 %) and 35 women (46 %). There were 20 patients with type1 diabetes and 56 with type 2; there were 8 (40%) men in the type1 group and 33 (59%) men in the type 2. The patients with type1 diabetes were diagnosed at a mean age significantly younger than those in the type 2 diabetes (26±15 years vs. 42±11 years, respectively (p<0,001). The patients with type1 diabetes were started on hemodialysis at a younger mean age than those with type 2 diabetes (44±15 years vs. 56±11 years, respectively (p<0,001)). The period between the diagnosis of diabetes and commencement of dialysis was shorter in, the patients with type 2 diabetes than those with type 1 diabetes, (15.1±7 years vs. 18.8 ± 5 years, respectively) but the difference was not statistically significant.
Almost all the diabetic patients had at least one microangiopathic complication; retinopathy was found in 95.4% of the patients and neuropathy in 67.1%. Furthermore, 82 % of the diabetic patients had at least one macroangiopathic complication; hypertension in 98.2 % of the cases, cardiac ischemia diagnosed by electrocardiography in 69.2% of cases (81% of type 2 diabetes and 50% of type 1 diabetes) and echography in 47.4% of cases (57.1% of type 2 diabetes and 20% of type 1 diabetes), arteritis confirmed in 12.1 %, and limb amputation in one patient.
Hyperglycemia was found in all our patients. The median glucose level was higher in the patients with type 1 than those with type 2 diabetes. However, the median HbA1C was higher in the patients with type 2 diabetes (8.52 + 2.33 mmol/l). The patients with type 1 diabetes had hypercholesterolemia with a mean serum level of 224 ± 146 mg/l.
| Discussion|| |
Though the causes of renal diseases are similar all over the world, their incidences differ significantly among countries. The diabetic nephropathy and hypertensive nephropathy are the main causes of ESRD in USA (76.6%),  In our study, diabetic nephropathy (DN) came third in prevalence, but this must be considered with caution because the causes of ESRD were unknown in 38.7% of our patients, compared to only 15.3% and 10.3% respectively in Europe and USA. ,
In the developed countries, the fraction of ESRD patients with diabetes appears to be increasing. In USA, the prevalence of diabetes among dialyzed patients jumped from 19 to 30% between 1985 and 1992  and in France, the prevalence doubled in six years from 1989 to 1995.  This increase seems due to the ageing of the population, since incidence of type 2 diabetes increases with age, besides the social and nutritional factors such as over weight and ingestion of fast food. Furthermore, there has been a significant increase in the prevalence of diabetes type 2 on dialysis in the developed countries. They represented 96% of the diabetics in Japan, 87% in France and 64% in USA. ,,, In our study, they represented 73.7%.
ESRD occurs, on the average, seven years after the onset of clinical nephropathy, which itself appears after 15 to 20 years of evolution of diabetes. The patients in our study reached ESRD in a comparable period.
The management of diabetic patients on dialysis is difficult because of the associated extra renal morbidity. In the USA, the percentage of ESRD diabetics who have at least one comorbidity increased from 66 to 85% between 1976 and 1989, whereas it only increased from 57 to 66% in non-diabetics on dialysis.  This comorbidity explains the higher mortality noticed among diabetics with ESRD.
Diabetic retinopathy is one of the main causes of blindness; its prevalence is about 60 to 80% after 10 years of evolution of diabetes. , In our study, the prevalence of retinopathy was higher than that reported in the literature being 95.75% and 91.45% in diabetics type 2 and type 1 respectively
The prevalence of diabetic neuropathy is difficult to estimate because it's often asymptomatic and there are no specific complementary exams to confirm its diagnosis.
The cardio-vascular complications such as ischemic cardiac disease, myocardial infarction, heart failure and stroke are especially frequent in diabetic patients but are, in general, more serious in type 2.  In our study, the myocardial ischemia was diagnosed by ECG and echography in a high percentage of the diabetic patients.
The cerebrovascular accidents occur in 12.7% of diabetics on dialyses in France, 7% in Italy and 6% in UK. , In our study, no case of stroke was observed. The arteritis is a serious disease that results in five fold increase of the cardiovascular risk In our study, 12.1% of patients had this complication. Furthermore, amputation was indicated in one case in our study. This rate is very low compared to those noticed in France (17.6%), UK (6%) and Italy (3%). ,
We conclude that renal failure is a serious complication of diabetes and its prevalence is constantly increasing. It represents a real problem for public health and requires multi disciplinary approach for prevention and treatment of complications including family doctors, diabetologists, and nephrologists besides the cooperation of the patient.
| References|| |
|1.||Halimi S, Zmirou D, Benhamou PY, et al. Huge progression of diabetes prevalence and incidence among dialysed patients in mainland France and overseas French territories. A second national survey six years apart. (UREMIDIAB 2 study). Diabetes Metab 1999;25:507-12. |
|2.||Thomas SM, Viberti GC. Is it possible to predict diabetic kidney disease? J Endocrinol Invest 2000;23:44-53. [PUBMED] |
|3.||Cordonnier D. Nephropathie diabetique, IRT et dialyse. Les dossiers du nephroscope - Rein et Diabete - 2. Roche Pharma 2000. |
|4.||Maisonneuve P, Agodoa L, Gellert R, et al. Distribution of primary renal diseases leading to end stage renal failure in the United States, Europe and Australia/New-Zealand: results from an international comparative study. Am J Kidney Dis 2000;35:157-65. [PUBMED] |
|5.||Woredekal Y, Barth RH. Tiptoeing through a minefield: Hemodialysis in the diabetic. Semin Dial 1997;10(4):215-8. |
|6.||Parving HH, Gall MA, Skott P, et al. Prevalence and causes of albuminuria in non insulin dependent diabetic patients. Kidney Int 1992;41:758-62. |
|7.||Bergrem H, Leivestad T. Diabetic nephropathy and end stage renal failure: the Norwegian story. Adv Ren Replace Ther 2001;8(1):4-12. |
|8.||Charra B Vovan C, Marcelli D, et al. Diabetes mellitus in Tassin, France: remarkable transformation in incidence and outcome of ESRD in diabetes. Adv Ren Replace Ther 2001;8(1):42-56. |
|9.||Ritz E, Rychlik I, Locatelli F, Halimi S. end stage renal failure in type 2 diabetes: a medical catastrophe of worldwide dimensions. Am J Kidney Dis 1999;34(5):795-808. |
|10.||Friedlander MA, Hricik DE. Optimizing end-stage renal disease therapy for the patient with diabetes mellitus. Semin Nephrol 1997;17(4):331-45. |
|11.||de Lemos JA, Hillis LD. Diagnosis and management of coronary artery disease in patients with end-stage renal disease on hemodialysis. J Am Soc Nephrol 1996; 7(10):2044-54. |
|12.||12- Catalano C, Postorino M, Kelly PJ, et al. Diabetes mellitus and renal replacement therapy in Italy: prevalence, main characteristics and complications. Nephrol Dial Transplant 1990;5 (9):788-96. |
Nephrology and Dialysis Department, UHC Ibn Rochd, Casablanca