| Abstract|| |
To determine the risk factors for nephropathy in diabetic patients and to study the management of diabetic nephropathy (DN), we conducted a hospital-based prospective study in the Internal Medicine department of our hospital on 60 patients with DN and 60 diabetic patients without DN. An odds ratio (OR) disclosed the following risk factors: Hypertension (OR = 2.06), family history of diabetes (OR = 1.23), family history of DN (OR = 2.86), uncontrolled hyperglycemia (OR = 11.80), obesity (OR = 1.07), duration of diabetes between 11 and 20 years (OR = 4.69), smoking (OR = 2.79), alcohol consumption (OR = 3.75), other complications (OR = 2.03), lack of physical activity (OR = 1.51) and anemia (OR = 2.29). According to these risk factors, we suggest that improving patient's knowledge on diabetes and its treatment, life style modifications and aggressive management of the disease may delay the progression of disease to advanced stages.
|How to cite this article:|
Ahmed MA, Kishore G, Khader HA, Kasturirangan MN. Risk factors and management of diabetic nephropathy. Saudi J Kidney Dis Transpl 2013;24:1242-7
|How to cite this URL:|
Ahmed MA, Kishore G, Khader HA, Kasturirangan MN. Risk factors and management of diabetic nephropathy. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2020 Feb 29];24:1242-7. Available from: http://www.sjkdt.org/text.asp?2013/24/6/1242/121310
| Introduction|| |
Diabetic nephropathy (DN) is an important microvascular complication of long-standing non-insulin-dependent diabetes mellitus as well as insulin-dependent diabetes mellitus, and it is associated with considerable morbidity and mortality. The prevalence of diabetes mellitus (DM) is increasing, and it is estimated that there are 30 million diabetics in India, of which 6.6 million are expected to develop DN.
Type 2 DM is five times more common and microalbuminuria is higher in Indians than in Europeans. 
DN is a clinical syndrome characterized by persistent albuminuria, relentless decline in glomerular filtration rate (GFR) and elevated arterial blood pressure. This is usually followed by a more rapid progression of other secondary complications (retinopathy, neuropathy and diabetic feet). DN is a leading cause of end-stage renal disease (ESRD),  which has increased due to an increase in the incidence of diabetes.  Although patients with Type 1 diabetes have a much higher risk of developing chronic kidney disease, Type 2 diabetes is far more prevalent; therefore, many more patients with Type 2 diabetes have ESRD. 
As diabetes is a chronic condition and leads to several complications,  strict treatment compliance and life style modification are very essential.
The aim of this study was to determine the risk factors for DN patients and to suggest some management plans accordingly.
| Materials and Methods|| |
A hospital-based prospective study was conducted in the medicine inpatient department of the Kempegowda Institute of Medical Sciences and Research Center Hospital, Bangalore. A total of 120 patients were included in the study and the study population was divided into two groups, group I consisting of 60 diabetic patients showing signs of micro/macro-albuminuria with albumin level in urine ≥30 mg/24 h as cases and 60 diabetic patients with normal albumin level in urine <30 mg/24 h were included in group II as controls. The study criteria included diabetic inpatients of either gender diagnosed with diabetes and DN with age >18 years and >5 years duration of diabetes, but pregnant diabetic patients were not included in the study.
A patient data collection form was designed and used for collecting the required data. In order to determine the risk factors, interviews of the patients/care givers with a specific questionnaire format were performed. Body mass index (BMI) was calculated by using the formula of weight (Kg)/height (m 2 ). HbA1c level of >8% indicated poor diabetic control.
Consents to participate in the study were obtained from all the patients or their care givers. The study project was executed according to the permission granted by the Human Ethical Committee of V.I.P.S, Bangalore.
| Statistical Analysis|| |
The collected data were analyzed by descriptive statistical analysis. Chi-square/Fisher exact test was used to determine the significance of the study parameters on a categorical scale between the two groups. Odds Ratio (OR) has been computed to determine the association of the risk factors with DN. P-values <0.05 were considered significant.
| Results|| |
Of the 120 study patients, 40 (33.3%) were in the age group of 51 - 60 years, 40 (33.3%) in the age group of 61 - 70 years, 16 (13.3%) were in the age group of 41 - 50 years, 16 (13.3%) were in the age group of 71 - 80 years, two were in the age group of 21 - 40 years and four were in the age group of >80 years. There was no significant difference between the case and the control groups in terms of age distribution (P = 0.107).
Of the study participants, 73 (60.8%) were male and 47 (39.2%) were female. The number of male participants in group I was 39 (65%) and that in group II was 34 (56.7%), whereas there were 21 (35%) female patients in group I and 26 (43.3%) female patients in group II. The samples were gender matched (P = 0.350). The education level was statistically similar between the two groups, with P = 0.590.
Forty-nine (40.83%) patients with BMI >30 kg/m 2 were classified as overweight and 47 (39.17%) patients with BMI between 25 and 30 kg/m 2 classified as mildly obese; 24 (20%) patients had BMI <25 kg/m 2 , who were at a low risk for obesity. Both DN and non-DN diabetics were BMI matched (P = 0.619).
In the DN group, microalbuminuria was found in 44 (73.3%) patients whereas macroalbuminuria was found in 16 (26.7%) patients.
A statistically significant correlation was found between prevalence of DN and fasting blood sugar, post-prandial blood sugar and random blood sugar, with P ≤0.001 [Table 1]. The DN patients had an average HbA1c level of 9.84 ± 0.63, which was higher than that in the non-DN group, whose average HbA1c was 8.67 ± 1.18; this was statistically significant ( P ≤0.001). The OR for developing DN for patients who were hyperglycemic was higher (OR = 11.80) (95% confidence interval (CI95%) = 1.45 - 95.39) [Table 1].
|Table 1: Comparison of vital and blood parameters in the two groups of patients [diabetic nephropathy (DN) and non-DN].|
Click here to view
The average of the serum creatinine levels in the DN group was 5.14 ± 2.84 μg/dL and that in the non-DN control group was 1.41 ± 0.59 μg/dL.
Fifty-one (85%) DN patients and 44 (73.3%) non-DN patients had hypertension. The average duration of hypertension in the DN group was 10.1 ± 5.21 years and that in the non-DN group was 6.71 ± 1.41 years. The duration of hypertension was longer among the DN patients as compared with that among the non-DN patients. The average systolic blood pressure in the DN patients was 150.20 ± 17 mmHg and that in the non-DN patients was 136.83 ± 13.66 mmHg, whereas the average diastolic blood pressure was 93.2 ± 9.48 mmHg and 86.3 ± 9.24 mmHg in these groups, respectively. There was a significant relationship between systolic hypertension, diastolic hypertension and DN ( P ≤0.001), with an OR of 2.06 for developing DN in patients who have hypertension [Table 2].
|Table 2: Comparison of the risk factors in the two groups of patients [diabetic nephropathy (DN) and non- DN].|
Click here to view
A significant relationship was also found between duration of diabetes and DN ( P ≤0.001). The average duration of diabetes was 14.8 ± 4.40 years in the DN patients and 9.43 ± 3.50 years in the non-DN patients. The OR for developing DN among patients who had diabetes duration between 10 and 20 years was 4.69 (CI95% = 2.17 - 10.17), which was highly significant [Table 2].
The odds for developing DN in patients having a family history of only diabetes was not significant (P = 0.648), but there was a trend in patients who had a family history of DN (P = 0.088) (OR = 2.80) (CI95% = 0.83 - 9.49) [Table 2].
There were 39 (65%) smokers in the DN group and 24 (40%) smokers in the non-DN group. The average duration of smoking among the DN patients was 19.2 ± 4.80 years and that among the non-DN patients was 14.8 ± 4.82 years. A statistically significant relationship was found between DN and smoking (P = 0.006), and the odds for developing nephro-pathy in smokers was 2.79 (CI95% = 1.33 -5.87) [Table 2]. However, BMI did not seem to influence the development of DN (P = 0.711) (OR = 1.07) [Table 2].
In the DN group, 59 (98.3%) patients manifested other complications such as hypertension, retinopathy and neuropathy, whereas 58 (96.7%) patients in the non-DN group manifested such complications. The odds for developing DN in patients having other complications was 2.03 (CI95% = 0.18 - 23.01) [Table 2].
There were 40 (66.7%) DN patients and 44 (73.3%) non-DN patients with a history of anemia; there was a trend between anemia and DN (P = 0.027), and the odds for developing DN in patients who had anemia was 2.29 (CI95% = 1.09 - 4.78) [Table 2].
[Table 3] and [Table 4] show the treatment details of drugs in the DN and non-DN patients. Insulin was used in 54 (90%) and oral hypoglycemic drugs (OHA) in 25 (41.7%) DN patients, in contrast to the use of insulin in 27 (45%) and OHA in 43 (71.7%) non-DN patients [Table 3] and [Table 4].
|Table 3: Treatment details in the two groups of patients [diabetic nephropathy (DN) and non-DN].|
Click here to view
|Table 4: Treatment details under the anti-diabetics category of drugs in both groups [diabetic nephropathy (DN) and non-DN].|
Click here to view
[Table 5] summarizes the comorbidities present in both study groups. In the DN group, 51 (85%) patients had hypertension, 21 (35%) had dyslipidemia, 29 (48.3%) had retinopathy, 17 (28.3%) had neuropathy, seven (11.7%) had IHD, five (8.3%) had CCF and diabetic foot, four (6.7%) had MI, two (3.3%) had TB and asthma and one (1.7%) had left ventricular failure. In comparison, in the non-DN group, 44 (73.3%) patients had hypertension, 23 (38.3%) had neuropathy, 17 (28.3%) had dyslipidemia, 14 (23.3%) had retinopathy, five (8.3%) had CCF and two (3.3%) had diabetic foot, MI and left ventricular failure.
|Table 5: Co-morbidities along with diabetes in both groups of patients [diabetic nephropathy (DN) and non-DN].|
Click here to view
| Discussion|| |
In our study, uncontrolled hyperglycemia, duration of diabetes, hypertension, family history of DN, inadequate diabetic diet knowledge, smoking, alcohol consumption, secondary diseases, obesity and no physical exercise were the positively related risk factors for the development of DN.
The treatment patterns in both groups were insulin and OHGs. In nephropathy patients, hemodialysis was another option for treatment. The different classes of drugs used for the treatment of co-morbidities were calcium channel blockers, angiotensin-converting enzyme I and angiotensin receptor blockers, diuretics, opioid analgesics, β blockers and TCA.
Despite modern treatment and self-monitoring of blood glucose, patients with diabetes may still develop renal complications. Accordingly, early management of the risk factors and early detection of DN may arrest the progression of the disease.
The multifactorial approach targeting the main risk factors (hyperglycemia, hypertension, dyslipidemia and smoking) and the use of renoprotective agents such as the drugs that act on the renin - angiotensin - aldosterone system may delay progression of kidney disease in diabetics.
Therefore, any program that aims to reduce the magnitude of DN should focus on the main risk factors such as control of blood glucose levels and hypertension. Improving patient's knowledge on diabetes and its treatment, life style modifications and aggressive management of the disease would also help delay the progression of disease to advanced stages.
| Acknowledgment|| |
The authors wish to express their sincere gratitude to the staff of the Department of Pharmacy Practice, VIPS, Bangalore.
Source of Support: Nil.
Conflict of Interest: None declared.
| References|| |
|1.||Nand N, Aggarwal HK, Sharma M. Recent advances in the management of diabetic nephropathy. J Indian Acad Clin Med 2001;2:78-84. |
|2.||Rehman G, Hamayun M. Studies on diabetic nephropathy and secondary disease in type 1 diabetes. Int J Diab Dev Ctries 2004;24:50-5. |
|3.||Afkhami-Ardekani M, Modarresi M, Amirchaghmaghi E. Prevalence of microalbuminuria and its risk factors in type 2 diabetic patients. Indian J Nephrol 2008;18:112-7. |
|4.||Richard AH, David JQ, Herfindal ET, Gourely DR. Text book of Therapeutics: Drug and disease management. 8 th ed. Philadelphia (USA): Lippincott Williams and Wilkins; 2006. p. 1142-6. |
|5.||Ahmad U, Nor MI, Ali O. Risk factors for diabetic nephropathy among non insulin dependent patients at city halls staff clinic in kualalumpur. Malays J Public Health Med 2001;1:16-21. |
Mohamed Akheel Ahmed
Department of Pharmacy Practice, Visveswarapura Institute of Pharmaceutical Sciences, BSK-II Stage, Bangalore
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]