RENAL DATA FROM THE ARAB WORLD
|Year : 2016 | Volume
| Issue : 2 | Page : 348-355
|Prevalence and determinants of microalbuminurea among type 2 diabetes mellitus patients, Baghdad, Iraq, 2013
Ali Abdalkader Ali1, Faris Hassan Al Lami2
1 NCD Department, Directorate of Public Health, Ministry of Health, Baghdad, Iraq
2 Community and Family Medicine Department, College of Medicine, Baghdad University, Baghdad, Iraq
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|Date of Web Publication||11-Mar-2016|
| Abstract|| |
Microalbuminuria (MAU) is an early marker of diabetic nephropathy (DN), which accounts for a significant reduction in life expectancy of diabetic patients. The progression of DN from the appearance of clinical proteinuria to end stage renal failure is usually irreversible. Increased levels of urinary albumin secretion may represent a more generalized vascular damage. This is the first study conducted in Iraq to determine the prevalence and potential risk factors of MAU among Type 2 diabetes mellitus (T2DM) patients. A cross-sectional study was conducted on a systematic random sample of 224 eligible T2DM patients aged 25-64 years attending a DM clinic in Baghdad. A questionnaire was developed to gather basic and clinical data, besides anthropometric measurements, and laboratory assessment of lipid profile, HbA1c, serum creatinine, albumin, and microalbumin/creatinin in urine. MAU was defined as albumin/creatinine ratio 30-300 mg/g on two occasions. Only 36 cases (16.1%) had MAU. A statistical significant association found between MAU and educational level (P = 0.009), family history of hypertension (P = 0.024) and DN (P = 0.013), history of hypertension (P = 0.001), duration of angiotensin-converting-enzyme inhibitor drug intake in hypertensive patients (P = 0.001), body mass index (BMI) (P = 0.014), and waist to hip ratio (P = 0.006). Logistic regression analyses revealed two independent risk factors influencing MAU: diastolic blood pressure [odds ratio (OR) = 1.08, 95% confidence interval (CI): 1.007-1.118] and BMI (OR = 1.17, 95% CI: 1.037-1.220). The prevalence of MAU is not low among DM patients. Mandatory screening of all DM patients and amelioration of the assigned significant risk factors are recommended.
|How to cite this article:|
Ali AA, Al Lami FH. Prevalence and determinants of microalbuminurea among type 2 diabetes mellitus patients, Baghdad, Iraq, 2013. Saudi J Kidney Dis Transpl 2016;27:348-55
|How to cite this URL:|
Ali AA, Al Lami FH. Prevalence and determinants of microalbuminurea among type 2 diabetes mellitus patients, Baghdad, Iraq, 2013. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2020 Jan 25];27:348-55. Available from: http://www.sjkdt.org/text.asp?2016/27/2/348/178561
| Introduction|| |
The increasing prevalence of Type 2 diabetes mellitus (T2DM) worldwide is reaching epidemic proportions and is becoming a major public health problem.  The importance of T2DM is further emphasized by epidemiological studies that clearly shows excess mortality associated with T2DM, as well as an increased risk of other T2DM-related complications which have a significant economic impact on the health system worldwide. 
Around 10-20% of people with T2DM die of kidney failure. , Diabetic nephropathy (DN) accounts for a significant reduction in life expectancy of diabetic patients. Microalbuminuria (MAU) is an early marker of DN.  Without any intervention, in T2DM patients, 20-40% with MAU progress to overt nephropathy and 20 years later, approximately 20% develop end stage renal disease (ESRD). 
MAU in diabetic patients is a risk factor for cardiovascular disease, and identifies patients who need more rigorous cardiovascular risk management, especially more intensive blood pressure control, and strict attention to glycemic control and lipid levels. ,, Recent studies have demonstrated that the onset and course of DN can be ameliorated to a very significant degree by several interventions, but these interventions have their greatest impact if instituted at a point very early in the course of the development of this complication. Thus, the finding of MAU is an indication of screening for possible vascular disease and aggressive intervention to reduce all cardiovascular risk factors [e.g., lowering of low density lipoprotein (LDL) cholesterol, antihypertensive therapy, cessation of smoking, institution of exercise, etc.].  The progression of DN from the appearance of clinical proteinuria to ESRD is usually irreversible. , Therefore, detection of MAU as early as possible in the course of the disease is very important. 
In Iraq, the prevalence of DM among adults is 10.4%, which means that around three million Iraqi individuals are suffering from DM.  In spite of this large number of DM cases and the feasibility of prevention or delaying ESRD, little is known about the problem of early DN in the country. This study was conducted to estimate the prevalence and identify potential determinants of MAU among T2DM patients attending a Diabetes Center in Baghdad, Iraq, 2013.
| Patients and Methods|| |
A cross-sectional study conducted on a systematic random sample of T2DM patients attending the Diabetic Center in Eastern side of Baghdad during the period January to May, 2013. The following variables were obtained using a questionnaire filled through direct interview with the study participants: age, sex, level of education, marital status, smoking habit, family history of hypertension and DM, comorbid illnesses, and type of diabetes therapy. Anthropometric measures (body mass index (BMI) and waist to hip ratio) and blood pressure were measured. Laboratory investigations included lipid profile, HbA1c, serum creatinine and albumin, and microalbumin/creatinin in urine. Microalbuminurea was measured three times one month apart using early morning urine specimen. Exclusion criteria were the presence of overt proteinuria, urinary tract infection, hematuria, ketonuria, pregnancy, heart failure, and use of systemic steroids in the past four weeks.
MAU is considered positive when urinary albumin to creatinin ratio (ACR) is 30-300 mg/g creatinin in two of the three tests within 3-6 months period in a spot urine sample. , Measurement of urine creatinin was performed by using (Reflotron ® Creatinine) test strip utilizing Reflotron ® Plus Roche Germany and measurement of urine micro-albumin was performed by using ORG 5MA Micro-Albumin Germany ELISA Kit utilizing Awareness Technology, Inc., Micro plate Reader (USA).
The Statistical Package for Social Sciences (SPSS) version 18 (SPSS Inc., Chicago, IL, USA) used for data entry and analysis. Chi-square test of independence was used to test the association between categorical data. P ≤0.05 was considered significant. Logistic regression analysis was performed to identify the significant unconfounded risk factors. Odds ratio (OR) and its 95% confidence interval (CI) were calculated.
Official approval and ethical consideration
Approval of the Iraqi Ministry of Health was granted and a written informed consent from each participant was obtained.
| Results|| |
The total number of eligible T2DM patients who accepted to participate was 245; 224 patients continued in the study for the three visits. The overall response rate was 91.4%. The number of the T2DM patients who tested positive for MAU (ACR of 30-300 mg/g on two occasions) was 36 making a prevalence rate of 16.1% (95% CI: 11.3-20.9%).
The age range was 25-64 years; around 39% of the patients were in the age category of 50- 59 years; the least was in the age group 60+ years (8.9%). Male:female ratio was 1.4:1.
A comparison of those with and without MAU for sociodemographic variables revealed a significant association with marital status (P = 0.001) and education status (P = 0.009) [Table 1].
|Table 1: Distribution of the study group by microalbuminurea and basic demographic characteristics, smoking habit, and physical activity.|
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A similar comparison was made for family history for certain diseases, history of hypertension and hypertension medication. A significant association was found with positive family history of hypertension (P = 0.024), family history of DN (P = 0.013), hypertension (P = 0.001), and the duration of angiotensisn converting enzyme inhibitors (ACEIs) or angiotensin receptors blockers (ARBs) medication use (P = 0.001) [Table 2].
|Table 2: Distribution of the study group by microalbuminurea and family history for certain diseases, comorbid illnesses and hypertension medication.|
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None of the DM-related characteristics presented in [Table 3] showed a significant association with presence of MAU (P >0.05). Similarly, none of the following biochemical attributes were significantly associated with MAU: serum cholesterol (P = 0.08), serum triglyceride (TG) (P = 0.72), high-density lipoprotein (HDL)-cholesterol (P = 0.34), serum LDL-cholesterol (P = 0.55), high serum creatinine (P = 0.59), and abnormal estimated glomerular filtration rate (eGFR) (P = 0.25) [Table 4].
|Table 3: Distribution of the study group by microalbuminurea and diabetes mellitus-related characteristics.|
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|Table 4: Distribution of the study group by microalbuminurea and abnormal biochemical findings.|
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The prevalence of MAU in the subjects with normal BMI was 10%; compared to 9% and 23% for overweight and obese subjects, respectively, as shown in [Table 5]. A significant association found between BMI and MAU (P = 0.014). The proportion of MAU was significantly higher in patients with central obesity (abnormal waist-hip ratio) compared to those with normal waist-hip ratio (18%) (P = 0.006). Logistic regression analysis was applied. MAU was the dependant variable, and the following were significant covariates: hypertension with OR = 1.061, 95% CI: 1.007-1.118, P = 0.026 and BMI with OR = 1.125, 95% CI: 1.037-1.220, P = 0.004.
|Table 5: Distribution of the study group by microalbuminurea and certain anthropometric measurements.|
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| Discussion|| |
The prevalence of MAU in T2DM patients was 16.1%. Several epidemiological studies conducted in different Asian countries reported prevalence rates of MAU ranging between 8% and 32% among T2DM patients. , The prevalence rate was similar to the result in Saudi Arabia (16.8%),  Iran (14.2%),  and Sweden (16%).  However, the prevalence rate was 27% in Oman,  and 61% in the United Arab Emirates.  The difference may be attributed to the differences in the age distribution of the studied sample, the definition of MAU and method of assessment.
The high prevalence among single patients noticed in this study is consistent with a study conducted in Iran, 2012 on 1557 patients aged more than 18 years.  This is supported by a qualitative study that explored how spousal support influences dietary changes following a diagnosis of T2DM in middle-aged and older adults. 
The significant association of MAU with education status is consistent with a two years follow-up study conducted on 173 diabetic patients in The Netherlands. The study showed that diabetic people with low level of education have lower utilization rates of checks and services relevant for diabetes care, and a worse outcome in terms of complications.  Similar findings were reported in a Chinese study in 2008. 
The significant association of MAU with positive family history of hypertension is consistent with a study conducted by Keller et al, 1996, in Germany.  Similarly, the significant association with positive family history of DN is consistent with other studies that demonstrated a genetic susceptibility contributing to the development of DN in patients with both T1DM and T2DM. ,
Significant association was found between hypertension and MAU which is consistent with Al-Futaisi et al  and Unnikrishnan et al  studies. High diastolic blood pressure was a significant independent risk factor for MAU (OR = 1.061, 95% CI: 1.007-1.118, P = 0.026). This is consistent with other studies tackling this variable. ,
Regarding the use of ACEI or ARB medication among hypertensive patients, the prevalence of MAU showed no statistical significance association with the use of ACEI or ARB medication (P = 0.15). By further stratification of the users by the duration of use (˃2 years and ≤2 years), a statistically significant inverse association was seen with MAU by binary analysis. Other studies also demonstrated the inverse association with angiotensinconverting-enzyme use. , Similarly, obesity (BMI ≥30) was also a significant risk factor in binary and logistic regression analysis. This is supported by two studies. , The significant association between MAU and waist hip ratio is consistant with other studies conducted in The Netherlands  and China.  The logistic regression analysis did not prove this variable as a significant factor.
In this study, no significant association was found with age and sex. This is consistant with many studies tackling these variables. ,, Similarly, the following biochemical measures were evaluated and were found not significantly associated with MAU: HbA1c, serum cholesterol, HDL, LDL, TG, and creatinin levels. Many studies conducted in many countries found similar results. ,, The nonsignificant association with eGFR is consistant with a study conducted by Nosadini et al 2000 in Italy. 
| Conclusion|| |
Around one of every six patients with T2DM had MAU. High blood pressure and obesity were significant predictors and should be corrected. All T2DM patients should have regular screening for MAU, and the health facilities need to provide the necessary equipment to conduct this investigation.
Since the study design is a cross-sectional, temporal relationship cannot be ascertained. Moreover, referral bias should be considered, as the study conducted in a specialized center, and the sample may not represent all patients in the community.
Conflict of interest: None declared.
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Ali Abdalkader Ali
NCD Department, Directorate of Public Health, Ministry of Health, Baghdad
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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