Relationship between glycosylated haemoglobin and risk of microalbuminuria in patients with type 2 diabetes mellitus

 

 

Abstract               Diabetes mellitus (DM) is one of the most common chronic diseases in most countries. Diabetic nephropathy (DN) is one of the most common complications, and an important cause of renal failure. Microalbuminuria is the earliest clinically detectable stage of diabetic kidney disease at which appropriate interventions can retard, or even reverse, the progress of nephropathy. Glycosylated haemoglobin (GHb) is a useful index of mean glycaemia during the preceding 120 days. It is also a predictor of complications as measures reducing HbA1c correspondingly reduce the risk of complications. The present study was done to evaluate the relationship between duration of diabetes, degree of hyperglycemia and the incidence of microalbuminuria in patients with diabetes mellitus. Methods: It was Prospective Study, subjects were chosen from the Out Patient Department and Indoor Patient Department of Medicine, M.G.M. Medical College and L.S.K. Hospital, Kishanganj, Bihar, from the population in the city of Kishanganj and peripheral villages of Kishanganj District. The duration of study was from December 2015 to August 2017. The study group consists hundred cases of 20-60 years age group from rural and urban area after following the exclusion and inclusion criteria. We divided hundred patients in four age groups i.e. 20-30 years, 31-40 years, 41-50 years and 51-60 years of age group. A short history and clinical examination of the patients were obtained regarding the blood pressure, history of smoking, alcohol intake and after taking the verbal consent of the patient after that blood and Urine samples were collected. Blood and Urine samples were tested in the Department of Biochemistry, M.G.M. Medical College and L.S.K. Hospital, Kishanganj, Bihar. Results: In the present study we divided total 100 patients in four age groups out of them 58 were male and 42 we female. Maximum number of patients belongs to 51-60 years of age group. Among them 34% (17) were male and 26% (13) were female. Present study showed a positive correlation of microalbuminuria with duration of diabetes and level of glycaemic control (measured by HbA1c levels), which is in accordance with many previous reports. Also, presence of concomitant hypertension and smoking were important risk factors in early development of nephropathy. Therefore, regular screening for microalbuminuria in addition to continuous HbA1c estimation are important tools in the management of DM. Conclusion: It was concluded that the prevalence of microalbuminuria in diabetic patients in this study was found to be as high, which needs of therapeutic and preventive measures. Being a developing country, there is a need of microalbuminuria and HbA1C testing in both newly diagnosed as well as already diagnosed type 2 diabetic patients as an early marker of renal risk factor.

Key Word: glycosylated haemoglobin, microalbuminuria.

 

 

 

 

INTRODUCTION

Diabetes mellitus (DM) is one of the most common chronic diseases in most countries^.1 Diabetic nephropathy (DN) is one of the most common complications, and an important cause of renal failure.² Microalbuminuria is the earliest clinically detectable stage of diabetic kidney disease at which appropriate interventions can retard, or even reverse, the progress of nephropathy^.3 Glycosylated haemoglobin (GHb) is a useful index of mean glycaemia during the preceding 120 days.⁴ It is also a predictor of complications as measures reducing HbA1c correspondingly reduce the risk of complications^.5 The present study was done to evaluate the relationship between duration of diabetes, degree of hyperglycemia and the incidence of microalbuminuria in patients with diabetes mellitus. This correlation can have important implications in deciding how strictly the blood sugar levels of diabetic patients need to be controlled for optimum health and prevention of complications like diabetic nephropathy. The first detectable sign of kidney damage is the appearance of microalbuminuria^.6 This allows early intervention with the goal of delaying the onset of overt diabetic nephropathy^.7 To maximize prevention of microalbuminuria development, blood pressure should be maintained at less than 130/80 mm Hg, and HbA1c should be kept below 7%.⁵ The level of glycaemic control also plays an important role in the transition from normoalbuminuria to microalbuminuria to macroalbuminuria.⁸ Hence, two important recommendations for the follow-up of diabetics include monitoring of glycaemic status by HbA1c and screening for nephropathy with urine microalbumin to assess disease progression and to detect potential progression towards end organ damage.⁹ Diabetes itself is not a high mortality condition, but is a major risk factor in other causes of death and has a high attributable burden of disability.¹⁰ Diabetic nephropathy, a common sequelae of uncontrolled diabetes, greatly affects the quality of life and contributes to decreased life expectancy.¹¹ Good glycaemic control is the key to preventing the onset of diabetic nephropathy. Duration of diabetes and level of glycaemic control has a significant contribution for the development of microalbuminuria by prolonged exposure to hyperglycaemia induced advanced glycosylation end products accumulation. The fact that presence of microalbumin can lead to adverse outcomes in diabetics, and the recognition that its risk factors and clinical course are amenable to treatment provide a genuine case for action. Nephropathy is one of the complications of type 2 diabetes mellitus that could lead to end stage renal disease. Persistent microalbuminuria is the best predictor of high risk of developing diabetic nephropathy. The relation between HbA1c and microalbuminuria with the duration of diabetes is not clear.

MATERIALS AND METHODS

Type of Study: Prospective Study

Study Area and Study Population: The subjects were chosen from the Out-Patient Department and Indoor Patient Department of Medicine, M.G.M. Medical College and L.S.K. Hospital, Kishanganj, Bihar, from the population in the city of Kishanganj and peripheral villages of Kishanganj District.

Study Duration: The duration of study was from December 2015 to August 2017.

Ethical Consideration: A synopsis of this research study design consists of Introduction, Aims and Objectives and protocol were submitted for approval after getting the permission from the Ethical Committee, M.G.M. Medical College and L.S.K. Hospital, Kishanganj, Bihar.

Eligibility of the study population: The study group consists hundred cases of 20-60 years age group from rural and urban area after following the exclusion and inclusion criteria. We divided hundred patients in four age groups i.e. 20-30 years, 31-40 years, 41-50 years and 51-60 years of age group. A short history and clinical examination of the patients were obtained regarding the blood pressure, history of smoking, alcohol intake and after taking the verbal consent of the patient after that blood and Urine samples were collected. Blood and Urine samples were tested in the Department of Biochemistry, M.G.M. Medical College and L.S.K. Hospital, Kishanganj, Bihar.

Samples were collected for estimation of:

• Fasting Plasma Glucose.
• Post Prandial Plasma Glucose.
• HbA1c.
• Microalbuminuria.(Urine)
• Urea.
• Serum Creatinine.

The tests were done in Selectra-pro-S auto analyzer. Strict external quality control using sera with known values are performed to validate the results.

Inclusion Criteria:

• Patients suffering from type 2 Diabetes Mellitus for at least 2 to 10 years were included in the stidy group.
• The patients were between the age group of 20-60 years of rural and urban area.

Exclusion Criteria:

The patients suffering from anemia, any other diseases or person using drugs that could affect HbA1c levels and microalbuminuria were excluded from the study.

 

 

 

 

RESULTS

Table 1: Age and Sex Wise Distribution

Table No: 1 shows age and sex wise distribution of the present study. In the present study we divided total 100 patients in four age groups out of them 58 were male and 42 we female. Maximum number of patients belongs to 51-60 years of age group. Among them 34% (17) were male and 26% (13) were female.

Table 2: Socio-demographic Status

 

Table 3: Smoking Status

 

Table 4: Range of Systolic and Diastolic Blood Presure

 

Table 5: Urea and Creatinine level

 

Table 6: Distribution of Biochemical Investigations

 

Table 7: Presence of Microalbuminuria in Diabetic patients

Table 8: Correlation between HbA1c and Micro Albumin

 

DISCUSSION

Age and Sex distribution: Table No: 1 shows age and sex wise distribution of the present study. In the present study we divided total 100 patients in four age groups out of them 58 were male and 42 we female. Maximum number of patients belongs to 51-60 years of age group. Among them 34% ¹⁷ were male and 26%¹³ were female. The age range of patients in our study was 30- 80 years with the mean age of 52.2 years. Similar mean age was observed in various other studies by Chowta NK et al, Kanakmani J et al, Maskari FA et al.^12-14 Although the exact reason why the residents of developing countries, especially Asian, are more prone to diabetes at a younger age remains speculative, there is growing evidence to support the concept of the ‘Asian Indian Phenotype’. The term refers to the peculiar metabolic features of Asians characterized by a propensity to excess visceral adiposity, elevated serum triglycerides and an increased ethnic susceptibility to diabetes.^15,16. Diabetic nephropathy is one of the most serious long-term complications of diabetes mellitus. Various epidemiological studies and cross-sectional studies have reported many variations in prevalence of microalbuminuria. Vijay et al. reported a prevalence of 15.7% in 600 type 2 diabetic patients in Chennai.¹⁷ Huraib et al reported a prevalence of 16.8% among 125 type 2 diabetic patients in Saudi Arabia.¹⁸ Varghese et al. reported a prevalence of 36.3% in 1425 type 2 diabetic patients in Chennai.¹⁹ The variation in the prevalence of microalbuminuria can be attributed to several factors such as ifference in population, the definition of microalbuminuria, the methods of measurement of icroalbuminuria and urine collection etc. Huraib et al. also used immunoturbidity method for the assessment of microalbuminuria¹⁸ which is the same method followed in the present study.

Smoking Status: Microalbuminuria is a useful predictor of renal failure in diabetics. The causal risk factors for microalbumin are poor glycaemic control and raised blood pressure. Duration of diabetes, male sex and smoking as additional risk factors for microalbuminuria.²⁰

Range of Systolic and Diastolic Blood Presure: The first detectable sign of kidney damage is the appearance of microalbuminuria.¹⁶ This allows early intervention with the goal of delaying the onset of overt diabetic nephropathy^.21 To maximize prevention of microalbuminuria development, blood pressure should be maintained at less than 130/80 mm Hg, and HbA1c should be kept below 7%.²² The level of glycaemic control also plays an important role in the transition from normoalbuminuria to microalbuminuria to macroalbuminuria.¹² The causal risk factors for microalbumin are poor glycaemic control and raised blood pressure.²³ Studies show that once microalbuminuria is present, it is most likely to progress to protienuria in approximately 20- 50% of the subjects and is accelerated by the presence of hypertension. Smoking has been described to be a major risk factor for the development of microalbuminuria. In our study, of the total microalbumin positive patients, 57(65.5%) were also hypertensive and 52 (59.7%) were smokers. This is in agreement with many earlier studies^.24 Diabetes itself is not a high mortality condition, but is a major risk factor in other causes of death and has a high attributable burden of disability.²⁵ Diabetic nephropathy, a common sequelae of uncontrolled diabetes, greatly affects the quality of life and contributes to decreased life expectancy.²⁶ Good glycaemic control is the key to preventing the onset of diabetic nephropathy. Duration of diabetes and level of glycaemic control has a significant contribution for the development of microalbuminuria by prolonged exposure to hyperglycaemia induced advanced glycosylation end products accumulation. The fact that presence of microalbumin can lead to adverse outcomes in diabetics, and the recognition that its risk factors and clinical course are amenable to treatment provide a genuine case for action.

 

CONCLUSION

Present study showed a positive correlation of microalbuminuria with duration of diabetes and level of glycaemic control (measured by HbA1c levels), which is in accordance with many previous reports. Also, presence of concomitant hypertension and smoking were important risk factors in early development of nephropathy. Therefore, regular screening for microalbuminuria in addition to continuous HbA1c estimation are important tools in the management of DM. Treatment of hypertension and aggressive lifestyle changes including measures to quit smoking should be given topmost priority. The rising prevalence of diabetes can produce major constraints on health care budget. This urgently calls for not only good control of diabetes to prevent nephropathy but also to address the larger issue of primary prevention of diabetes, that is, reduction in the prevalence of diabetes itself by aggressive lifestyle modifications. It was concluded that the prevalence of microalbuminuria in diabetic patients in this study was found to be as high, which needs of therapeutic and preventive measures. Being a developing country, there is a need of microalbuminuria and HbA1C testing in both newly diagnosed as well as already diagnosed type 2 diabetic patients as an early marker of renal risk factor. The present study emphazises education about strict glycaemic control and testing for microalbuminuria which is an early indicator of diabetic nephropathy, mandatory for all type 2 diabetic patients. Urinary microalbumin excretion correlated significantly with duration of diabetes. Increased HbA1c level positively correlated with microalbuminuria.

 

REFERENCES

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22.  Jha P, Das BKL, Shreshtha S, Majhi S, Chandra L. Sharma S et al. Glycaemic status, lipid profile and proteinuria in diabetic nephropathy. JNepal Med Assoc 2012; 49(178): 43-6.
23. Choo-Kang E, Reid HL. Microalbuminuria in diabetes mellitus. Prio Onl J 2008.
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