|Year : 2015 | Volume
| Issue : 2 | Page : 191-197
Clinical profile of patients with diabetic nephropathy in a tertiary level hospital in Dhaka, Bangladesh
Sheikh MohammedShariful Islam1, Md Serajul Islam2, Lal B Rawal3, AKM Mainuddin3, Mohammad Wahiduzzaman4, Louis W Niessen5
1 International Center for Diarrheal Disease Research, Bangladesh; Center for International Health, University of Munich, Germany,
2 Department of Community Medicine, Ad-Din Medical College, Bangladesh
3 Center for International Health, University of Munich, Germany
4 Bangladesh Institute of Health Science, Dhaka, Bangladesh
5 Centre for Applied Health Research and Delivery, Liverpool School of Tropical Medicine, Liverpool, UK; Department of International Health, Johns Hopkins School of Public Health, Baltimore, USA
|Date of Web Publication||16-Dec-2015|
Sheikh MohammedShariful Islam
Center for Control of Chronic Disease, International Center for Diarohheal Disease Research, 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka - 1212
Source of Support: None, Conflict of Interest: None
Background: Diabetic nephropathy (DN) is one of the major causes of morbidity and mortality among patients with diabetes worldwide. Data on DN patients in Bangladesh are scarce. Objectives: The aim of this study was to determine the clinical status of patients with DN and its associated factors in Bangladesh. Materials and Methods: A cross-sectional study was conducted among 130 DN patients admitted in Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM) hospital in Dhaka from May to July 2010. We collected data using structured questionnaires, anthropometric, biochemical, and clinical measurements. Multiple regression analyses were performed to examine the relationships between independent variables and factors associated with DN. Results: The mean age of the patients was 56.50 ± 14.2 years. The mean duration of hypertension, diabetes, and DN was 7.32 ± 5.42, 10.08 ± 6.8, and 3.24 ± 3.67 years, respectively. The mean HbA1c was 10.07 ± 3.27%, and mean serum creatinine 2.91 ± 1.98 mg/dl. The correlation coefficient matrix suggests relationships between many of the patients' characteristics and clinical outcomes. Multiple logistic regression analysis shows that the duration of DN (>3 years) is associated with female sex (odds ratio [OR] 1.01, 95% confidence interval [CI] 0.97-2.12), systolic blood pressure (OR 1.04, 95% CI 0.78-1.53), serum creatinine (OR 1.04, 95% CI 0.96-1.87), HbA1c (OR 1.12, 95% CI 0.89-2.01), and duration of hypertension (OR 1.06, 95% CI 0.83-2.37). Conclusion: The results show that among the study participants DN develops earlier with a shorter duration of hypertension and diabetes, providing a strong case for promoting effective strategies for optimum management of diabetes and hypertension in the clinics.
Keywords: Bangladesh, diabetes, diabetic nephropathy, hypertension
|How to cite this article:|
Islam SM, Islam MS, Rawal LB, Mainuddin A, Wahiduzzaman M, Niessen LW. Clinical profile of patients with diabetic nephropathy in a tertiary level hospital in Dhaka, Bangladesh. Arch Med Health Sci 2015;3:191-7
|How to cite this URL:|
Islam SM, Islam MS, Rawal LB, Mainuddin A, Wahiduzzaman M, Niessen LW. Clinical profile of patients with diabetic nephropathy in a tertiary level hospital in Dhaka, Bangladesh. Arch Med Health Sci [serial online] 2015 [cited 2019 Jun 25];3:191-7. Available from: http://www.amhsjournal.org/text.asp?2015/3/2/191/171902
| Introduction|| |
Hypertension and diabetes have become epidemic in many developing countries, including Bangladesh.  Previous studies have reported that in patients with type 2 diabetes in Bangladesh, a great majority have uncontrolled diabetes, hypertension and a high proportion of chronic kidney diseases. , The frequent coexistent of hypertension and diabetes is associated with increased risk of cardiovascular diseases, ischemic stroke, retinopathy, and chronic kidney diseases.  The prevalence of hypertension ranges from 22% to 80% in patients with kidney diseases. , Diabetic nephropathy (DN) is the major microvascular complication of diabetes and the leading cause of end-stage renal disease (ESRD) globally, causing high morbidity and mortality in patients with diabetes. , If diabetes is not treated early and adequately, many patients will reach advanced and irreversible DN. 
Evidence suggests that type 2 diabetes starts at a younger age among Asian people compared to Caucasians and that genetic factors and lifestyle risk factors are more common in Asian people.  Also, as compared with Caucasians, South Asians have a 3-fold greater risk of developing DN and an almost 40-fold greater risk of developing DN, possibly due to a higher prevalence of insulin resistance in the latter. , A population-based study in India demonstrated that the prevalence of overt nephropathy was 2.2% (95% CI 1.51-2.91), microalbuminuria was 26.9%; common risk factors for DN and microalbuminuria were duration of diabetes and levels of HbA1c, and systolic blood pressure (BP). , A multi-country study in Asia, showed high prevalence (58.6%) of micro or macroalbuminuria, indicating an impending pandemic of diabetic cardiovascular and renal diseases in Asia, with potential economic consequences. 
DN poses a huge economic burden for developing countries, such as Bangladesh. The DiabCare study in Bangladesh showed that the prevalence of DN among diabetes patients was 8.6% in an urban hospital, and a recent study showed a prevalence of 6.4% in Rajshahi. , The DiabCare Bangladesh 2008 study evaluated the current status of diabetes care in Bangladesh as a continuation of a similar cross-sectional study conducted previously in 1998. This comprehensive study of diabetes management only reported on the prevalence of DN in Bangladesh based on a clinical survey but did not present on the clinical findings of patients with DN. Information about the clinical profile of DN patients and identifying its associated factors are essential for developing prevention strategies and might help the physicians provide better clinical management. However, to the best of our knowledge, there is no published data describing the clinical status of DN patients in Bangladesh. The objective of this study was to describe the current clinical status of DN patients and its associated factors in a tertiary hospital in Bangladesh.
| Materials and Methods|| |
Study design and population
We carried out a cross-sectional study in the nephrology department of BIRDEM hospital from May to July 2010. BIRDEM is a 550-bed tertiary level hospital and World Health Organization affiliated center of excellence for diabetes, with multidisciplinary clinical settings for all cases of medicine and surgery. This site was selected because of the availability of a large number of DN patients admitted from all over Bangladesh. The outpatient department (OPD) of BIRDEM hospital caters service to a large number of patients every day including new and old cases of diabetes. Patients with suspected kidney diseases are referred from the OPD to the nephrology department for further evaluation and management. The nephrology department has two units and provides services for 45-75 patients each day, including services for dialysis and renal transplantation. The inclusion criteria were male and female patients aged 20 years and above, clinically diagnosed with DN at the nephrology department of BIRDEM, and willing to participate voluntarily and provide written informed consent. The exclusion criteria were those patients undergoing dialysis, renal transplantation, and having other serious complications.
We enrolled 147 patients for the study, nine patients refused to complete the data collection, three patients were not eligible due to other comorbid complications, and five patients had missing data and were not included in the analysis. Finally, 130 patients were included in the final analysis. Convenience sampling was used as a sampling design. Data were collected through interviewer assisted face-to-face interview, review of patient clinical and biochemical records, anthropometric measurements and a clinical examination using a semi-structured questionnaire and checklist. The attending physician, nurse, and consultants were informed about the research objectives, procedures, and inclusion and exclusion criteria.
We collected data on sociodemographic indicators (age, sex, average monthly income, family size, occupation, religion, and education), systolic and diastolic BP weight, height, body mass index (BMI). HbA1c, serum creatinine, and urinary albumin were measured in the BIRDEM laboratory. The duration of diabetes, hypertension and DN, patient's medication history and co-morbidities were obtained from clinical records. BP was measured twice (in the sitting position, after a 10 min rest) to the nearest 2 mmHg, using an mercury sphygmomanometer. Reported values are the average of the two readings. Hypertension was defined as systolic pressure ≥140 mmHg or diastolic pressure ≥90 mmHg or use on anti-hypertensive medication, according to the guidelines of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High BP.  Patients were weighed in light clothes, without shoes, and height was recorded using a clinical height scale. BMI was calculated as weight (kg) divided by squared height (m). Spot urine sample was collected at random to measure urinary albumin concentration. DN is classically defined as a progressive rise in urine albumin excretion in the absence of other renal diseases, which is often coupled with increasing BP, declining glomerular filtration and eventually ESRD.  Estimating glomerular filtration rate (eGFR) was calculated using the modified diet in renal disease equation by the USA National Kidney Foundation with a reference range of normal glomerular filtration rate (GRF) values in young individuals is from 80 to 130 mL/min, 1/1.73 m 2 , declining at ~10 mL/min/decade after 50 years of age. DN was diagnosed by the attending consultant at the Nephrology Department based on the previous reports of the patients biochemical tests of urine albumin, serum creatinine, eGFR, BP, and clinical assessment.
This study was approved by the Institutional Review Board of National Institute of Preventive and Social Medicine, Dhaka, Bangladesh. Written informed consent was obtained from all participants prior to inclusion in the study, in accordance with the Helsinki declaration and research ethics.  The participants were fully informed about their rights to refuse participation and to withdraw from the interview, and the physical and clinical examinations at any time during the study.
Results are presented as mean ± standard deviation (SD) for continuous variables, and as frequencies and percentages/proportions for categorical variables. Descriptive statistics was used to identify the prevalence of DN among different subgroups. We conducted a bivariate analysis to determine any association between independent and dependent variables. Further, we conducted multiple regression analyses to examine relationships between independent variables and the outcome variables (to identify factors associated with DN), and adjusted for potential confounding factors. All statistical analyses were conducted with SPSS (Version 15.2; Chicago, IL, USA). Statistical significance was considered as P < 0.05.
| Results|| |
A total of 130 patients with DN were studied, with mean ± SD age 56.50 ± 14.1 years. Most (57%) of the respondents were male, and 6.2% had completed an undergraduate or higher levels of education. By occupation, 40% of the respondents were daily wagers/labors, followed by 19.2% service holders, 17.7% businessmen, and 8.5% housewives. The mean family income was Bangladesh taka 20,715.38 ± 11,519.61. The mean family size was 6.08 ± 1.725 with most participants (66.9%) having 5-7 members in the family [Table 1].
The mean durations of hypertension, diabetes, and DN were 7.32 ± 5.42, 10.08 ± 6.08 and 3.24 ± 3.67 years, respectively. Using the mean duration of DN as a cut-off point, 44.6% of males and 30% of females had had DN for ≥3 years. The mean BMI was 26.15 ± 0.21 kg/m 2 and mean systolic and diastolic BP were 132 ± 22.29 and 80 ± 11.01 mmHg, respectively. The mean HbA1c was 10.07 ± 3.27% (95% CI: 9.50-10.65) and mean serum creatinine was 2.91 ± 1.98 mg/dl (95% CI: 2.57-3.26). Almost three-quarters of the respondents (58.5%) had albuminuria of 0.5-1.5 g/24 h, followed by 37.7% at 200-500 mg/24 h and 3.8% at 2-5 g/24 h. A total of 57% participants had hypertension, and 43% had normal BP [Table 2].
Almost all anthropometric and clinical measurements were greater among the patients with mean duration of DN ≥3 years than in those with <3 years. For example, the BMI of the respondents with mean duration of DN ≥3 years was greater (27.59 ± 0.21) than for those with <3 years (25.43 ± 0.21); and this finding was statistically significant (P < 0.001). Similarly, the systolic and diastolic BPs were greater among the patients with mean duration of DN ≥3 years than in those with <3 years; again, these differences were statistically significant (P = 0.01 and P < 0.001, respectively). Patients with mean duration of DN ≥3 years had high serum creatinine levels (mean and SD 3.35 ± 1.92 mg/dl) compared with DN with mean duration <3 years (mean and SD 2.64 ± 1.99 mg/dl). This difference was statistically significant (P = 0.04). Though the HbA1c was higher among patients with duration of DN ≥3 years (10.39 ± 2.97%) compared with those who had DN for <3 years (9.88 ± 3.45%), this association was not statistically significant (P = 0.39). Both duration of hypertension and duration of diabetes were longer among the patients with DN for ≥3 years compared with those who had DN for <3 years, which were statistically significant with P < 0.001.
All patients were on an antidiabetic treatment plan and the therapeutic regimens were classified as insulin injection only (45.4%); oral hypoglycemic agent (OHA) only (33.1%); combined therapy with insulin and OHA (17.7%), and diet and exercise therapy (3.8%). Almost three-quarters of the patients suffered co-morbidity, including retinopathy (34.6%), cardiovascular disease (20%), neuropathy (14.6%) and diabetic foot (3.8%). More than half (57%) of the participants were hypertensive and on antihypertensive drugs, of which most were on beta blockers (38.4%), followed by calcium channel blockers (23.3%), angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) (15.1%), or other drugs (23.3%).
[Table 3] describes the relationships among some general characteristics and clinical outcomes in people with DN. The correlation coefficient matrix shows strong relationships between many of the patients' characteristics with the clinical outcomes. For example, the age of the participants was associated with the duration of T2DM and duration of DN (r 0.432, P < 0.001, and r 0.387, P < 0.001, respectively). Similarly, the monthly income of the participants was correlated with the duration of diabetes (r 0.290, P = 0.001). There was also strong correlation between other clinical outcomes; for example, duration of DN with the duration of diabetes (r 0.473, P < 0.001); serum creatinine levels (P = 0.006) and systolic and diastolic BPs (P < 0.001). However, the duration of hypertension was negatively correlated with most of the patients' characteristics and clinical outcomes, including duration of diabetes, duration of DN, HbA1c levels, serum creatinine levels and BP.
|Table 3: Correlations coefficient between general characteristics and clinical outcomes among the patients with HTN and DN|
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Results of multiple logistic regression analysis shows that the duration of DN (<3 years = 0 vs. ≥ 3 years = 1) is associated with sex (OR 1.01 [95% CI 0.97-2.12] ), systolic BP (OR 1.04 [95% CI 0.78-1.53] ), serum creatinine (OR 1.04 [95% CI 0.96-1.87] ), HbA1c (OR 1.12 [95% CI 0.89-2.01] ) and duration of hypertension (OR 1.06 [95% CI 0.83-2.37]) adjusting for other variables [Table 4].
|Table 4: Multiple logistic regression showing association of duration of DN (<3 years = 0 versus ≥3 years = 1) with outcome variables|
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| Discussion|| |
This study provides an evidence base for the current clinical status of DN patients in a tertiary hospital in Bangladesh. Not surprisingly, on average, those whose duration of DN was longer were in an older age group than those whose duration of DN was shorter; this difference was statistically significant (P < 0.001). Some studies conducted in other countries have demonstrated relationships between hypertension, diabetes and DN. ,, Age and sex are important risk factors for chronic kidney diseases. In our study, the mean age of the DN patients was 56.50 ± 14.1 years and the male to female ratio was 1:1.3. These characteristics were comparable with the study conducted in Pakistan (mean age 61.64 ± 0.48 years).  However, in developed countries, most of the DN patients are older than 65 years.  Therefore, we can easily imagine that those with diabetes in Bangladesh are particularly vulnerable to the development of microvascular complications of diabetes, including DN. Our study presents some key point features of DN patients from an urban tertiary hospital in Bangladesh, such as lower age, low use of angiotensin-converting enzyme inhibitor in hypertensive and proteinuric diabetics.
This study is one of relatively few from South-East Asia looking at the clinical status and management of DN. The relationship between BP and DN seems to be a complex one, with nephropathy leading to higher BP, and higher BP accelerating the course of nephropathy. Hypertension is the single most important cause of progression and point of successful intervention in DN.  Among Indo-Asians, the declining rate of renal function is accelerated, perhaps because of the differences in protective effects from antihypertensive drugs. , A study in Hong Kong showed that although most patients (96.1%) were receiving treatment for hypertension, only 25.6% had systolic or diastolic BP below the 130/85 mmHg targets.  A microalbuminuria study showed that only 11.6% of the patients had systolic and diastolic BP below the 130/80 mmHg targets.  In our study, 57% DN patients were hypertensive; a finding that was similar to a study in Korea.  This indicates that there might be some patients with resistant hypertension among the DN patients studied, but this was outside the scope of this study.
A study in Pakistan identified a number of secondary diseases associated with DN and Type 2 diabetes, including retinopathy (59.8%), hypertension (40.0%), diabetic foot (47.0%) and neuropathy (29.2%).  That study established a relationship between education and secondary diseases associated with DN and diabetes. Those who had no formal education were more likely to suffer many disease conditions than those who had a university education and above. In that study, the mean duration of diabetes was 16.17 ± 0.33 years, which was more than our study participants. The DiabCare Bangladesh study also showed a significant relationship between hypertension and increased prevalence of all three of these microvascular complications. This was supported by the results presented based on the logistic regression analysis, which showed that - independent of other factors - longer duration of diabetes was associated with all the three microvascular complications: HbA1c with retinopathy and neuropathy; older age (>60 yr) with nephropathy and neuropathy; and systolic BP >125 mmHg with nephropathy.  In our study, about 59% participants had albuminuria of 0.5-1.5 g/24 h compared to 30% in the Korean epidemiology study on hypertension  and 24.9% in a study conducted in Hong Kong. 
We found that most of the anthropometric and clinical outcomes were greater among the patients who had a longer duration of DN than in those having DN for a shorter duration. These outcomes include mean BMI, systolic BP, diastolic BP, and serum levels of creatinine and HbA1c levels. Similarly, the duration of diabetes was longer among the patients having a longer duration of DN than in those having DN for a shorter duration (P < 0.001). Previous studies have established the duration of diabetes as one of the major risk factors for DN. , In our study, the mean duration of diabetes was 10.08 ± 6.8 years, but was significantly higher among the group of participants who had longer duration of DN (13.34 ± 6.42, P < 0.001). This finding highlights the importance of screening all patients with diabetes, irrespective of their duration of the disease that will ultimately help to identify people at risk of developing DN and to develop appropriate strategies for prevention and management of DN. Further, the duration of DN in our study was correlated with duration of diabetes (r.473, P < 0.001) and other clinical outcomes, including serum creatinine levels (r 0.239, P = 0.006), systolic BP (r.334, P < 0.001), and diastolic BP (r.336, P < 0.001).
Currently, it is suggested that DN occurs as a result of the interaction between genetic and environmental factors.  This concept does not diminish the importance of the study of specific genetic polymorphisms, which might make it possible to identify groups at high risk of developing DN, thus providing novel therapeutic targets or individualized treatment strategies for both the prevention and treatment of this complication. This aspect was not included in our study, because of technical and financial limitations.
A recent meta-analysis of the prospective studies evaluating the effect of ACE inhibitors in patients with type-2 diabetes - with either micro- or macroalbuminuria, hypertension and prehypertension - revealed a significant risk reduction of 15% in cardiovascular events as compared with patients treated with other hypotensive agents, along with a marked renoprotective effect of ACE inhibitors.  In our study, only 15% patients were on ACE inhibitors/ARBs, suggesting the need for appropriate management of hypertension among type 2 diabetes patients during early stages of the disease. 
This study had a number of limitations. First, this was a hospital based study conducted in a tertiary hospital in Dhaka city in the Department of Nephrology, where only patients with suspected kidney diseases are referred. Therefore, the results of this study might not represent the DN population in Bangladesh. Second, albuminuria was measured only once in the hospital using a spot urine sample. Microalbuminuria is not a sensitive and specific a predictor of DN. However, this may not alter the inferences drawn because most of the epidemiological studies also used only a single measure as it is easy to perform, accurate and recommended by American Diabetes Association guidelines. Third, since the BP was measured in the hospital setting, the white coat effect could not be ruled out. However, we conducted two measurements with 10 min intervals at resting conditions and considered the average of the two readings. Lastly, the laboratory data for biological samples were collected from patients' hospital records, which could not be verified with the participants. In this case, a nationally representative multicenter prospective cohort study would have provided better evidence on the prevalence of DN and association with the duration of hypertension in Bangladesh. Also, we could not measure GRF, lipid profile and other biochemical parameters, which could have assisted in understanding the relationship between hypertension and DN.
Patients with hypertension and diabetes in our study developed DN earlier with a short duration of both these conditions compared to the Western population. Large-scale longitudinal studies of diabetes for detecting the incidence, conversion and factors for DN are warranted. Further, we found a relationship between duration of diabetes with the duration of hypertension, duration of DN, serum creatinine and BP, stressing for an aggressive and sustained reduction in BP, along with improved glycemic control, medication adherence and lifestyle modification. As DN is a costly condition, preventive approach and early screening at the primary healthcare level are recommended.
| Acknowledgments|| |
The authors gratefully acknowledge the support from Dr. Hilary Cadman, ELS, Cadman Editing Services, Australia for editorial review. We would like to thank the staff of Nephrology Department of BIRDEM and the study participants for providing valuable data.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]