Department of Nephrology, Ibrahim Medical College & BIRDEM General Hospital, Dhaka, Bangladesh
Department of Internal Medicine, Ibrahim Medical College & BIRDEM General Hospital, Dhaka, Bangladesh
Department of Medicine, Delta Medical College and Hospital, Dhaka, Bangladesh
Department of Cardiology, National Institute of Cardio-Vascular Diseases (NICVD), Dhaka, Bangladesh
and objectives: Diabetes mellitus is
one of the most common causes of chronic kidney disease (CKD). The prevalence
of CKD in type 2 diabetes mellitus (T2DM) in Bangladesh is not well described.
The present study aimed to find out the prevalence of CKD stages 3-5 and its
risk factors among selected Bangladeshi T2DM patients.
This cross-sectional study was conducted in BIRDEM (Bangladesh Institute of
Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders) General
Hospital, Dhaka, Bangladesh from July to December 2015. Diagnosed adult T2DM
patients were consecutively and purposively included in this study. Pregnant women,
patients with diagnosed kidney disease due to non-diabetic etiology, acute
kidney injury (AKI), AKI on CKD and patients on renal replacement therapy were
excluded. Age, gender, body mass index (BMI) and laboratory parameters were
recorded systematically in a predesigned data sheet. Diagnosis of CKD and its stages
were determined according to Kidney Disease: Improving Global Outcomes (KDIGO)
Clinical Practice Guidelines 2012 and estimated glomerular filtration rate
(eGFR). Estimated GFR was calculated by using Modification of Diet in Renal
Disease (MDRD), Cockcroft-Gault (CG) and Chronic Kidney Disease Epidemiology (CKD-EPI)
creatinine based formula.
A total of 400 patients with T2DM of various durations were enrolled in the
study. Out of 400 patients, 254 (63.5%), 259 (64.75%) and 218 (54.5%) cases had
CKD stages 3-5 according to MDRD, C-G and CKD-EPI equations respectively. CKD
was significantly more common in
females (p<0.001) and in cases with long duration of diabetes (≥5 years; p=0.007). CKD stages
3-5 were significantly associated with hypertension (χ2=5.2125, p =0.02) and good control of diabetes (HbA1c <7%) as evidenced by higher proportion of
CKD in them (73.3%) compared to those with poor glycemic control (52.1%).
More than half of T2DM patients had CKD stages 3-5. Female gender, duration of
diabetes and hypertension were significant risk factors and should be emphasized
for the prevention of CKD in T2DM. Glycemic control may not reduce CKD in
IMC J Med Sci 2017; 11(1): 19-24
Address for Correspondence: Dr. Muhammad Abdur Rahim, Assistant Professor, Department
of Nephrology, Ibrahim Medical College & BIRDEM General Hospital. 122 Kazi
Nazrul Islam Avenue, Dhaka, Bangladesh. Email: firstname.lastname@example.org
mellitus (DM) is a global public health problem. The prevalence of DM,
particularly type 2 DM (T2DM), is increasing more in low and middle-income
countries . DM is now one of the leading causes of chronic kidney disease
(CKD) and end-stage renal disease (ESRD) both in developed and developing
countries [2-7]. Approximately, 40% of all diabetic patients develop nephropathy
and one-third to half of the patients requiring renal replacement therapy for their
ESRD is primarily due to DM [8-11]. Increased longevity, long duration of DM,
poor glycemic control, hypertension, dyslipidemia and other diabetic
complications are established risk factors for nephropathy and CKD in diabetic
patients . The prevalence of nephropathy and CKD in patients with T2DM is 10.8%
to 46% in different studies, largely depending on screening methods used.
However, only limited information is available on prevalence of CKD among
Bangladeshi population with T2DM . Therefore, the present study
was designed to evaluate the prevalence and potential risk factors of CKD
stages 3-5 among Bangladeshi patients withT2DM.
cross-sectional study was conducted at the out-patient department (OPD) of Bangladesh
Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic
Disorders (BIRDEM) General Hospital, Dhaka, Bangladesh from July to December
2015. Diagnosed adult T2DM cases of either sex, irrespective of duration of
diabetes were consecutively and purposively included in this study. Pregnant
ladies with T2DM, patients with diagnosed kidney disease due to non-diabetic etiology,
acute kidney injury (AKI), AKI on CKD and patients with a diagnosis of end
stage renal disease (ESRD) on maintenance hemodialysis or continuous ambulatory
peritoneal dialysis and renal transplant recipients were excluded from the
study. Age, gender, BMI and laboratory parameters were recorded systematically
in a predesigned data sheet. Enrolled patients were evaluated clinically for microvascular
(retinopathy, nephropathy and neuropathy) and macrovascular (coronary artery
disease, cerebrovascular disease including stroke and transient ischemic attack
and peripheral vascular disease) complications. Diagnosis of CKD and its stages
were determined according to the KDIGO 2012 clinical practice guideline for the
evaluation and management of chronic kidney disease  using estimated glomerular
filtration rate (eGFR). Estimated GFR was calculated by 4-variable Modification of Diet in Renal
Disease (MDRD), Cockcroft-Gault (C-G) and the Chronic Kidney Disease
Epidemiology (CKD-EPI) creatinine based equations [14-17]. Stage 3 CKD was further sub typed as stage
3a (eGFR 45-59 ml/min/1.73m2) and 3b (eGFR 30-44 ml/min/1.73m2)
based on eGFR values. Cases diagnosed as CKD stages 3-5 (eGFR 45 to < 15
ml/min/1.73m2) by CKD-EPI formula was only considered for
determining the association between different variables. The qualitative data
were presented in percentages and quantitative in mean with standard deviation
(SD). χ2 -test was used to determine the association
total of 400 T2DM patients were enrolled of which 169 and 231 were males and
females respectively. The mean age of the study population was 54.9±10.5 years
and the mean duration of diabetes from detection was 11.6±7.6 years. The mean
HbA1c was 9.1±2.0% indicating poor glycemic control (Table-1). Diabetes related
chronic complications of the study population are presented in Table-2.
Table-1: Baseline characteristics of the study population (n=400)
Table-2: Microvascular and macrovascular complications among the study
of 400 enrolled cases, 29.8%, 37.8% and 54.5% had neuropathy, retinopathy and
CKD respectively. Macrovascular complications were present in 11.0% to 25.8%
cases. Out of 400 cases, 254 (63.5%), 259 (64.75%) and 218 (54.5%) cases had
CKD stages 3-5 according to MDRD, C-G and CKD-EPI methods respectively. Detail
results of CKD stages 3-5 by MDRD, C-G and CKD-EPI methods are shown in
Table-3: Frequency of different stages of CKD according to different equations
among the study population (n=400)
of CKD stages 3-5 diagnosed by CKD-EPI formula was considered to find out the
association of CKD stages 3-5 with different variables namely gender, family
history of diabetes, duration of diabetes, hypertension, BMI, dyslipidemia and
HbA1c status. In our study, CKD stages 3-5 was associated in significantly (χ2=18.4, p≤0.001)higher proportion in females compared to males (63.6% vs. 42%) andin patients
with diabetes of more than 5 years duration (59.6%) compared to those of less
than 5 years (30.0%; χ2 =19.25, p≤.001). CKD stages 3-5 were present in 57.2% cases having
pre-existing or concomitant hypertension while it was 42.7% among those who had
no hypertension. It was interesting to
note that CKD stages 3-5 were present in higher number of cases (73.3%) having
good glycemic control (HbA1c <7%)
compared to those who had poor glycemic control (HbA1c ≥7%). On the
other hand, there was no significant association of CKD with family history of
diabetes,dyslipidemia and BMI (Table-4).
of CKD stages 3-5 in relation to different risk factors
DM is one
of the most common causes of CKD. Most patients with CKD remain asymptomatic in
early stages. Therefore, in the current study we have tried to evaluate
clinically significant CKD stages 3-5 among T2DM patients. CKD implies
considerable morbidity, mortality and health-care related costs . Diagnosis
of CKD in diabetic patients warrants significant changes in management of
patients, both for DM and other cardiovascular risk factors. Many CKD patients
die of cardiovascular events before reaching ESRD . Worth
mentioning that, early stages of diabetic nephropathy also increase
cardiovascular risks by many folds .
of the present study showed that over half of the patients (54.5% to 64.8%) with
T2DM had CKD stages 3-5 irrespective of methods/formulas used for estimation of
eGFR. Depending on different equations used, the overall rates of CKD stages
3-5 were almost similar by three different methods. Studies from UK, USA, Spain
and Australia have reported the prevalence of CKD in T2DM patients as 27.5%
(stage 3-5), 43.5%, 27.9% and 47.1% respectively [21,2,22,23]. The rate is
almost similar (23.8 to 46.0%) in developing countries [7,12,24,25]. The wide variation of
prevalence of CKD among the T2DM cases in different studies may reflect quality
of diabetes care, screening methods used and stages of CKD included in these
present study, we have used the number of patients diagnosed as having CKD
stages 3-5 by CKD-EPI method for assessing its relation with different factors.
We have found that CKD was significantly more common in females, inpatients with hypertension and in those with long
duration of diabetes. These are well recognized risk factors for CKD in
diabetes and have been reported in several studies done in developed as well as
developing countries of the world [7,12,23,25]. It was interesting to note that
CKD was present in significantly higher proportion in those who had adequate
glycemic control (HbA1c <7%). But this finding is not unusual. Recent
investigations contradict the previous thought that the strict glycemic control
prevents microvascular diabetic complications . Some observed that microvascular complications could not be
altered by near-normalization of glucose . Previous study in
Bangladesh observed significantly higher microvascular complications in cases
with strict glycemic control compared to those with inadequate glycemic control
. It may be possible that strict glycemic control may have injurious
effects on kidney due to sustained low blood sugar level.
study had some potential limitations. It was a single center study, done in a
tertiary care hospital with relatively small number of patients with T2DM. It might
not be generalized for Bangladeshi T2DM subjects. Moreover, we did not estimate
urine for albumin to creatinine ratio (UACR) or 24-h urinary total protein, by
which a good number of patients with early diabetic nephropathy/CKD could be
identified. We only relied on eGFR. Further study including multiple centers,
large number of study participants and evaluation of all stages of diabetic
nephropathy/CKD would provide a more representative picture in this regard from
conclusion, it can be said that, CKD stages 3-5 were present in more than 50%
of patients with T2DM in this study and the prevalence was significantly higher
in patients with hypertension and long duration of diabetes. Strict glycemic
control may not prevent or reduce CKD in diabetes. Optimum control of
hypertension may prevent the development of CKD and its progress in patients
with T2DM. Physicians, especially those, who serve the diabetic patients at all
levels starting from the primary care setting, should be aware of the possible
risk factors of complications and should educate the patients about those
express our acknowledgement to all our colleagues who helped us to collect data
from the study participants.
Conflict of interest: None declared.
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