الفهرس 
INTRODUCTION AND AIM OF THE WORKOnly 14 pages are availabe for public view
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Abstract
Diabetic nephropathy is a kidney disease associated with long-standing hyperglycemia. It is one of the common severe complications in diabetic patients leading to end stage renal disease (ESRD). By time, 30 - 40% of diabetic patients develop DN. DN is a clinical syndrome characterized by persistent albuminuria and/or a progressive decline in renal function. However, albuminuria is an early clinical manifestation of DN, and decreased GFR occurs later.
Because albuminuria can be reversed and the future development of overt DN and renal damage can be significantly reduced, screening for albuminuria and timely therapeutic intervention has become the standard of care worldwide. The ability to identify which diabetic individuals are at high risk of albuminuria would be helpful for the monitoring and early treatment of chronic kidney disease.
The general objective of the study was conducted to develop and validate a screening tool for prediction of DN among type 2 diabetic patients in Alexandria and specific objectives were:
1. To estimate the prevalence of albuminuria among type 2 diabetic patients attending primary health care centers in Alexandria.
2. To identify determinants of albuminuria among type 2 diabetic patients.
3. To develop and validate a prognostic scoring scheme for predicting albuminuria among type 2 diabetic patients.
4. To construct a structural equation model to identify the causal pathway of albuminuria among type 2 diabetic patients.
The study was conducted among T2DM patients attending primary health care centers in Alexandria using a cross sectional study followed by a case control design. A total of 415 type 2 diabetic patients were enrolled in the study.
A multistage random sampling technique was used. Three primary health care centers were randomly selected to represent the eight health districts of Alexandria. In each center, one day each week (not always the same day) was randomly selected and the diabetic patients who attended that day were recruited till reach the required sample size.
Selected patients were subjected to urine analysis for quantitative assessment of albuminuria in urine and were classified into:
Cases: Type 2 diabetic patients who are diagnosed as having albuminuria.
Controls: Type 2 diabetic patients who are free from albuminuria.
A predesigned structured data collection sheet consists of two parts was prepared and was used to collect the following data from participants:
Part I: Socio-demographic data such as age, sex, marital status, level of education and occupation.
Part II: Data from participants’ medical record:
• Medical data such as the duration of DM, complications of DM, treatment used for DM, family history of diabetes, history of hypertension, smoking status, systolic and diastolic blood pressure, body weight and height.
• Laboratory data such as lipid profile, creatinine, fasting blood sugar (FBS), and glycosylated hemoglobin levels (HbA1c).
Laboratory investigations were done for the detection of DN (presence of albumin or protein in urine). Urine samples were collected from the T2DM participants and examined for the presence of albuminuria (micro-albuminuria and macro-albuminuria). Urine analysis was performed in the laboratory of Medical Research Institute (Alexandria University).
The study revealed the following main results:
The overall prevalence of diabetic nephropathy (albuminuria) among T2DM patients was 32.3%. The prevalence of micro-albuminuria was 30.8% and the prevalence of macro-albuminuria was 1.5%.
The prevalence of micro-albuminuria was higher in males than females T2DM patients (34.9% and 28% respectively). In contrast, the prevalence of macro-albuminuria was higher in females than males T2DM patients (2.0% and 0.6% respectively). But, there was no statistically significant difference between males and females regarding the prevalence of albuminuria (MCE, p = 0.185).
About 42% of the studied population had uncontrolled HbA1c.
The percentage of obesity and overweight was 53% among T2DM patients.
There was no significant difference between cases and controls regarding socio-demographic characteristics except for age, where 94% of cases were in the age group more than 40 years old compared to 84% of controls.
Cases were:
- 3 time more likely to be more than 40 years old than controls (OR = 3.003, 95% CI= 1.03 -6.5).
- 70 times more likely to have duration of diabetes more than 10 years than controls (OR = 69.7, 95% CI= 31.8 – 153.1).
- Twice more likely to be smokers than controls (OR = 1.9, 95% CI= 1.03- 3.4).
- 2.4 times more likely to have family history of diabetes than controls (OR = 2.4, 95% CI= 1.5 – 4.1).
- 3.4 times more likely to have family history of hypertension than controls (OR = 3.4, 95% CI= 1.9 – 5.8).
- 3.7 times likelihood to be obese than controls (OR = 3.7, 95% CI= 2.3 – 5.7).
- 6.2 times more likely to have hypertension than controls (OR= 6.2, 95% CI = 3.8 – 10.1).
- 2.7 times more likely to have uncontrolled FBS than controls (OR = 2.7, 95% CI = 1.7 – 4.2).
- 5 times more likely to have uncontrolled HbA1C than controls (OR = 4.9, 95% CI = 2.1 – 5.2).
- 4 times more likelihood to have abnormally high total serum cholesterol than controls (OR = 3.9, 95% CI = 3.2 – 7.7).
- 2.6 times more likely to have abnormal serum TG levels than controls (OR = 2.6, 95% CI = 1.5 – 4.6).
Logistic regression revealed that family history of diabetes, duration of diabetes, hypertension, HbA1c, triglycerides and neuropathy were significant predictors for occurrence of DN.
The total risk score for development of DN ranged from 0 which is the lowest risk score to 11 which is the highest risk score. The mean score is 3 (SD = 0.9) and the median score is 2 points with good internal validity.
The risk score showed good discrimination and calibration with an area under ROC curve of 0.972. A cut of point 2.25 yielding 87% sensitivity and 85% specificity.
The current risk score had three risk strata for occurrence of albuminuria (low, intermediate, and high) and it is exponentially increased with increasing risk. T2DM patients with score below 2.25 are classified as low risk group. Those having a score from 2.25 to 4.75 are classified as medium risk and those having score more than 4.75 are considered high risk for occurrence of albuminuria.
SEM analysis revealed that the duration of diabetes has a large direct significant causal effect on the occurrence of albuminuria (0.689), hypertension has significant small direct causal effect on albuminuria (0.107). HbA1c has a significant small direct effect on albuminuria (0.204).