A higher prevalence of microalbuminuria in women in a diabetes management program at a public hospital in the south of Santa Fe province.

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1 A higher prevalence of microalbuminuria in women in a diabetes management program at a public hospital in the south of Santa Fe province. Sánchez Azcona P. 1, Quaglia, N.B. 2 1 Phisiology and Biophysics. Medicine. School of Medicine and Health Sciences. Universidad Abierta Interamericana. Rosario. Santa Fe. Argentina. 2 Phisiology and Biophysics. Medicine. School of Medicine and Health Sciences. Universidad Abierta Interamericana. Rosario. Santa Fe. Argentina. Pharmacology. School of Biochemical and Pharmaceutical Sciences. Universidad Nacional de Rosario. Santa Fe. Argentina. ABSTRACT Diabetes control and associated risk factors are a public health problem. The aim of this study was to characterize diabetic patients with at least 10 years duration of disease who attended Hospital Provincial Alejandro Gutiérrez in Venado Tuerto city as part of a specific diabetes management program. An observational and cross-sectional study was performed with data obtained from medical records (n = 88). Ninety-two percent (92%) (CI: %) of patients had type 2 diabetes; mean age 63.0 ± 10.9 years and mean body mass index (BMI, kg/m 2 ) 30.9 ± 6.4. BMI was significantly higher in women than men. The following prevalences were found: hypertension (HT): 77.8% ( %); microalbuminuria: 46.2% ( %); total cholesterol >200 mg/dl: 38.5% ( %); triglycerides > 150 mg/dl: 41.0% ( %). Microalbuminuria tended to be associated with the presence of hypertension and with a BMI > 27 kg/m 2. The significantly higher prevalence of microalbuminuria found in women as compared to men may be possibly related to female overweight. Rev Argent Endocrinol Metab 48: , 2011 No financial conflicts of interest exist. Key words: Diabetes, obesity, hypertension, diabetic nephropathy, dyslipidemia INTRODUCTION Diabetes mellitus (DM) is associated with other pathologies that increase its morbid effects. Thus, obesity is a well known risk factor for type 2 diabetes (DM2). Obesity reduces life expectancy in general and obese persons have a poorer quality of life. Diabetic patients also suffer from dyslipidemia and hypertension (HT). There is much evidence showing that the complications of DM accelerate and become more serious when diabetic patients suffer from HT (1). The chronic complications of DM include diabetic microangiopathy, that causes kidney, eye, neurological and skin complications (2,3). Diabetic nephropathy (DN) is one of the most serious complications of this disease and a common cause of end-stage chronic kidney disease and the beginning of a renal replacement therapy (2,4). In the central area of Argentina, the prevalence of diabetes was approximately 7% and increased to 15.1% in persons over 60 years old (5). In order to improve the quality of life of diabetic patients and delay the onset of nephropathy, particularly, and of

2 complications, in general, it is important to institute in these patients a proper hygienicdietary and drug therapy, in addition to compliance with therapy and disease follow-up. Hospital Alejandro Gutiérrez is the only public hospital in the city of Venado Tuerto and, until recently it had a specific Program for the treatment of diabetic patients in that town. The implementation of this program allowed the interdisciplinary treatment of these patients. There is no data available showing the global features of the patients included in this specific program. The general purpose of this work was to characterize the diabetic patients with at least 10 years duration of disease that were treated in such a hospital as members of the program and thus, estimate the frequency of associated co-morbidities, such as HT and dyslipidemias, and of kidney complications, determined by the presence of microalbuminuria. MATERIAL AND METHODS Hospital Alejandro Gutiérrez is in the city of Venado Tuerto, in the General López District, in the province of Santa Fe. The city has a population of 90,000 inhabitants approximately, and an area of scope of nearly 200,000 people. It is the highest complexity public health institution of the General López District. In 2002, it was categorized as a teaching hospital, a Training and Teaching Committee was organized and the organization of post-degree courses started. In 2007, a program called Tarde de Diabetes (An Afternoon of Diabetes) was implemented and was effective up to This program had 447 medical records and became the only service that worked with such a centralized document. In this context, an observational and cross-sectional study was performed with data obtained from medical records of diabetic patients of Hospital Alejandro Gutiérrez in the city of Venado Tuerto. The treating physician provided photocopies of the medical records where the identity of patients was not revealed, thus complying with the provisions of Law The total number of medical records amounted to 88 (diabetic patients of the Tarde de Diabetes program with at least 10 years duration of disease). Variables to be studied -qualitative Nominal measurement level: gender; DM type; HT defined as blood pressure 140/90 mmhg; presence of microalbuminuria, defined as urinary albumin excretion of mg/24 h. -quantitative Quantitative discrete measurement: age. Quantitative continuous measurement: triglycerides. height, weight, total cholesterol and Considering height and weight, body mass index (BMI) was calculated, also as quantitative continuous.

3 Data Analysis Quantitative continuous variables were considered to obtain summary information (means or medians, as applicable). They were subsequently used as variables of nominal measurement level taking into account the pathological cut-off point for each of them. Frequencies were estimated and expressed with 95% confidence intervals. For quantitative variables, summary measures included the mean ± SEM, or the median in the case of triglycerides. The comparison between means (ANOVA or non-parametric test, as applicable) and the analysis of potential associations (either Chi square or Fischer test, as applicable) were performed as required. Excel 2003 and Epi Info were used for data management and statistical analysis. Values of p<0.05 were considered as statistically significant. RESULTS The sample population was made up of 88 diabetic patients with over 10 years duration of the underlying disease. Out of that figure, 53.4% ( %) were women and 46.6% ( %) were men. The patients mean age was 61.2 ± 12.3 and their BMI /Kg/m 2 ) 30.8 ± 6.3. Women s BMI (Kg/m 2 ) was higher than men s (31.8 vs. 29.0, respectively; p = 0.04). Figure 1. Of the 88 patients of the sample population, 8% ( %) corresponded to DM1 and 92% ( %) to DM2. The analysis was subsequently performed by classifying patients according to the type of DM. The following results were obtained for mean age and BMI. - The mean age (years) of DM1 patients was 41.8 ± 10.8; and that of DM2 patients was 62.9 ± 10.9 (p=0.0001). - The BMI (Kg/m 2 ) in DM1 patients was 25.9 ± 2.71 and in DM2 patients, 30.9 ± 6.4 (p=0.03). In the group of DM2 (n=81) patients, we assessed the proportion of patients with HT, independently of their disease control, and with microalbuminuria. Table I. The average of total cholesterol (mg/dl) in DM2 patients was ± 41.7 and that of total triglycerides (TG) (mg/dl) to ± TG median was 132 mg/dl. The proportion of DM2 patients with cholesterol and triglycerides values above acceptable levels versus non-acceptable levels was also assessed. The proportion of patients with cholesterol > 200 mg/dl was 38.5% ( %) and that of patients with TAG>150 mg/dl was 41.0% ( %). Table I. Finally, it was interesting to assess some possible associations between the studied variables, particularly those that may be related to the presence of microalbuminuria, considering it as a marker of early kidney failure.

4 Figure 1. BMI (kg/m 2 ) according to gender in diabetic patients (n=88). *p<0.05. (References: IMC =BMI; varones=men; mujeres=women) TABLE I: proportion of DM2 patients with HT, micralbuminuria, cholesterol >200mg/dl and triglycerides> 150 mg/dl. Percentages are expressed with their corresponding 95% CI. Patients % 95% CI HT Microalbuminuria Cholesterol > 200 mg/dl Triglycerides >150 mg/dl Figure 2. Proportion of patients with microalbuminuria (grey) or without microalbuminuria (white) with or without HT (n=78) (References: % de pacientes = patients %; No = No; Sí = Yes; (HTA) = (HT))

5 Figure 3. Proportion of patients with microalbuminuria (grey) or without microalbuminuria (white) with BMI (kg/m 2 ) < or BMI 27. (n = 74). (References: % de pacientes= patients %; (IMC) = (BMI) Microalbuminuria used to be associated (Fisher Test, p = 0.06) with the presence of HT. Microalbuminuria was found in 51.7% of patients with HT and only in 27.8% of patients with properly controlled blood pressure. Figure 2. A potential relationship between the presence or absence of microalbuminuria in the same group of patients was subsequently evaluated, if their BMI (kg/m 2 ) was < or 27 kg/m 2 (Chi square test, p = 0.09). Microalbuminuria was found in 30.4% of patients with BMI < 27, while patients with BMI 27 accounted for 54.9% of patients. Figure 3. DISCUSSION In Argentina, nearly two thirds of the DM population suffer from or are at risk of developing chronic complications, which are the main reason for the high socioeconomic cost of this disease. This suggests that the health care system in Argentina will be forced to invest resources in recovery and rehabilitation more than in prevention, thus causing an increase in costs and a reduction in efficient investments (6). People at a higher risk of developing diabetes are those with a family history of disease, obesity, impaired glucose tolerance and/or impaired fasting glucose, hypertension, high blood cholesterol levels and/or high blood triglycerides levels, women who suffered from gestational diabetes and those who gave birth to babies of more than 4 kg. Furthermore, possibilities increase after 45 years of age (7). The distribution of DM clinical types in the general population according to medical literature shows that DM1 affects between 10 and 15% of diabetic patients and DM2 approximately 85% (8.9). Data shows that such proportion also existed among patients that participated in the Diabetes Program. In this study it was not possible to establish the prevalence of diabetic patients in connection with the number of patients treated at this Hospital. However, it is worth mentioning at this point the survey performed by De Sereday et al., which has been considered as an epidemiological data model in our country for prevalent pathologies including obesity, hypertension, hyperlipidemia and diabetes. This study was carried

6 out in the central area of Argentina with a sample that included the city of Venado Tuerto and considered that in the total sample (consisting of 4 towns in that region), the prevalence of diabetes for persons of ages similar to the mean age of the patients evaluated in this study, i.e, between and 60-69, was 12.2% and 15.1%, respectively (n=1794) (5). DM2 is a condition closely related to obesity (7,9). We should not forget that, although this index corresponds to total study patients (i.e. DM1 and DM2 patients), since less than 10% corresponds to DM1 in our study, the value presented is clearly influenced by the BMI of DM2 patients [BMI DBT2 (kg/m 2 ) = 30.9 ± 6.4]. It should be noted that, in this study, all patient s disease had over 10 years duration and a mean duration of approximately 15 years, which confirms the difficulties for achieving weight loss or for keeping weight within acceptable levels when weight loss has been achieved. In connection with this issue, De Sereday et al had previously found that the prevalence of obesity in the central region under study and considering individuals between and years old, represented 34.9% and 37.8%, respectively (n=2397). The authors expressed not only the frequency of obesity but also they refer to overweight (BMI 25 kg/m 2 ), what affects approximately 2/3 of the population (5). Likewise, it should be noted that among the patients studied, the BMI was higher in women than in men. This is consistent with recent data from a similar population which show a potentially higher tendency to overweight in women, particularly among young women (10). In the patients included in this study, it was found that although the mean plasma levels of total cholesterol were below the cut-off value as well as the triglycerides median, approximately 40% of the population had plasma levels consistent with values of higher cardiovascular risk. It should also be noted that in the case of triglycerides, the study showed individual values high enough to alter sample distribution, and as a consequence of that, mean values were expressed as a median in order to have a more reliable summary value. An analysis of the median showed that 50% of the patients studied had TG values not beyond 132 mg%. However, as already stated, 41% of patients had values beyond the acceptable limit of 150 mg%. Thus, the high average value found and its wide variability could be justified. It would be interesting to know about the use of lipid-lowering drugs in these patients although this issue was not part of the design of this study-- in order to have more information about the possibilities of lipid control. However, the absence of full data about the use of lipidlowering drugs in the studied sample does not allow for conclusions. Most investigators agree that HT frequency in DM patients, particularly DM2, is higher than the frequency noticed in the population in general. The co-existence of HT and DM is a risk factor of cardiovascular, cerebrovascular and peripheral vascular disease (11). It is common to detect DM upon a diagnosis of HT and, in turn, it is usual to diagnose HT at the time of detecting DM. HT is present, for instance in 67.7% of diabetic patients recently diagnosed between 30 and 79 years old (1). In Argentina, it was found that HT coexists with DM in about 50% of middle-aged or older persons, if higher mean ages of diabetic patients are considered (12,1). Taking into account that the patients included in this study had a mean age of 63 years old and a duration of disease of at least 10 years, our results were consistent with the data found in the medical literature. It should be noted, however, that, due to the characteristics of the study performed, there is no information on the use of antihypertensive drug therapy in these patients. DN is one of the most serious complications of the disease that affects one third of patients with both types of DM and although, in general terms, such condition is fortunately decreasing thanks to improved medical treatment (13), in our country, DN is

7 the most frequent cause of chronic terminal kidney failure. In 2005, it accounted for 35% of patients that started chronic dialysis treatment, what means 49 patients per million inhabitants (14). When the presence of microalbuminuria was evaluated in DM2 patients, it was found in over 45% of patients. As these patients had disease duration of at least 10 years, they can be expected to exceed the third reported in the literature. It has already been said that microalbuminuria is an incipient renal failure marker. In the studied population, the prevalence of microalbuminuria was mainly related to HT in DM 2 patients. This is consistent with the fact that HT is a risk factor for kidney disease. In fact, more than half of HT patients had microalbuminuria. On the other hand, as the average BMI found was surprisingly high and taking into account that, according to specific literature, obesity itself causes kidney disease - mainly glomeruloesclerosis, favoring renal failure and glomerular hyperfiltration (13) - the potential relationship between BMI and microalbuminuria in this group was evaluated. Indeed, a BMI above 27 kg/m 2 was found to be associated with the presence of microalbuminuria, thus supporting the hypothesis that also in the studied group, obesity is a risk factor for the kidney complications of diabetic disease. Finally, it is interesting to note that, according to this study, women showed higher overweight than men. This might probably, and at least partly, justify the fact that microalbuminuria prevailed in women in this study (55.8% of women had microalbuminuria vs 34.4% of men, p=0.05). DM and its complications are a growing problem requiring joint efforts to plan and consolidate strategies not only to delay or prevent its onset but also to minimize and postpone the onset of its potential complications. For this purpose, a joint work between health care professionals and patients is required, to raise awareness on the need for compliance with both drug therapy and hygienic-dietary recommendations; in the latter case focusing on maintenance of proper BMI. Acknowledgements: Authors thank both the Directors and professionals that participated in the Tarde de Diabetes program of Hospital Alejandro Gutiérrez of the city of Venado Tuerto, for their cooperation in this study. REFERENCES 1. Fundación para el Estudio de Hipertensión Arterial y Factores de Riesgo Cardiovascular. Burlando Guillermo, Sánchez Ramiro, Editores. Normativa. Hipertensión Arterial y Diabetes. Disponible en: Acceso: 27 de noviembre de Martinez Castelao. Formación continuada en Nefrología. El caso de la diabetes mellitus y la enfermedad renal crónica. Nefrología. 29:1-5, Asensio-Sánchez, Rodriguez-Delgado, García-Herrero, Cabo-Vaquera, García-Loygorri. Microalbuminuria and diabetic retinopathy. Arch Soc Oftalmol 82: 85-88, Timpe EM, Amarshi N, Reed PJ. Evaluation of angiotensin-convertin enzyme inhibitor use in patients with type 2 diabetes in a state managed care plan. Am J Manag Care 10: 124-9, 2004

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