Original articleHigh prevalence of chronic kidney disease in population-based patients diagnosed with type 2 diabetes in downtown Shanghai
Introduction
The incidence and prevalence of kidney failure caused by diabetes are rising, and its outcome is poor. Diabetes has become the most common cause of end-stage renal disease (ESRD) in some developed countries (U.S. Renal Data System, 2005). In the United States, diabetic nephropathy (DN) accounts for about 40% of new cases of ESRD (Centers for Disease Control and Prevention, 2005). In China, the rapid rise of diabetes mellitus also predicts a future prominent role of this disease in managing progressive renal failure, although glomerulonephritis (GN) is still the most common cause of ESRD (Lin, 2003, Wang et al., 2005). The increased prevalence of ESRD has fueled a rising interest in the evaluation of kidney damage and renal function among diabetic patients.
The Kidney Disease Outcomes Quality Initiative (K/DOQI) of the National Kidney Foundation (NKF) defined chronic kidney disease (CKD) as either kidney damage or decreased glomerular filtration rate (GFR) for 3 months or more (Levey et al., 2003, National Kidney Foundation, 2002); hence, both kidney damage and kidney function could be estimated by understanding CKD. There are few epidemiological data regarding the prevalence of CKD among Chinese patients diagnosed with diabetes.
Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies. Persistently increased excretion of albumin is a sensitive marker for CKD due to diabetes, glomerular disease, and hypertension (NKF, 2002). Albumin-to-creatinine ratio (ACR) in a spot urine specimen has replaced protein excretion in a 24-h collection as the preferred method for measuring proteinuria (American Diabetes Association, 2004, Ginsberg et al., 1983, Nathan et al., 1987, Rodby et al., 1995, Schwab et al., 1987, Zelmanovitz et al., 1997). Many earlier studies focused on serum creatinine levels as a marker of renal function (Iseki et al., 1997, Jones et al., 1998, Levey et al., 1988); however, creatinine was prone to being influenced by muscle mass, diet, and the method of assay (Clase et al., 2002a, Clase et al., 2002b). More recently, GFR has been considered the best indicator of renal function (Levey et al., 2003, National Kidney Foundation, 2002). Measuring GFR is expensive and cumbersome, and various methods of calculating estimated GFR from serum creatinine concentration have been studied, including the Cockcroft–Gault equation (Cockcroft & Gault, 1976) and several equations derived from the Modification of Diet in Renal Disease (MDRD) study population (Levey et al., 1999). The use of GFR estimates based on serum creatinine has gained popularity in both research and clinical practice, although some authors doubted their usefulness in epidemiological research (Bostom et al., 2002, Lin et al., 2003, Manjunath et al., 2001). We used increased ACR in a spot urine specimen as the marker of kidney damage and applied Cockcroft–Gault equation for estimating GFR in our study.
DN as evidenced by albuminuria, elevated blood urea nitrogen, and elevated blood creatinine is an excellent predictor for the presence of diabetic retinopathy (DR). Moreover, diabetic patients with nephropathy and retinopathy had lower GFR than diabetic patients with nephropathy but without retinopathy (Parving, Mogensen, Thomas, Brenner, & Cooper, 2005). An increased decline in GFR was significantly associated with DR among patients with nephropathy (Rossing et al., 2004, Trevisan et al., 2002). However, the relationship between CKD and DR was less predictable among patients with diabetes.
Therefore, we set out to accomplish two goals in this study. We calculated the estimates of the prevalence of CKD as manifested by albuminuria and/or low GFR (<60 ml/min/1.73 m2) determined using the Cockcroft–Gault equation in Chinese patients diagnosed with type 2 diabetes aged over 30. We also evaluated the relationship between CKD and DR among this population.
Section snippets
Study population
A cross-sectional study to evaluate the prevalence of diabetic complications in Chinese patients diagnosed with type 2 diabetes aged over 30 was planned in downtown Shanghai. According to an estimated DN prevalence rate of 33% in China (Xiang, 2003, Zhang et al., 2002), an admissible error of 0.03 (about 10% prevalence rate of DN), and a precision of 0.05, a sample of 944 patients was estimated (n=1.962×33×67/32=944). Because about 60 diagnosed diabetic patients lived in a residential area
Result
A final sample of 1039 patients was investigated. A total of 1009 patients including 390 male patients and 619 female patients were analyzed in this study based on data integrity. From these 1009 patients, albuminuria and the digitally stored fundus photographs were investigated and evaluated in 1003 and 671 patients, respectively. The mean age (±S.D.) of these 1009 patients was 66.16±11.54 years and the mean duration of diabetes (±S.D.) was 7.94±7.17 years.
Table 1 presents the clinical
Conclusion
Increasing evidence indicates that some adverse outcomes of CKD can be prevented or delayed by early detection and treatment (Remuzzi, Ruggenenti, & Perico, 2002). Unfortunately, CKD is underdiagnosed and undertreated, resulting in lost opportunities for prevention (Coresh et al., 2001, McClellan et al., 1997, Obrador et al., 1999). The prevalence of diabetes has increased markedly all over the world and diabetes was at increased risk for CKD. A better understanding of the prevalence of CKD and
Acknowledgments
This study was funded by grants to Renming Hu from the Shanghai Science and Technology Commission (04dz19504), the Key Project of National Natural Science Foundation of China (30230380), the National Natural Science Foundation of China (39900072), the Chinese High Tech Program (2002BA711A05 and 2001AA221201), and the National Key Basic Research and Development Program (2002CB713703). We hereby express our heartfelt thanks to Drs. Jingchong Fang, Min He, Wei Li, Xiufang Yang, Kuixiang Huang,
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