Microalbuminuria and metabolic risk factors in patients with type 2 diabetes in primary care setting in Thailand

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Abstract

Objective

To determine the prevalence of microalbuminuria and associated risk factors in patients with type 2 diabetes in primary care.

Methods

Clinical information of diabetic patients in 70 primary care units in Thailand was collected in a cross-sectional survey. Multinomial logistic regression model was used to examine several clinical risk factors with microalbuminuria and macroalbuminuria.

Results

A total of 4162 patients were included. The prevalence of microalbuminuria was 39.12% and macroalbumninuria was 7.83%. The proportion of patients with HbA1c < 7% was 37.9%. Independent risk factors for microalbuminuria and macroalbuminuria included HbA1c (adjusted OR 1.54, 95%CI 1.30–1.83 and 2.06, 95%CI 1.49–2.84 per unit increase in HbA1c, respectively), triglyceride ≥1.7 mmol/L (1.31, 1.11–1.56 and 1.44, 1.06–1.98), hypertension (1.31, 1.10–1.54 and 1.64, 1.23–2.20), and duration of diabetes ≥5 years (1.31, 1.11–1.55 and 2.39, 1.74–3.28). Metabolic syndrome was associated with macroalbuminuria (OR 1.36, 95%CI 1.01–1.84).

Conclusion

The high prevalence of microabuminuria and suboptimal glycemic control for the diabetic patients were found to highlight the need to improve in control of glycemia and metabolic risk factors.

Introduction

The epidemic of type 2 diabetes is one of the major public health concerns worldwide due to its high prevalence and its serious complications. Diabetes currently affects approximately 170 million people throughout the world [1] and 3 million people in Thailand [2]. Diabetes is a major cause of chronic kidney disease and end stage renal diseases. Albuminuria is a well-known predictor of renal disease in patients with diabetes [3], [4]. The American Diabetes Association recommends screening for microalbuminuria in all type 2 diabetic patients annually [5]. Identification of those patients with microalbuminuria would enable an appropriate and timely management for the patients. Previous studies have shown a high prevalence of microalbuminuria (39.8%) among Asian patients with diabetes [6], including in Thai patients (43.3%) [7]. However, the study used only screening test for microalbuminuria and the sample size of Thai patients was relatively small.

Studies have consistently shown the association of metabolic syndrome and some of its components including hypertension, hyperglycemia and obesity with an increased risk of microalbuminuria and chronic kidney disease in diabetes patients [8], [9], [10], [11], [12]. However, the association between albuminuria and dyslipidemia especially triglyceride were less consistent [11], [12], [13], [14], [15], [16], [17]. The present study was aimed to re-evaluate the prevalence of microalbuminuria and its association with metabolic risk factors in patients with diabetes of primary care clinics in a nationwide survey of diabetes management in Thailand.

Section snippets

Methods

We conducted a baseline survey of diabetes management in primary care level in 8 provinces including 8 units in general hospitals, 9 units in community hospitals, and 53 units in health care centers. In general, diabetes patients were initially diagnosed and treated at a community hospital, and/or general hospital. After the initial treatment, patients who reside in rural areas and are on oral antiglycemic medication are usually referred to follow up at the health care centers. For those who

Study population

The study involved a multi-center cross-sectional study. The survey team contacted a number of general hospitals, community hospitals and health care centers and invited them to participate in the study. Eligible subjects were type 2 diabetic patients who attended the outpatient care of the participating centers irrespective of age, duration of diabetes, and treatment. In each center, diabetic patients were randomly sampled from the diabetes patients who visited the primary care clinics during

Data collection

Data related to medical history were reviewed from the medical records of each selected patient. Clinical information of the last visit within 3 months was abstracted by the participating physicians and reported. Prior to the study, physicians and nurses of the participating hospitals and health care centers were trained for data collection methods and anthropometric measurement. The anthropometric measurements including weight, height, and waist circumference were obtained from the last visit.

Definition

Type 2 diabetes is defined as fasting plasma glucose of ≥7 mmol/L or use of diabetes medication or previously diagnosed diabetes. Hypertension is defined according to the WHO guidelines as systolic blood pressure (SBP)  140 mm Hg and/or diastolic blood pressure (DBP)  90 mm Hg, and/or use of antihypertensive medication. Low high density-lipoprotein cholesterol (low HDL-C) is defined as HDL-C < 1.03 mmol/L for men and < 1.29 mmol/L for women. Elevated low-density lipoprotein cholesterol (LDL-C) is defined

Statistical analysis

Patient characteristics and outcomes as categorical variables were compared using Chi-squared test, and those for continuous variables were compared using F-test for normally distributed data and Mann–Whitney U-test for non-normal. The comparison of patients’ characteristics were done among microalbuminuria, macroalbuminuria and normoalbuminuria and among different clinical settings. Variables that were significantly associated with outcome of normoalbuminuria, microabuminuria and

Results

Overall, a total of 4162 patients with diabetes were enrolled in the study, of these 566 were recruited in general hospitals, 1142 in community hospitals and 2454 in primary care units. Table 1 shows the patients’ characteristics according to the treatment setting. In general, the characteristics of the patients in 3 settings were relatively similar in age, duration of diabetes (years), BMI, waist circumference and HbA1c level. Albuminuria was slightly higher in patients from general hospitals

Discussion

This study supports the evidence of high prevalence of microalbuminuria (39.12%) and macroalbiuminuria (7.83%) among patients with diabetes in primary care settings in Thailand. We found an association of albuminuria with poor glycemic control (as measured by HbA1c), elevated triglyceride, elevated LDL-C, hypertension and metabolic syndrome. Over half of the patients had suboptimal glycemic control at a target level of HbA1c at 7% and were found in both normoalbuminria and albuminurian

Conflict of interest

The authors declare that they have no conflict of interest.

Acknowledgements

The authors would like to thank all the participating hospitals and health care centers who participate in this study. We thank Professor Dr. Amnuay Thithapandha for his kindness in helping edit the manuscript.

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