The influence of diabetes on microalbunimuria

Younes S and Shbani A

Published on: 2024-03-13

Abstract

Diabetes is currently the leading cause of end-stage renal disease (ESRD) in both the United States and Europe. The prevalence of type 2 diabetes is increasing, leading to a longer life expectancy for individuals with diabetes. Consequently, there has been a rise in the number of patients with diabetic ESRD seeking treatment in ESRD programs that previously denied them. This trend has contributed to the overall increase in ESRD cases. Nephropathy, a condition affecting 20–30% of individuals with type 1 or type 2 diabetes, is a significant risk factor for developing end-stage renal disease. However, it is important to note that only a smaller proportion of individuals with type 2 diabetes progress to end-stage renal disease. Nonetheless, due to the higher prevalence of type 2 diabetes, these patients constitute more than half of all diabetic patients initiating dialysis. Recent studies have demonstrated the effectiveness of various therapies in managing diabetic ESRD.

Keywords

Diabetes; ESRD

Introduction

End-stage renal disease (ESRD) is now primarily caused by diabetes in both the US and Europe. This can be attributed to the increasing prevalence of diabetes, especially type 2, the longer lifespan of individuals with diabetes, and the inclusion of diabetic ESRD patients in ESRD treatment programs that previously excluded them [1–3]. Nephropathy, a condition affecting the kidneys, is present in 20–30% of individuals with type 1 or type 2 diabetes. However, only a smaller percentage of individuals with type 2 diabetes progress to ESRD [4,5]. Nonetheless, due to the higher prevalence of type 2 diabetes, these patients constitute more than half of all diabetic patients who require dialysis. Recent studies have shown that various therapies can effectively slow down the development and progression of diabetic nephropathy. However, these interventions are most successful when initiated promptly upon the manifestation of the problem [6,7]. India, the second-most populous country globally, has been significantly affected by the global diabetes epidemic [8].

Methods and Materials

We conducted a review by searching the Google Scholar, PubMed, and Directory Open Access Journal databases for relevant information using keywords such as diabetes, diabetes disorders, microalbunimuria, ESRD, insulin, albumin, insulin receptors, and type 2 diabetes to identify primary comparative studies on the effect of microalbunimuria on diabetes. The quality and strength levels of the results were considered, and when available, meta-analyses and systematic reviews, large epidemiological studies, and randomized control trials represented the main source of data.

Results

Prevalence of Diabetes

According to the International Diabetes Federation, nearly half of all individuals with diabetes reside in China (98.4 million), India (65.1 million), and the United States (2013). Diabetes is a complex disease in India, where a combination of genetic and environmental factors contribute to obesity, which is linked to improving living standards, urban migration, and lifestyle changes. Although obesity is a significant risk factor for diabetes, limited research has been conducted on this risk factor in India [9,10]. India has higher incidences of diabetes compared to Western countries, despite having lower rates of overweight and obesity. This suggests that diabetes may develop in Indians with a lower body mass index (BMI) compared to Europeans [11].

Poor Glucose Control and Diabetes

The microvascular and macrovascular changes associated with diabetes are a result of poor glycemic control, as observed in the diabetic population of India. These changes can increase the risk of complications such as diabetic myonecrosis and muscular infarction [12]. Although HbA1c is the internationally recognized standard test for identifying uncontrolled diabetes, it is not widely accessible in India. Additionally, there is a lack of motivation to initiate insulin therapy among both healthcare professionals and patients in India, unlike in European countries [13,14]. The most common concerns related to insulin use include weight gain, hypoglycemic events, and fear of injections. Early detection and screening for prediabetes, especially in pregnant women, children, and individuals with a BMI of 25, can lead to improved overall health outcomes [15]. Continuing medical education programs for primary care physicians can help overcome the resistance to initiating treatment and promote adherence to diabetes management programs. These programs play a significant role in achieving target glycemic levels and preventing complications. Early initiation of insulin therapy, appropriate dosages of oral hypoglycemic agents, and lifestyle modifications can also have long-term benefits in managing the disease [16,17]. By addressing these concerns and implementing early detection strategies, society can achieve better health outcomes [18]. The provision of continuing medical education programs for primary care providers can help overcome resistance to initiating treatment and promote adherence to diabetes management programs, ultimately leading to improved glycemic control and prevention of complications [19,20]. Early initiation of insulin therapy, optimal dosages of oral hypoglycemic agents, and appropriate lifestyle modifications all contribute to effective disease management in the long run [21].

Figure 1: ESRD Disorders.

Figure 2: Microalbunimuria.

Microalbuminuria and Diabetics

Microalbuminuria can be identified by measuring elevated amounts of albumin in both spot samples (30–300 mg/L) and 24-hour urine samples (between 30-300 mg/24 hours) [22]. To ensure accuracy, these measurements should be taken at least twice, ideally three times, over a period of two to three months [23]. On the other hand, macroalbuminuria, also known as "albuminuria," refers to albumin levels that exceed the upper limit. In some cases, the upper limit value is denoted as one less than the actual value, such as 299 instead of 300, to indicate macroalbuminuria [24,25].

When collecting urine samples for albumin-to-creatinine ratio (ACR) testing to diagnose microalbuminuria, caution must be exercised [26]. It is recommended to collect the first urine sample in the morning. Additionally, individuals should avoid vigorous exercise for at least 24 hours prior to the test [27-29]. If the initial result is positive, the microbial albumin urine test should be repeated after three to six months [26,30,31].

It is important to note that individuals with excessive or inadequate muscle mass may perform poorly on the test. This is due to changes in the muscle's creatinine levels [32,33]. Normal albumin excretion is less than 30 mg/day (20 mcg/min), while persistent albumin excretion between 30 and 300 mg/day (20 to 200 mcg/min) is now referred to as moderately increased albuminuria. In diabetic patients, particularly those with type 1 diabetes, this may indicate early diabetic nephropathy, unless there is another underlying renal disease [34-37].

Role of Microalbuminuria

Excretion rates exceeding 300 mg/day (200 mcg/min) are considered severe albuminuria, which is the new terminology for what was previously known as macroalbuminuria. It is also referred to as overt proteinuria, clinical renal disease, or dipstick-positive proteinuria [38]. The risk of developing overt diabetic nephropathy is closely correlated with albumin excretion rates at all levels, even though the cut-offs for moderately and significantly elevated albuminuria help assess the risk of nephropathy progression.

The presence of microalbuminuria can be stabilized or reversed through appropriate interventions. It has been observed that maintaining normal blood glucose levels can prevent the progression from normal to microalbuminuria [39,40]. Once clinical proteinuria appears (dipstick positive, >500 mg/L), renal impairment is likely to worsen. It is important to note that proteinuria refers to the total amount of proteins in the urine, while albuminuria specifically refers to the amount of albumin in the urine. A level of albuminuria of 300 mg/L is approximately equivalent to a level of proteinuria of 500 mg/L [41]. Hypertension can further accelerate the decline in renal function. Given that ischaemic tissue damage is a major contributor to late complications of diabetes such as retinopathy, neuropathy, heart disease, and peripheral arterial disease, treatment with human recombinant erythropoietin may be beneficial. However, it is worth mentioning that there is currently insufficient evidence to fully support this hypothesis [22,42,43].

The risk of developing diabetic eye disease, heart disease, or a stroke is heightened in individuals with anemia, as indicated by a study. Patients who have both diabetes and anemia are more likely to experience premature death compared to those with diabetes alone [44]. Fortunately, anemia can be treated, and there are benefits to be gained, including increased energy levels, activity levels, and overall quality of life. Treating anemia not only reduces morbidity and mortality rates but also improves energy, vitality, and overall well-being. Studies have shown that treating anemia may delay the onset of various complications associated with diabetes, such as kidney, eye, and nerve damage. The specific course of treatment will depend on the underlying cause of the anemia [45]. In some cases, it may be recommended to take vitamin and iron supplements. For anemia related to kidney disease, the red blood cell distribution width (RDW) may be measured to assess the variability in the size of circulating red blood cells, which can be obtained from standard automated complete blood counts. Research has reported that red blood cell distribution width (RDW) is a risk marker for cardiovascular disease (CVD) morbidity and mortality in various study populations [46].

International Journal of Endocrinology and Diabetes