Dash Suresh Chandra, Agarwal Sanjay Kumar, Panigrahi Ansuman, Mishra Jayanti, Dash Debadutta
Emeritus Professor in Medicine (Nephrology), Kalinga Institute of Medical Sciences, KIIT University, Bhubaneswar, Orissa.
Professor and Head, Department of Nephrology, All India Institute of Medical Sciences, New Delhi.
J Assoc Physicians India. 2018 Mar;66(3):30-3.
The study was designed to find out frequency of (i) Diabetes mellitus (DM) as a cause Chronic Kidney Disease (CKD), (ii) Association between diabetic-CKD (diabetic patients who subsequently developed CKD as complication), hypertension (HT) and obesity. Further assessment was made to (iii) Identify percentage of diabetics attending medical and nephrology OPD had prior testing for proteinuria and or creatinine.
After ethical consideration this prospective observational study was conducted on consecutive 6175 patients who gave consent to participate in two major referral hospitals one in Delhi and other in Bhubaneswar (BBSR). Primary hypertension was defined as blood pressure of ≥140/90 mmHg detected before onset of DM or detected together in the absence of CKD (elevated serum creatinine S Cr ≥1.7 mg/dL and or proteinuria > 0.3g/24H). Upper limit of serum creatinine was kept at 1.7 mg for this study. Mean value of three estimations on different days was recorded. Detail clinical history of DM and HT was taken. Body Mass Index (BMI), ocular fundi examination, urine analysis, serum creatinine, lipid profile, blood glucose, HbA1C tests were conducted in all patients. They were regularly followed up in renal clinic at about 2 month interval for repeat investigations. Blood pressure in nondiabetic-CKD patients was recorded for comparison. Further, consecutive diabetic patients attending general medicine OPD for first time were examined, their previous investigations were carefully scrutinized and recorded. Urine for albuminuria and serum creatinine were tested every month over a period of one year.
In Delhi diabetic-CKD was observed in 68.4% and the same was 56.2% in BBSR giving a combined figure of 62.3 percent. On close analysis of past record primary hypertension was observed in 75.4% who subsequently developed diabetes and CKD. Frequency of association between diabetic-CKD and HT were 88.2% and 69.3% in two cities respectively, combined frequency being 78.7 percent. Association of diabetic-CKD and obesity was 55.1 % and 55.9% in two cities respectively with combined frequency of 55.5 percent. In contrast obesity in non-diabetic-CKD patients in Delhi and BBSR was found in 43.1% and 18.5% respectively, combined frequency being 30.8%. Fifty four percent of diabetic patients who attended medical OPD for the first time were found to have proteinuria and elevated serum creatinine. However, they were not earlier tested for those parameters. Hence, they were unaware of CKD.
Diabetes was found to be a bigger cause (62.3%) of CKD than what has been reported thus far in India. At presentation association of diabetic-CKD with HT was recorded higher (78.7%) in India. Hence use of the syndrome "DHKD", (complex of diabetes, hypertension and kidney disease) is justifiable. Our study shows 54.4% of diabetic patients attending medicine OPD were uninvestigated by either physician or GP for CKD because urine albumin and serum creatinine tests were lacking. Thus, progression to CKD in many patients went unnoticed. Syndromic diagnosis of "DHKD" therefore in our view is important to create general awareness for early detection and effective treatment of diabetic nephropathy.
本研究旨在查明（i）糖尿病（DM）作为慢性肾脏病（CKD）病因的发生率，（ii）糖尿病合并慢性肾脏病（随后发生慢性肾脏病并发症的糖尿病患者）、高血压（HT）和肥胖之间的关联。进一步评估（iii）确定在医学门诊和肾病门诊就诊的糖尿病患者中先前进行蛋白尿和/或肌酐检测的百分比。
经伦理审查后，对连续6175例同意参与研究的患者进行了这项前瞻性观察性研究，这些患者来自德里的一家和布巴内斯瓦尔（BBSR）的另一家两家主要转诊医院。原发性高血压定义为在糖尿病发病前检测到的血压≥140/90 mmHg，或在无慢性肾脏病（血清肌酐升高，S Cr≥1.7 mg/dL和/或蛋白尿>0.3g/24H）的情况下同时检测到的血压。本研究中血清肌酐的上限设定为1.7 mg。记录不同日期三次测量的平均值。采集糖尿病和高血压的详细临床病史。对所有患者进行体重指数（BMI）、眼底检查、尿液分析、血清肌酐、血脂谱、血糖、糖化血红蛋白（HbA1C）检测。他们每隔约2个月在肾脏门诊定期随访以进行重复检查。记录非糖尿病慢性肾脏病患者的血压以作比较。此外，对首次到普通内科门诊就诊的连续糖尿病患者进行检查，仔细审查并记录他们之前的检查结果。在一年的时间里，每月检测尿液中的蛋白尿和血清肌酐。
在德里，糖尿病合并慢性肾脏病的发生率为68.4%，在布巴内斯瓦尔为56.2%，综合发生率为62.3%。对既往记录进行仔细分析发现，在随后发生糖尿病和慢性肾脏病的患者中，原发性高血压的发生率为75.4%。糖尿病合并慢性肾脏病与高血压的关联发生率在两个城市分别为88.2%和69.3%，综合发生率为78.7%。糖尿病合并慢性肾脏病与肥胖的关联在两个城市分别为55.1%和55.9%，综合发生率为55.5%。相比之下，德里和布巴内斯瓦尔非糖尿病慢性肾脏病患者的肥胖发生率分别为43.1%和18.5%，综合发生率为30.8%。首次到医学门诊就诊的糖尿病患者中有54%被发现有蛋白尿和血清肌酐升高。然而，他们之前并未对这些指标进行检测。因此，他们并不知道自己患有慢性肾脏病。
在印度，糖尿病被发现是慢性肾脏病的一个比迄今报道更大的病因（62.3%）。在印度，糖尿病合并慢性肾脏病与高血压的关联发生率在就诊时更高（78.7%）。因此，使用“糖尿病高血压肾病综合征（DHKD）”这一综合征是合理的。我们的研究表明，54.4%到医学门诊就诊的糖尿病患者未被内科医生或全科医生检查过是否患有慢性肾脏病，因为缺乏尿白蛋白和血清肌酐检测。因此，许多患者慢性肾脏病的进展未被注意到。因此，我们认为“糖尿病高血压肾病综合征（DHKD）”的综合征诊断对于提高公众对糖尿病肾病早期检测和有效治疗的认识很重要。
