Proteinuria Ratio and Related Factors in Type 2 DM Patients:

A Hospital-Based Study in Somalia

Abstract

Background: Diabetic nephropathy, a complication of diabetes mellitus, is marked by proteinuria, excess protein in the urine. Understanding these factors is crucial for early detection and intervention to prevent kidney damage in this population.

Objective: This study investigates the prevalence of proteinuria and associated factors among type 2 diabetes patients in Mogadishu, Somalia.

Methods: This retrospective cross-sectional design study was conducted at the Somali-Turkey Training and Research Hospital in Mogadishu, Somalia for the last six months. The study enrolled 529 diabetic patients who met the criteria. We measured the participants’ anthropometric measurements of height, weight, body mass index (BMI), and waist circumference, and some biochemical analyses like fasting glucose, glycosylated hemoglobin A1C (HbA1C), urinalysis, lipid profile, and renal function tests were also measured. Proteinuria rate and related laboratory and demographic parameters were analyzed.

Results: There were 177 (33.5%) males and 352 (66.5%) females. Three-quarters of the participants, or 176, were in the 45-54 age range. Twenty percent of people had proteinuria overall. Multivariable analysis showed that waist (β =0.893, 95% CI: 0.818-0.974), p=0.010), serum creatinine (β =0.064, 95% CI: 0.017-0.232, p=0.001), urea (β =1.025, 95% CI: 1.002-1.048), p=0.030), and sodium (β =1.119, 95% CI: 0.921-1.361, p=0.013) levels to have association with proteinuria levels.

Conclusion: In our study, patients with type 2 diabetes had a high prevalence of proteinuria. In low-resource settings, screening with urinalysis is strongly recommended for all diabetic patients to guarantee appropriate care and stop the development of end-stage renal disease.

Keywords: Proteinuria, hyperglycemia, Somalia, nephropathy, CKD.

INTRODUCTION

Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both [1]. Diabetes is one of the world’s most common metabolic disorders, and its prevalence has been increasing in recent decades [2]. As per the World Health Organization (WHO) Diabetes Country Profile Somalia 2016, the prevalence of diabetes was 4.8% in the total population, with males 5.2% and females 4.5% [3]. On the other hand, The International Diabetic Federation’s Diabetic Atlas 2019 estimated the prevalence to be 4.1% [4].

In Somalia, as in many other Sub-Saharan African (SSA) countries, there is increasing urbanization and dietary change towards Western diets. These demographic and epidemiologic trends toward diet-related noncommunicable diseases (NCDs), such as diabetes, cardiovascular disease (CVD), osteoporosis, and certain malignancies, are accompanied by a nutrition transition [5]. Reduced physical activity, a stressful lifestyle, increased alcohol use, and cigarette use, according to the WHO, intensify the impacts of the dietary shift [6].

Microalbuminuria, which evolves into proteinuria, is one of the first clinically detectable abnormalities in diabetic nephropathy [7]. Proteinuria is a defining feature of diabetic nephropathy: microalbuminuria is the primary early predictor of diabetic glomerulopathy progression, and proteinuria can be seen as a measure of nephropathy severity and a promoter of nephropathy progression [8]. Diabetic nephropathy is the leading cause of End-Stage Renal Disease (ESRD) in many countries, accounting for around 20% of cases of chronic renal failure.

Diabetic kidney disease (DKD) is a serious and irreversible microvascular consequence characterized by persistent proteinuria, hypertension, and a steady loss of renal function. It contributes to a greater risk of illness and death caused by kidney failure and heart disease. Precise identification and measurement of proteinuria are crucial in the diagnosis and treatment of chronic renal illness [9].

The burden of kidney disease is increasing in Somalia. One study from Mogadishu by Sari et al. [10] reported that more than half of the patients admitted to the internal medicine clinic had acute or chronic kidney disease.

There is minimal data on the prevalence of diabetic nephropathy and diabetes in Somalia. Few studies have been done on Somali patients who migrated to foreign

countries, and few researches from a specific group of

diabetic people in Somalia [11, 12].

This study aimed to assess the prevalence of proteinuria in patients with type 2 diabetes in a single center, Mogadishu, Somalia, and identify associated factors.

SUBJECTS AND METHODS

This investigation employed a retrospective cross- sectional design. The study site was Mogadishu Somali- Turkey Training and Research Hospital, Somalia’s largest teaching hospital, located in the capital city Mogadishu. The timeframe for data collection spanned for six months and included all adult patients with type 2 diabetes who visited the clinic during that period.

Certain exclusion criteria were applied. These criteria encompassed patients with fever, elevated urine protein (proteinuria), urinary tract infections (UTIs), pregnancy, and confirmed or suspected kidney, liver, or other systemic diseases. Additionally, individuals not diagnosed with hypertension yet taking Renin- angiotensin system (RAS) blockers for prevention were excluded.

Following ethical approval from the hospital’s Institutional Review Board (IRB), a retrospective analysis was conducted using anonymized patient data retrieved from electronic medical records. Due to the retrospective nature, informed consent was waived.

Data collection encompassed sociodemographic details (age, sex, smoking status) and clinical information (comorbidities, medication history) retrieved from medical records of 529 diabetic patients meeting the inclusion criteria (Fig. 1). A diabetic nurse performed standardized anthropometric measurements of height, weight, body mass index (BMI), and waist circumference on an empty stomach during morning hours. Central obesity was defined as exceeding specific waist circumference thresholds (90 cm for men, 80 cm for women). Body mass index classification followed World Health Organization (WHO) guidelines, categorizing patients as overweight (BMI 25-30 kg/m2) or obese (BMI > 30 kg/m2). Medical examinations such as blood pressure were measured on the left arm at heart level during enrollment using a mercury sphygmomanometer with appropriate cuff sizes. Hypertension was defined according to European Society of Cardiology (ESC) guidelines (office systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg) or documented use of antihypertensive medication [13, 14].

Urinalysis was performed using an automated urine sediment analyzer (UriSed 3 PRO) interfaced with a urine strip reader (LABUMAT 2). Proteinuria was defined as daily urinary protein excretion exceeding 150 mg [15]. Statistical analysis utilized IBM SPSS Statistics software (version 20.0). The normality of continuous variables was assessed using the Kolmogorov-Smirnov test. Data were presented accordingly: normally distributed data

as mean ± standard deviation, non-normally distributed data as median (interquartile range). Categorical data were presented as frequencies and percentages. Group comparisons for continuous variables employed either the parametric t-test (normally distributed) or the non- parametric Mann-Whitney U-test. Univariate regression analysis identified potential proteinuria markers. Multivariable regression analysis was also performed. Binary logistic regression was run. P-value less than or equal to 0.05 was taken as statistically significant.

Afterward, important parameters were incorporated into a multivariable binary logistic regression model to investigate predictors of proteinuria. For each independent variable, odds ratios (OR) were computed along with their corresponding 95% confidence intervals (CI). The threshold for statistical significance was established at a two-tailed p-value below 0.05.

This work has been reported according to STROCSS criteria [16].

RESULTS

This study included 529 patients with type 2 diabetes mellitus who presented to the Department of Internal Medicine in Mogadishu Somali Turkey, Training and Research Hospital outpatient clinic.

Table 1: Sociodemographic characteristics of the patient.

Table 2: Basal characteristics of the patients with proteinuria and without proteinuria.

HDL-c, high density lipoprotein; LDL-C, low density lipoprotein; TC, total cholesterol; TG, triglycerides; HS-CRP, high-sensitivity C-reactive protein; OAD, oral anti-diabetes drug; BMI, body mass index; HbA1c, haemoglobin A1c

*p value <0.05 was considered significant

Of the 529 diabetic patients in this study, 352 (66.5%) were females and 177 (33.5%) were males. 176 (33.3%) of the participants were aged between 45 and 54. The mean age of proteinuric and non-proteinuric patients was 54.4 years and 51.3 years, respectively (Table 1).

Table 3: Univariate and multivariable analysis of predictors of proteinuria.

Of the 529 patients studied, 106 (20%) had proteinuria. We found no significant association between gender, smoking, hypertension, HbA1c, and proteinuria. We found there is a significant association  between age, BMI, and proteinuria (p value<0.02 and 0.03, respectively). The renal function test assessed as serum urea and creatinine were higher in people with proteinuria than those without proteinuria (p<0.001). The mean serum triglycerides were significantly higher in the proteinuria group than in the non-proteinuric group (p=0.001) (Table 2).

106 (20%) of the 529 patients that were examined had proteinuria. We could not discover any correlation between proteinuria, smoking, hypertension, or HbA1c and gender. Age (p=0.021) and BMI (p=0.003) were shown to be significantly different among those with and without proteinuria. People with proteinuria had higher serum urea and creatinine levels in the renal function test than people without proteinuria (p<0.001). Table 2 shows that there was a significant difference (p=0.001) in the mean blood triglycerides between the proteinuric and non-proteinuric groups.

Proteinuria levels were used as dependent variables in univariate and multivariable analyses for potential proteinuria associations (Table 3). A multivariable revealed Waist (β =0.893, 95% CI (0.818-0.974),

p =0.010), serum creatinine (β =0.064, 95% CI: 0.017-

0.232), p =0.001), urea (β =1.025, 95% CI: 1.002- 1.048),

p=0.030), and sodium (β =1.119, 95% CI: 0.921-1.361),

p=0.013) levels to had association with proteinuria

levels.

DISCUSSION

In many African nations, diabetes remains untreated for extended periods, and newly diagnosed diabetics commonly present established complications. In nations classed as high-income by the World Bank, the majority

HS-CRP, high-sensitivity C-reactive protein; OAD, oral anti -diabetes drug; HDL-High density lipoprotein; TG, triglycerides; BMI, body mass index

* p value <0.05 was considered significant, CI: Confidence interval, OR: Odds ratio

+nagelkareke R square =0.408, Omnibus tests of model coefficients =p<0.001

of diabetics are over 60. Still, in low- and middle- income countries, most diabetics are between 40 and 60 and of working age [2]. The mean age of diabetic patients in our current study was 54 years, and this number is comparable to that of low-income countries as per the International Diabetic Federation (IDF). Diabetic nephropathy occurs in 20-40% of patients with diabetes and is the single leading cause of End-Stage Kidney Disease (ESKD) in Western countries [17]. Diabetic kidney disease is characterized by excessive urinary albumin excretion and loss of kidney function. The prevalence and severity of diabetic nephropathy have consistently been higher in Blacks than in other races [18]. In sub-Saharan Africa, the prevalence of MA ranges from 10.7% in Tanzania to 58% in Nigeria [19- 21]. In this study, proteinuria was prevalent in 20% of the population.

Prior research has shown a wide range in the prevalence of microalbuminuria among diabetic patients, from 20% to 61% [22-24]. A study in Senegal by Djiby et al. [25] investigated the prevalence of microalbuminuria and related risk factors in a diabetic population. They found a prevalence rate of 27.14% among the 221 participants, similar to the results observed in the present study.

At univariate analysis, we observed a statistically significant correlation between proteinuria, urea, serum creatinine levels, sodium, and potassium levels.

In clinical practice, serum creatinine concentration is frequently used to indicate Glomerular Filtration Rate (GFR) and renal function [26]. Analysis of proteinuria shows early-stage renal illness, whereas GFR estimates its progression. Renal disease can be detected early if specific glomerular and tubular function markers are examined, according to Shemesh et al. [27], blood creatinine concentrations remained within the reference interval in a reasonable majority of patients with severely impaired GFR. Creatinine serves as an imperfect biomarker of glomerular filtration rate (GFR) due to its dependence on muscle mass. Consequently, fluctuations in muscle mass can lead to variations in the total creatinine pool independent of actual changes in GFR [26]. These findings highlight the limitations of serum creatinine as a marker of renal function, particularly in the early detection of diabetic nephropathy. Therefore, a cautious interpretation of creatinine levels is warranted. To enhance the assessment of renal function in diabetic patients, we recommend employing proteinuria or albuminuria alongside serum creatinine. This combined approach is particularly crucial for diabetic children and elderly individuals, as these populations often have lower muscle mass, potentially affecting serum creatinine concentrations and compromising its accuracy as a standalone marker.

Our findings indicate a strong connection between electrolyte levels and the presence of protein in urine (proteinuria). This aligns with previous research by

Kumari et al. [28], who explored the relationship between blood electrolyte levels and kidney function in diabetic patients. Their study notably showed that diabetics with elevated creatinine levels, a marker of impaired kidney function, had statistically significant decreases in blood sodium and increases in blood potassium compared to those with normal creatinine. These electrolyte imbalances are more likely to occur in the presence of high blood sugar, glucosuria, and hyponatremia. Scientific evidence suggests that electrolyte imbalances are associated with declining kidney function in diabetic patients.

Effective proteinuria management in diabetic patients requires an individualized approach. The primary goals involve achieving good glycemic control, potentially limiting dietary protein intake and smoking cessation. In cases where persistent proteinuria coincides with hypertension, blockade of the renin-angiotensin- aldosterone system (RAAS) may be warranted.

LIMITATIONS

This is a study in a single center and, therefore, not representative of Somalia at large, whereas it could be used as a baseline for further studies with large geographical areas. Since our study is based on the retrospective analysis of patients’ files from the health information system, we could not find the duration of diabetes in all our patients.

CONCLUSION

To summarize, the overall prevalence of proteinuria at our clinic in Mogadishu, Somalia was 20%. Those with proteinuria also showed some degree of renal impairment, illustrated by significantly higher serum creatinine levels than those without proteinuria. Considering the increasing incidence of type 2 diabetes in Somalia and the lack of proper primary health care in Somalia, we recommend raising awareness of chronic diseases, implementing proper and effective primary health care, and screening for Proteinuria or Microalbuminuria (MA) to reduce the future burden of diabetic renal disease.

ETHICS APPROVAL

Mogadishu Somali Turkiye Training and Research Hospital approved this study with an approval number of MSTH/6540. All procedures performed in studies involving human participants were following the ethical standards of the institutional and/ or national research committee and the Helsinki Declaration.

CONSENT FOR PUBLICATION

Informed consent was obtained from the participants of this study.

AVAILABILITY OF DATA

Data is available with the corresponding author upon request.

None.

FUNDING

CONFLICT OF INTEREST

The authors declare no conflict of interest.

AKNOWLEDGEMENTS

Declared none.

AUTHORS’ CONTRIBUTION

All the authors contributed equally to the publication of this article.

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