Prevalence of Diabetic Nephropathy Among Diabetic Patients in Al_Wahda Hospitals, Yemen

Introduction

Diabetes mellitus (DM), commonly known as diabetes refers to a group of chronic systemic non-communicable diseases characterized by abnormally high blood glucose levels termed as hyperglycemia caused due to the resistance and lack of insulin production, or uncontrolled glucagon secretion [1-3]. Being one of the top 10 causes of global mortality, diabetes has turned into a global epidemic and a massive threat to public health with an estimated number of 451 million adult patients worldwide in 2017 which may rise to 693 million by 2045 if no worthwhile preventive actions are taken immediately [4,5]. According to National Diabetes Statistics Report, 2022, more than 37 million United States adults are currently living with diabetes and 1 in every 5 of them are unaware of having it [6]. Diabetes is the eighth leading cause of mortality and the leading cause of end-stage renal disease (ESRD) and renal failure, lower-limb amputations, and adult blindness in the United States of America (USA) [7].

Type 1 and type 2 are the 2 most common types of DM although some other categories including maturity-onset diabetes of the young, gestational diabetes mellitus, neonatal diabetes, and secondary diabetes resulting from endocrine disease or hereditary diseases or medications such as corticosteroids, thiazide diuretics, beta-blockers, antipsychotics, statins, etc [8-10]. Type 1 DM, also known as juvenile diabetes or insulin-dependent diabetes mellitus is caused due to insulin deficiency resulting from the death of pancreatic beta-cells and type 2 DM or non-insulin-dependent diabetes mellitus, which is far more prevalent, is largely the result of gradually poor glucose regulation caused by a combination of malfunctioning pancreatic beta cells and insulin resistance [11,12]. Type 1 DM is expected to afflict children and adolescents, but type 2 DM is thought to affect middle-aged and older individuals who have chronic hyperglycemia as a result of poor lifestyle and nutritional factors [13,14]. Persistent hyperglycemia due to type 1 and type 2 DM affects the vascular system and induces diabetic vascular complications including microvascular complications such as diabetic nephropathy, neuropathy, and retinopathy as well as macrovascular complications such as ischemic heart disease, coronary artery disease, peripheral vascular disease, and cerebrovascular disease leading to organ damage and failure in approximately one third to one-half of people living with diabetes [15-17].

Nephropathy is a serious consequence of DM that has a substantial impact on communities worldwide [18]. It is a disorder characterized by chronic albuminuria, decline in glomerular filtration rate, and elevated arterial blood pressure leading to progressive decline of kidney function and increased cardiovascular morbidity and mortality among 20% to 40% of people with type 1 and type 2 DM [19-21]. The occurrence of nephropathy has increased along with the prevalence of diabetes [22]. The association between hemodynamic and metabolic pathways, that are commonly disrupted in the setting of diabetes, are likely to have a role in the initiation and progression of nephropathy [23]. Nephropathy is a significant microvascular consequence of diabetes along with a high prevalence, mortality, and treatment expense, yet it is poorly understood and treated. The primary cause of the problem is a lack of early detection and effective treatment therapy and strategy [24]. Also, the pathophysiological development of nephropathy is significantly influenced by poor glycemic management, hyperlipidemia, smoking, oxidative stress, accumulation of advanced glycation end products, and environmental, genetic, and epigenetic variables [25]. Effective measures to reduce the risks of nephropathy or to slow down the progression include proper monitoring and control of blood glucose levels and hypertension either by doing physical exercise and maintaining a healthy diet and lifestyle or by taking blood glucose-lowering agents for glycemic control and antihypertensive drugs [26].

Nephropathy among diabetic patients is the leading cause of dialysis in many nations, including, Western regions, Asians, and Caucasians [17]. Diabetic complications, particularly renal disease, significantly raise the chance of severe illness and death among diabetic patients. The number of cases of nephropathy in diabetic patients continues to rise significantly along with its associated mortality and cardiovascular consequences [27]. Diabetes-associated nephropathy, the primary cause of chronic kidney disease has been found to be increased in overall Europe and countries of the other continents such as Japan and Nigeria as well [28,29]. Nephropathy-associated end-stage renal failure poses a significant health problem for the people living with diabetes besides their families and healthcare systems in both high and middle-income nations due to the uprising prevalence of diabetes worldwide [23].

Objective

The aim of this study is to find out the prevalence of diabetic nephropathy among diabetic patient in AL_WAHDA hospitals.

i. To determine the prevalence of diabetic nephropathy among diabetes.

ii. To identify demographic and clinical factors.associated with an increased risk of diabetic nephropathy.

Materials and Methods

Study Area and Setting

This study will be conducted at AL_WAHDA hospitals Dhamar Governorate, Yemen.

Study Design

This is retrospective, cross-sectional hospital-based study to findings diabetic patient with diabetic nephropathy in AL_WAHDA hospitals Dhamar Governorate, Yemen.

Study Population

This study will target the patients according to:

• Included Criteria: patient with a confirmed diagnosis of type 1 or type 2 diabetes.

• Excluded Criteria: patient with incomplete medical records or those with acute kidney injury.

Data Collection

The data will be collected using medical files for diabetic patient in Al_WAHDA hospitals

• Demographic Data: age, sex, ethnicity, special habitus and duration

• Clinical data: blood pressure, HbA1c, albumin /creatinine ratio, urine dipstick test and lipid profiles.

Statistical Analysis

Statistical package for social science (spss) will be used for data entry and analysis on. Data will be represented as finding on .Also on descriptive statistic in frequency and percentage for nominal variable and mean SD for continuous variable.

Sample Size

Based on preliminary data and the desired confidence intervals, calculate a sample size needed to detect the expected prevalence rate.

Ethical Consideration

• Obtain informed consent from all participants*.

• Ensure confidentiality and anonymity of patient*

Result

General (socio-demographic) characteristics of diabetic Patient's participation in this study (n=110)

As shown in Table 1, the most participation age group with diabetic nephropathy risk was adult patients, especially those aged 41-50 and >60 years, constituting 39.1% and 32.7% of the sample, respectively.

Table 1: Distribution of Patients by Age Group and Albumin-to-Creatinine Ratio (ACR) Category (n=110)

General (socio-demographic) characteristics of diabetic Patient's participation in this study (n=110)

According to Table 2, males (50.9%) and females (49.1%) were almost equally represented. Microalbuminuria was the predominant abnormality in both genders (30.9% in males, 31.8% in females). However, macroalbuminuria was slightly higher in males compared to females (5.5%). This indicates a marginally higher risk of advanced (11.8%) nephropathy among male patients.

                          Table 2: Distribution of Patients by Gender and Albumin-to-Creatinine Ratio (ACR) Category

Table 3: Association between Duration of Diabetes and ACR of diabetic patients’ participation in this study (n=110)

As presented in Table 3, longer duration of diabetes was associated with higher prevalence of albuminuria. Patients with >10years of diabetes showed the highest rates of macroalbuminuria (9.1%), compared to 0% among those with <1year of disease Microalbuminuria was most common in patients with 1-5years (25.5%) and >10years These findings confirm that diabetic kidney disease risk increases progressively (13.6%) with disease duration

                     Table 3: Association between Duration of Diabetes and Albumin-to-Creatinine Ratio (ACR)

Category In Table 4 Association between Type of Diabetes and ACR of diabetic Patient's participation in this study (n=110)

According to Table 4, Type II diabetes accounted for the majority of cases (92.7%). Both microalbuminuria (59.1%) and macroalbuminuria (14.5%) were more prevalent in TypeII compared to Type I (3.6% and 2.7%, respectively).This indicates that Type II diabetes patient's are at significantly higher risk of nephropathy than Type I patients.

                               Table 4: Association between Type of Diabetes and Albumin-to-Creatinine Ratio (ACR) Category

Table 5: Association between Treatment Regimen and ACR of diabetic patient's participation in this study (n=110)

As shown in Table 5, most patients were managed with or almedication plus diet/lifestyle modifications (76.4%). Within this group, microalbuminuria was most common (45.5%) and macroalbuminuria was also substantial(13.6%). Patient's on insulin only showed a relatively high prevalence of macroalbuminuria (1.8%), despite their smaller proportion. This suggests that patients requiring insulin may represent those with more advanced disease and thus higher nephropathy risk.

                  Table 5: Association between Treatment Regimen and Albumin-to-Creatinine Ratio (ACR) Category

Table 6: Association between Patient-Reported Symptoms and ACR of diabetic patients’ participation in this study (n=110)

According to Table 6, common symptoms included swelling of feet/ankles (14.5% nocturia (23.6%), foamy urine (4.5%), fatigue (50.9%), and loss of appetite (30%). Fatigue, and nocturia (15.5%) were especially associated with microalbuminuria. Notably (31.8%) of patients reported no symptoms, high lighting the silent progression of diabetic nephropathy (30%) and the importance of routine screening.

Table 6 association between patient-rpeported symptoms and albumin-to-creatine ratio ratio (ACR) Category.

Table 6: Association between Clinical Diagnosis of Nephropathy and ACR of diabetic patient's participation in this study (n=110)

As presented in Table 6 (second), only 9.1% of patients had a formal clinical diagnosis of nephropathy, despite higher proportions showing albuminuria (62.7%with microalbuminuria and 17.3% with macroalbuminuria). This indicates a significant gap between clinical recognition and early biochemical detection of nephropathy.

Table 6 Association between Clinical Diagnosis of Nephropathy and Albumin-to-Creatinine Ratio (ACR) Category.

Table 6 (second): Association between Time since Last Healthcare Visit and ACR of diabetic patient's participation in this study (n=110)

According to Table 7, patients with more recent healthcare visits (<3months) were more likely to have normal ACR (16.4%) compared to those with >1year since their last visit Conversely, macroalbuminuria was more prevalent in those who delayed. (0.9%) healthcare visits >1year (7.3%). This underscores the importance of regular medical follow-up in preventing progression of diabetic kidney disease.

Table 7: Association between Time since Last Healthcare Visit and Albumin-to-Creatinine Ratio (ACR) Category

Table 8: Association between Hypertension and ACR of diabetic patient's participation in this study (n=110).

As shown in Table 8, hypertension was present in 30.9% of participants. Among these macroalbuminuria was observed in 7.3% compared to 10% in non-hypertensives. However, microalbuminuria was higher in hypertensives (20%) compared to non hypertensives (42.7%). This suggests that hypertension is an important comorbidity contributing to early nephropathy.

Table 8: Association between Hypertension and Albumin-to-Creatinine Ratio (ACR) Category

Table 9: Association between Urine Dipstick Test Results and ACR of diabetic patient's participation in this study (n=110).

According to Table 9, dipstick testing showed limited sensitivity: 46.4%were negative or trace, yet 28 patients in this group had microalbuminuria on ACR testing. Only 3.6% of patients with macroalbuminuria were identified as>1+proteinuria on dipstick. This demonstrates the inadequacy of dipstick urinalysis alone for early nephropathy detection and highlights the superiority of quantitative ACR testing.

Table 9: Association between Urine Dipstick Test Results and Albumin-to-Creatinine Ratio (ACR) Category

Table 10: Association between Glycemic Control (HbA1c) and ACR of diabetic patient's participation in this study (n=110).

As presented in Table4.10, poor glycemic control (HbA1c>6.5%) was found in 71.8% of patients, and strongly associated with both microalbuminuria (44.5%) and macroalbuminuria (11.8%). In contrast, patients with prediabetes (5.7-6.4%) showed lower prevalence of albuminuria (6.4% microalbuminuria, 0.9 macroalbuminuria). This confirms hyperglycemia as a major risk factor for diabetic nephropathy.

Table 10: Association between Glycemic Control (HbA1c) and Albumin-to-Creatinine Ratio (ACR) Category

Discussion

This study provides a critical analysis of the prevalence and risk factors for Diabetic Nephropathy (DN) in cohort of 110 diabetic patient, using the Albumin-to-Creatinine Ratio (ACR)as an early biomarker. The findings reveal patterns that are largely consistent with the global body of evidence, while also uncovering significant gaps in local clinical practice that warrant urgent attention.

Age, Diabetes Type, and Disease Burden

The study revealed that the highest proportion of participants were in the 41-50 and over 60 age groups, which aligns with the cumulative nature of diabetic complications. Type II diabetes accounted for 92.7% of the sample and was associated with a higher prevalence of micro- and macroalbuminuria. These findings are consistent with the International Diabetes Federation (IDF) data indicating that Type II diabetes is the primary driver of DN worldwide, due to its high prevalence and prolonged undiagnosed hyperglycemia [62,63].

Disease Duration and Glycemic Control

As expected, there was a strong correlation between diabetes duration and the risk of nephropathy. Patients with a disease duration exceeding 10 years had the highest rate of macroalbuminuria (9.1%). This confirms the natural progression from normoalbuminuria to microalbuminuria and then overt proteinuria, as documented in the UKPDS study. Moreover, poor glycemic control (HbA1c ≥ 6.5%) was a major risk factor, present in 71.8% of patients and strongly associated with albuminuria. These findings support the conclusions of the DCCT/EDIC studies, which demonstrated that intensive glycemic control significantly reduces the risk of developing nephropathy [64,65].

Hypertension as a Comorbid Factor

Although the prevalence of hypertension (30.9%) in this cohort was lower than in other studies, its presence was associated with a higher prevalence of microalbuminuria. These results emphasize the synergistic role of hypertension and hyperglycemia in causing kidney injury. Both contribute to intraglomerular hypertension and fibrosis, accelerating renal function decline. This is consistent with the findings of the RENAAL study, which demonstrated that intensive blood pressure control is as crucial as glycemic control in slowing DN progression [66].

Diagnostic Gap and Superiority of Quantitative Screening

A concerning finding was the large disparity between the biochemical prevalence of albuminuria (80% of patients had elevated ACR) and the formal clinical diagnosis of nephropathy (9.1%). This indicates a significant shortfall in routine screening and early diagnosis. These results reinforce international guidelines from ADA and KDIGO, emphasizing the use of quantitative ACR as a primary and effective screening tool rather than urine dipstick testing [67,68].

Silent Nature of Disease and Importance of Follow-Up

The results underscore the asymptomatic progression of early-stage DN, with 30% of patients reporting no symptoms despite abnormal ACR levels. This aligns with the known clinical course, where symptoms typically appear only in advanced stages. Furthermore, delayed healthcare visits (>1 year since last check-up) were associated with higher rates of macroalbuminuria, highlighting the critical importance of regular, protocol-driven follow-up regardless of symptom presence [65,69].

Treatment Patterns and Disease Severity

The association between insulin therapy (alone or combined) and more advanced stages of nephropathy likely reflects that these patients represent a subgroup with longer disease duration, beta-cell failure, or treatment-resistant hyperglycemia. This aligns with the understanding that insulin requirement in Type II diabetes often indicates advanced disease, which carries a higher risk of microvascular complications, including nephropathy.

Conclusion

This study reveals a high prevalence of diabetic nephropathy among diabetic patients attending Al-Wahda Hospitals in Dhamar, Yemen, with the majority of cases identified as microalbuminemia. Diabetic nephropathy was strongly associated with longer diabetes duration, poor glycemic control and hypertension. A significant diagnostic gap was observed, as most patients with biochemical evidence of nephropathy lacked a formal clinical diagnosis. Urine dipstick testing showed limited sensitivity for early detection compared with quantitative Albumin-to-creatinine Ratio (ACR). These findings indicate that diabetic nephropathy is common, largely and insufficiently screening in this sitting under-diagnosed.

Recommendations

Routine quantitative ACR screening should be integrated into standard diabetic care for early detection of nephropathy. Improved glycemic and blood pressure control, regular patient follow-up, and enhanced clinician awareness are essential to prevent disease progression. Further prospective studies are recommended to assess long-term renal outcomes and the impact of early intervention strategies.

References