DIABETIC RETINOPATHY AMONG TYPE 2 DIABETIC PATIENTS PRESENTING WITH MICROALBUMINURIA

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1 ORIGINAL ARTICLE DIABETIC RETINOPATHY AMONG TYPE 2 DIABETIC PATIENTS PRESENTING WITH MICROALBUMINURIA Arshad Hussain 1, Iqbal Wahid 2, Danish Ali Khan 3 ABSTRACT INTRODUCTION: Diabetes mellitus is becoming a major contributor of morbidity and mortality in Pakistan. Diabetic retinopathy is one of the leading causes of blindness in the world that increases the chances of loosing eye sight about 25 times higher as compared to normal individuals. There are many precipitating factors of retinopathy such as duration and type of diabetes, hyperglycemia and microalbuminuria. OBJECTIVE: To determine the frequency of diabetic retinopathy among type 2 diabetic patients presenting with microalbuminuria. METHODOLOGY: This was descriptive cross sectional study carried out in Endocrinology department Northwest General Hospital Peshawar Pakistan. The Duration of study was one year from 12 July 2015 to 20 August A total of 186 patients fulfilling the inclusion criteria were selected through consecutive sampling. RESULTS: A total of 186 cases fulfilling the inclusion/exclusion criteria were enrolled in our study. Mean was ± SD 6.61 and % were male and 41.93% were female. Diabetic retinopathy was found that 53.76% while remaining 46.23% not having diabetic retinopathy. CONCLUSION: We concluded that there is a significantly high association between diabetic retinopathy and microalbuminuria and these patients may be offered in time diagnosis and management of diabetic retinopathy considering microalbuminuria as a marker. KEY WORDS: Frequency, Type 2 diabetes, diabetic retinopathy, microalbuminuria This article may be cited as: Hussain A, Wahid I, Khan DA. Diabetic retinopathy among type 2 diabetic patients presenting with microalbuminuria. NJMS. 2018; 3(1):29-34 INTRODUCTION Diabetes mellitus is a metabolic disorder of multiple etiologies characterized by chronic hyperglycemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action, or both. Diabetes mellitus is associated with micro vascular (i.e. retinal, renal, possibly neuropathic) and macro vascular (i.e. coronary, peripheral vascular) complications. 1 Diabetes is a leading cause of morbidity & mortality worldwide, and is sixth leading cause of death in United States accounting for more than 71,000 deaths a year. 1 Persistence of microalbuminuria in diabetic patients is a risk marker not only for kidney and cardiac disorders, but 1 Endocrinology Department Northwest General Hospital & Research Centre Peshawar Pakistan 2 Assistant Professor, Department of Community Medicine, Northwest School of Medicine, Peshawar, Pakistan 3 Assistant Director, Medical Education Department Northwest General Hospital & Research Centre Peshawar Pakistan Address for correspondence: Dr Arshad Hussain Assistant Professor Endocrinology Department Northwest General Hospital & Research Centre Peshawar Pakistan dr.arshad@nwgh.pk Date Received: October 04, 2017 Date Revised: November 27, 2017 Date Accepted: December 16, 2017 also for severe ocular morbidity. 2 Diabetic retinopathy is the most dreadful complication of all and is the leading cause of blindness worldwide. 1 The number of persons with diabetes worldwide is predicted to grow to 429 million by 2030, owing to the rising frequency of obesity, increasing life span, and improved detection of the disease. In India, an estimated 32 million persons had diabetes in 2000, and roughly 79 million will be affected by If the prevalence of complications remains unchanged, approximately 0.7 million Indians will have proliferative diabetic retinopathy and 1.8 million will have clinically significant macular edema that eventually, will lead to blindness. 4,5 These changes are caused by diabetes induced disorders like oxidative stress, dysregulation of NOS, AGE formation and NF-kB activation. 3 Among the multiple risk factors for diabetic retinopathy (DR), the duration of diabetes is probably the strongest predictor for the development and progression of retinopathy. Other well-known risk factors include glycemic control, hypertension, nephropathy and pregnancy. 4 Various studies have been done determining relationship between diabetic retinopathy and microalbuminuria in patients with type 2 diabetes mellitus. 4,6 Its relation with 29

2 retinopathy in type I diabetics is well established, however, in type 2 diabetes it s still not clear. A study done abroad shows that diabetic retinopathy is more common in patients with microalbuminuria. ± A study done in Pakistan shows frequency of retinopathy was higher in patients with microalbuminuria (45.4%) whereas in patients without microalbuminuria it was 24.3%. 1 Diabetic retinopathy is more common in patients with microalbuminuria. Based on the results of our study, patients will be offered in time diagnosis and management of diabetic retinopathy. Prophylaxis of diabetic retinopathy with strict glycemic control will reduce the incidence and progression of visual impairment, decrease the morbidity and improve the quality of life of patients with diabetes mellitus. METHODOLOGY This was descriptive cross sectional study carried out in Endocrinology department Northwest General Hospital Peshawar Pakistan. The Duration of study was one year from 12 July 2015 to 20 August A total of 186 patients fulfilling the inclusion criteria were selected through consecutive sampling. DATA COLLECTION PROCEDURE This study was carried out at Northwest General Hospital Peshawar Pakistan Peshawar, which is a tertiary care centre and all patients fulfilling the inclusion criteria were selected through consecutive sampling. Permission was obtained from Hospital Ethical Committee. Written informed consent was obtained from the patients. Name, age, and hospital ID number were entered in the performa. Complete history and clinical examination was done. Urinary microscopy and renal function test was done to fulfill the exclusion criteria. Their spot urine test for microalbuminuria was checked.retinoscopy was done by retinal camera for any evidence of diabetic retinopathy including micro aneurysms, dot and blot hemorrhages, soft and hard exudates, venous looping and beading, new vessel formation and maculopathy. All the findings so obtained by the researcher were confirmed by ophthalmologist and strict exclusion criteria was followed to avoid confounder and make the results unbiased. All data collected were entered in SPSS version 11. Mean±SD was calculated for continuous variables like age. Frequency and percentages were calculated for categorical variables like gender and diabetic retinopathy. RESULTS A total of 186 cases fulfilling the inclusion/exclusion criteria were enrolled to determine the diabetic retinopathy among type 2 diabetic patients, with microalbuminuria. In our study mean was ± SD 6.61 and 58.06% Age (in years) TABLE 1: AGE DISTRIBUTION Cases No. of patients % % % % % > % Total P valve 0.07 Gender TABLE 2: GENDER DISTRIBUTION Cases No. of patients % Male % Female % Total P valve

03 FIGURE 1: FUNDUS PHOTOGRAPH OF EARLY BACKGROUND DIABETIC RETINOPATHY SHOWING

3 TABLE 3: DISTRIBUTION OF DIABETIC RETINOPATHY Diabetic Retinopathy No. of patients % Yes No Total P valve 0.03 FIGURE 1: FUNDUS PHOTOGRAPH OF EARLY BACKGROUND DIABETIC RETINOPATHY SHOWING MULTIPLE MICROANEURYSMS FIGURE 2: RETINAL FINDINGS IN BACKGROUND DIABETIC RETINOPATHY, INCLUDING BLOT HEMORRHAGES (LONG ARROW), 31

FIGURE 3: FLUORESCEIN ANGIOGRAM DEMONSTRATING AN

FLUORESCEIN ANGIOGRAM DEMONSTRATING FOVEAL DYE

PHOTOGRAPH OF CLINICALLY SIGNIFICANT MACULAR

4 FIGURE 3: FLUORESCEIN ANGIOGRAM DEMONSTRATING AN AREA OF CAPILLARY NONPERFUSION (ARROW) FIGURE 4: FLUORESCEIN ANGIOGRAM DEMONSTRATING FOVEAL DYE LEAKAGE CAUSED BY MACULAR EDEMA FIGURE 5: FUNDUS PHOTOGRAPH OF CLINICALLY SIGNIFICANT MACULAR EDEMA DEMONSTRATING RETINAL EXUDATES WITHIN THE FOVEA 32

5 FIGURE 6: AGE DISTRIBUTION were male and 41.93% were female. Diabetic retinopathy was found that 53.76% while remaining 46.23% not having diabetic retinopathy. DISCUSSION Diabetes mellitus is becoming a major contributor of morbidity and mortality in Pakistan. World Health Organization report in his report shows that Pakistan has 5.2 million diabetic subjects, and the number is expected to increase to a staggering 13.9 million making it the 5th highest in the world by Diabetic retinopathy is one of the leading causes of blindness in the world that increases the chance of loosing the sight about 25 times higher compared to normal individuals. 8 Many studies have been undergone to find out the precipitated factors of retinopathy such as duration and type of diabetes, hyperglycemia, pregnancy, change in hormonal level, genetics and microalbuminuria. We planned this study to determine the frequency of diabetic retinopathy in patients with microalbuminuria in our setup. Based on the results of our study, patients may be offered in time diagnosis and management of diabetic retinopathy. Prophylaxis of diabetic retinopathy with strict glycemic control may reduce the incidence and progression of visual impairment, decrease the morbidity and improve the quality of life of patients with diabetes mellitus. In current study A total of 186 cases fulfilling the inclusion/exclusion criteria were enrolled to determine the diabetic retinopathy among type 2 diabetic patients, with microalbuminuria.in our study mean was ± SD 6.61 and 58.06% were male and 41.93% were female.diabetic retinopathy was found that 53.76% while remaining 46.23% not having diabetic retinopathy. Our findings are in agreement with a sutdy revealed that diabetic retinopathy is more common in patients with microalbuminuria. 4 Another study done in Pakistan shows frequency of retinopathy was higher in patients with microalbuminuria (45.4%) whereas in patients without microalbuminuria it was 24.3%. 9 Cruickshanks KJ and colleagues 74 investigated the relationship between microalbuminuria and the presence and severity of diabetic retinopathy in a large population-based cohort of individuals with diabetes they concluded that microalbuminuria is associated cross-sectionally with the presence of retinopathy in persons with diabetes and microalbuminuria may be a marker for the risk of proliferative retinopathy developing CONCLUSIONS We concluded that a significant association between diabetic retinopathy and microalbuminuria, however, the patients may be offered in time diagnosis and management of diabetic retinopathy considering microalbuminuria as a marker. ACKNOWLEDGEMENT We acknowledge the study participants who took time out for this study and shared their experience and views. NOTES ON CONTRIBUTORS The study was part of AH, IQ and DAK, all authors were involved in every part of Manuscript writing, analysis, Protocol developments, and data collection process. CONFLICT OF INTEREST Authors declare no conflict of interest. REFERENCES 1. Nisar S, Mateen F, Masud F. Frequency of retinopathy in type 2 diabetic patients with or without microalbuminuria. Pak J Med Health Sci 2010;4(4):

6 2. Bamashmus MA, Gunaid AA, Khandekar RB. Diabetic retinopathy, visual impairment and ocular status among patients with diabetes mellitus in Yemen: A hospital-based study. Indian J Ophthalmol. 2009; 57(4): Zhang W, Liu H, Caldwell RW, Caldwell RB. Inflammation and diabetic retinal micro vascular complications. J Cardiovascular Dis Res 2011;2: Mohan VKA, Nithyanandam S, Idiculla J. Microalbuminuria and low hemoglobin as risk factors for the occurrence and increasing severity of diabetic retinopathy. Indian J Ophthalmol 2011;59(3): Antonetti DA, Klein R, Gardner TW. Diabetic Retinopathy. N Engl J Med 2012;366(13): Chen H, Zheng Z, Huang Y, Guo K, Lu J, Zhang L. A microalbuminuria threshold to predict the risk for the development of diabetic retinopathy in type 2 diabetes mellitus patient. PLoS One 2012;7(5): Javadi MA, Katibeh M, Rafati N. Prevalence of diabetic retinopathy in Tehran province: a population-based study. BMC Ophthalmol. 2009;16: Taylor R, Williams R. Screening for Diabetic Retinopathy: An overview. Diabetic Medicine 1994;13: Cruickshanks KJ, Ritter LL, Klein R, Moss SE. The association of microalbuminuria with diabetic retinopathy. The Wisconsin Epidemiologic Study of Diabetic Retinopathy. Ophthalmology. 1993;100(6): Manaviat MR. Retinopathy and microalbuminuria in type II diabetic patients. BMC Ophthalmology 2004;4: Rani PK, Raman R, Gupta A, Pal SS, Kulothungan V, Sharma T. Albuminuria and Diabetic Retinopathy in Type 2 Diabetes Mellitus Sankara Nethralaya Diabetic Retinopathy Epidemiology And Molecular Genetic Study (SN-DREAMS, report 12). Diabetology & Metabolic Syndrome 2011;3: Molitch ME, Steffes MW, Cleary PA, Nathan DM. Baseline analysis of renal function in the Diabetes Control and Complications Trial. The Diabetes Control and Complications Trial Research Group [corrected]. Kidney Int 1993;43:

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