The Epidemiology Of Chronic Diabetic Complications Among The Patients Diagnosed With Type 2 Diabetes Aged Over 30 In The Shanghai Downtown

Objective:(1) Diabetic Nephropathy (DN): The prevalence of albuminuria and the risk factors associated with albuminuria were evaluated among the patients diagnosed with type 2 diabetes aged over 30 in the Shanghai downtown. We also evaluated the variability of randomized morning urinary albumin creatinine ratio among the three measurements and the relationship between albuminuria and diabetic retinopathy.(2) Chronic Kidney Disease (CKD): To evaluate the prevalence of chronic kidney disease and the risk factor associated with chronic kidney disease among the patients diagnosed with type 2 diabetes aged over 30 in the Shanghai downtown. To evaluate the relationship between chronic kidney disease and diabetic retinopathy.(3) Diabetic Retinopathy (DR): To evaluate the prevalence of diabetic retinopathy and the risk factors sassociated with diabetic retinopathy among the patients diagnosed with type 2 diabetes aged over 30 in the Shanghai downtown. To evaluate the correlation among diabetic retinopathy, chronic kidney disease, albuminuria and glomerular filter rate.(4) Diabetic macroangiopathy: The prevalence of the thickening of common carotid artery and carotid plaque was evaluated among the patients diagnosed with type 2 diabetes aged over 30 in the Shanghai downtown. We also investigated the risk factors associated with the thickening of common carotid artery and carotid plaque.(5) Additional Analysis 1—Metabolic Syndrome (MS): To calculate the prevalence of metabolic syndrome among the patients diagnosed with type 2 diabetes aged over 30 in the Shanghai downtown according to the International Diabetes Federation (IDF), the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III [ATP III]), the World Health Organization(WHO) and the Chinese Diabetes Society (CDS) definitions. To determine the most accurate metabolic syndrome definition among the definitions proposed by the IDF, ATP III and WHO by making a comparison of the three definitions and an evaluation of cardiovascular disease risks. To evaluate the cut-off point of waist circumference defined by the IDF definition for optimally defining metabolic syndrome in the Chinese patients diagnosed with type 2 diabetes aged over 30.(6) Additional Analysis 2—Status of diabetes management: To determine the status of diabetes management in the patients diagnosed with type 2 diabetes in the Shanghai downtown.Methods:1039 patients diagnosed with type 2 diabetes aged over 30 were investigated by cluster sampling in the Shanghai downtown and 1018, 1009, 762, 824, 1008 patients were analyzed in the analysis of diabetic nephropathy, chronic kidney disease, diabetic retinopathy, diabetic macroangiopathy and metabolic syndrome respectively. Body mass measurements including height, weight, waist circumference and hip circumference, resting blood pressure, fasting blood measures, randomized morning urinary albumin creatinine ratio were investigated. Digitally stored fundus images were shot by a non-mydriatic digital camera and evaluated according to international clinical diabetic retinopathy disease severity scales. Common carotid artery intima media thickness and carotid plaque were evaluated by the Doppler. Glomerular filtration rate was estimated by Cockcroft-Gault equation. The prevalence of albuminuria, chronic kidney disease, diabetic retinopathy, the thickening of common carotid artery, carotid plaque and metabolic syndrome was calculated respectively. The risk factors associated with albuminuria, chronic kidney disease, diabetic retinopathy, the thickening of common carotid artery intima-media thickness and carotid plaque were evaluated by spearman correlation and stepwise logistic regression. The concordance of urinary albumin creatinine ratio among the three measurements was evaluated by observed agreement. The relationship among albuminuria, glomerular filtration rate, chronic kidney disease and diabetic retinopathy was evaluated. The IDF definition was compared with the ATPIII and WHO definitions and carotid atherosclerosis was evaluated among the patients defined by the IDF, ATPIII and WHO definitions. The cut-off point of waistcircumference defined by the IDF definition was evaluated by an evaluation of carotid atherosclerosis. The status of diabetes management was evaluated according to the optimal control recommendations proposed by IDF, IDF Western Pacific Region, CDS and American Diabetes Association (ADA) in the diabetes patients.Results:(1) Diabetic nephropathy:1) The prevalence of albuminuria was 49.6% among the patients diagnosed with type 2 diabetes aged over 30 in the Shanghai downtown, 41.4% with microalbuminuria and 8.2% with macroalbuminuria.2) Microalbuminuria was significantly associated with systolic blood pressure, gender (female) and waist circumference. Macroalbuminuria was significantly associated with systolic blood pressure and duration of diabetes.3) Observed agreement in the albuminuric staging among the three urinary albumin creatinine ratio measurements was 73.3% (first vs second), 64.5% (first vs third) and 77.5% (second vs third). Observed agreement in the albuminuric staging between the single urinary albumin creatinine ratio measurement and all the three urinary albumin creatinine ratio measurements was 85.8% (first vs all three), 87.6% (second vs all three) and 81.9% (third vs all three).4) The percentage of diabetic retinopathy in the macroalbuminuric group (59.2%) was significantly higher than that in the normalbuminuric group (16.1%) and microalbuminuric group (24.6%).5) The macroalbuminuric patients with diabetic retinopathy had significantly increased fasting plasma glucose and HbA1c compared with the macroalbuminuric patients without diabetic retinopathy.(2) Chronic kidney disease:1) The prevalence of chronic kidney disease (stage 1-5) was 63.9% in the patients diagnosed with type 2 diabetes aged over 30 in the Shanghai downtown, 8.8% with chronic kidney disease stage 1, 22.3% with chronic kidney disease stage 2 and 32.8% with chronic kidney disease stage 3-5 (low glomerular filter rate) respectively. The prevalence of chronic kidney disease increased with age.2) The chronic kidney disease patients were older and had greater duration ofdiabetes, systolic blood pressure, urea nitrogen, uric acid, serum creatinine and the first urinary albumin creatinine ratio than those patients without chronic kidney disease.3) The male patients had the higher percentage with chronic kidney disease stage 3-5 and the female patients had the higher percentage with chronic kidney disease stage 1-2.4) Chronic kidney disease was significantly associated with female, age, systolic blood pressure and serum creatinine.5) 15.6% of the patients without chronic kidney disease had diabetic retinopathy and 27.6% of the patients with chronic kidney disease had diabetic retinopathy.6) The decrease of glomerular filter rate was significantly correlated with diabetic retinopathy after controlling for the variables of gender, age and the albuminuric staging by partial correlation analysis.(3) Diabetic retinopathy:1) The ungradable image rate was 12.4% among all the 1534 digital stored fundus images.2) The diabetic retinopathy patients were older and had greater duration of diabetes, fasting plasma glucose, HbA1c, urea nitrogen and serum creatinine than those patients without chronic kidney disease.3) The prevalence of nonproliferative diabetic retinopathy (NPDR) and proliferative diabetic retinopathy (PDR) was 21.6% and 1.3% respectively among all the 672 patients with gradable fundus images. The percentage of mild, moderate and severe nonproliferative diabetic retinopathy was 8.8%, 11.2% and 1.6% respectively.4) The prevalence of diabetic retinopathy increased with age, duration of diabetes and HbA1c.5) Diabetic retinopathy was significantly associated with the duration of diabetes and fasting plasma glucose.6) The percentage of macroalbuminuria among the patients without diabetic retinopathy was only 3.1%, however, the percentage of macroalbuminuria among the patients with proliferative diabetic retinopathy reached up to 33.3%.7) The decrease of glomerular filter rate was significantly correlated with diabetic retinopathy evern after controlling for the variables of gender, age and the albuminuric staging.8) The percentage of low glomerular filter rate among the patients without diabetic retinopathy was 25.1%, but the percentage of low glomerular filter rate among the patients with proliferative diabetic retinopathy reached up to 55.6%.(4) Diabetic macroangiopathy:1) The percentage of the thickening of common carotid artery was 23.3%.2) The independent risk factors associated with the thickening of common carotid artery were age, body mass index, systolic blood pressure, fasting plasma glucose and serum cholesterol.3) The percentage of carotid plaque was 37.1%.4) The independent risk factors associated with carotid plaque were age and fasting plasma glucose.(5) Additional Analysis 1—Metabolic Syndrome:1) The metabolic syndrome prevalence was 50.0%, 55.7%, 70.0% and 51.2% under the IDF, ATPIII, WHO and CDS definitions respectively. The prevalence of central obesity defined by the ATPIII definition was 4.1% in men and 30.2% in women.2) The male patients had greater waist circumference, waist hip ratio and the female patients had greater body mass index.3) The metabolic syndrome patients defined by the IDF definition had greater waist circumference and body mass index than those defined by the ATPIII and WHO definitions.4) The percentage of all the participants categorized as either having or not having the metabolic syndrome was 69.9% (under the IDF and ATPIII definitions) and 70.2% (under the IDF and WHO definitions).5) Common carotid artery intima media thickness of the metabolic syndrome patients defined by the IDF definition was thicker than those defined by the WHO and ATPIII definitions and the percentage of carotid plaque of the metabolic syndrome patients defined by the IDF definition was greater than those defined by the WHO and ATPIII definitions.6) When the cut-off point of waist circumference in men was modified from 90cm to 85cm, the prevalence of metabolic syndrome in men reached up to 55.3% from 35.2% defined by the modified IDF definition, moreover, common carotid arteryintima media thickness of the emerging male metabolic syndrome patients was significantly thicker than that defined by the original IDF definition.(6) Additional Analysis 2—Status of diabetes management:1) 18.1% (CDS and IDF Western Pacific Region recommendations), 15.0% (IDF recommendation) and 33.8% (ADA recommendation) of all the participants obtained the optimal fasting glycaemic control respectively. The percentage of HbA1c<6.5% and <7.0% among all the participants was 38.1% and 54.2% respectively.2) The percentage of systolic blood pressure<130mmHg and diastolic blood pressure<80mmHg among all the participants was 24.7% and 29.5% respectively. Only 15.0% of all the participants obtained the optimal blood pressure control.3) The percentage of serum cholesterol<4.5mmol/L and LDL<2.5mmol/L among all the participants was 21.6% and 24.7% respectively. The percentage of triglyceride<1.5mmol/L, <1.7mmol/L and <2.3mmol/L among all the participants was 44.7%, 55.8% and 75.3% respectively. The percentage of HDL>1.0mmol/L and >1.1mmol/L among all the participants was 75.0% and 61.6% respectively.4) Only 2.71% of all the participants obtained optimal glycemic, blood pressure, and serum lipid control (defined as HbA1c<6.5%, blood pressure<130/80 mmHg and LDL<2.6mmol/L).Conclusion:(1) Diabetic nephropathy:High prevalence of microalbuminuria observed in the patients diagnosed with type 2 diabetes aged over 30 in the Shanghai downtown was alarming. We agreed that at least two of the three randomized morning urinary collections were done in a 3- to 6-month period because of the day-to-day variability in urinary albumin excretion. The percentage of diabetic retinopathy among the patients with macroalbuminuria was 59.2%, and the macroalbuminuric patients with the significantly high plasma glucose and diabetic retinopathy were prone to diagnose diabetic nephropathy.(2) Chronic kidney disease:High prevalence of chronic kidney disease observed in patients diagnosed with type 2 diabetes aged over 30 in the Shanghai downtown was similar with that in the Western diabetic patients. Screening programme for glomerular filter rate in type 2diabetic patients should be performed even with normoalbuminuria. The decrease of glomerular filter rate might predict the occurrence of diabetic retinopathy among the patients diagnosed with type 2 diabetes.(3) Diabetic retinopathy.The prevalence of non-proliferative diabetic retinopathy and proliferative diabetic retinopathy observed in patients diagnosed with type 2 diabetes aged over 30 in the Shanghai downtown was 21.6% and 1.3% respectively. The independent risk factors of diabetic retinopathy were fasting plasma glucose and duration of diabetes. Albuminuria might predict the occurrence of diabetic retinopathy among the patients diagnosed with type 2 diabetes and the diabetic retinopathy patients should evaluate glomerular filter rate.(4) Diabetic macroangiopathy:The prevalence of the thickening of common carotid artery and carotid plaque in patients diagnosed with type 2 diabetes aged over 30 in the Shanghai downtown was 23.3% and 37.1% respectively. The risk factors of carotid atherosclerosis such as plasma glucose, blood pressure and serum lipid should be controlled aggressively.(5) Additional Analysis 1—Metabolic Syndrome:The metabolic syndrome prevalence was 50.0%, 55.7%, 70.0% and 51.2% under the IDF, ATPIII, WHO and CDS definitions respectively. The preferable IDF definition was served as a better predictor of cardiovascular disease risk in the Chinese patients diagnosed with type 2 diabetes aged over 30 compared with the ATPIII and WHO definitions. The modified cut-off point of waist circumference in men defined by the IDF definition specific for the Chinese population (from 90cm to 85cm) might be more suitable to predicting atherosclerosis.(6) Additional Analysis 2—Status of diabetes management:Only 2.71% of all the participants obtained optimal glycemic, blood pressure and serum lipid control, and the patients diagnosed with type 2 diabetes should be upgraded to more intensive therapy.