International Journal of Research in Medical Sciences

Sivasubramanian V et al. Int J Res Med Sci. 2019 May;7(5):1924-1928

www.msjonline.org pISSN 2320-6071 | eISSN 2320-6012

DOI: http://dx.doi.org/10.18203/2320-6012.ijrms20191702
Original Research Article

Correlation of HbA1c with urinary ACR, serum creatinine and eGFR

in type-2 diabetes mellitus at Puducherry, South India
Vithiavathi Sivasubramanian, Karthik Jetty, S. Senthil Kumar*

Department of General Medicine, Aarupadai Veedu Medical College and Hospital, Kirumambakkam, Pondicherry,
India

Received: 10 March 2019

Accepted: 23 March 2019

*Correspondence:
Dr. S. Senthil Kumar,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Diabetes Mellitus (DM) is a major emerging clinical health problem in this world. Anemia is a
common problem in diabetes. Type 2 DM comprises about 90% of diabetic population of any country.
Methods: A cross-sectional study carried out among 125 type 2 diabetic mellitus patients’ area at Department of
Medicine Aarupadai Veedu Medical college (AVMC) and hospital, Puducherry during the period from May 2018 to
October 2018.The objectives of the study were to evaluate the association of HbA1c with urinary ACR, eGFR and
serum creatinine in Type 2 diabetes mellitus. Data was analyzed using the SPSS version 20.0 software.
Results: The randomly selected study group comprised 100 type 2 DM patients and 25 control peoples of 35-70 years
of age. Type 2 DM patients were evaluated of HbA1c, normotensives or hypertensives. FBS, serum creatinine,
urinary albumin and creatinine were estimated. Urinary ACR and eGFR and were calculated. The data result was
expressed as mean and standard deviation. A probability value is less than 0.05 and it was considered statistically
significant.
Conclusions: Type 2 diabetes mellitus patients, HbA1c and duration of diabetes were the strongest predictors of
micro albuminuria and age was the strongest predictors of a low eGFR. The diabetes was poorly controlled, making
the progression to end stage renal failure in concern patients. They measure the prevention of urinary albumin
excretion, development of renal abrasion, smoking termination, strict glycaemic control and initiating lipid lowering
therapy.

Keywords: eGFR, HbA1c, Type 2 diabetes mellitus, Urinary ACR

INTRODUCTION diabetic nephropathy is estimated to turn into the most

frequent cause of ESRD in the developing world. About
Diabetes mellitus (DM) is a major emerging clinical 20% to 30% of people with either type 1 or type 2
health problem in this world. Anemia is a common diabetes develop nephropathy, whose incidence increases
problem in diabetes.1 It is a clinical syndrome with the duration of diabetes.4-6 Micro albuminuria
characterized by hyperglycaemia due to absolute or significantly increases the relative risk of development of
relative deficiency of insulin.2 Type 2 DM comprises diabetic nephropathy and is a risk factor for adverse
about 90% of diabetic population of any country. cardiovascular outcomes.7 In diabetic patients, glycemic
Diabetic nephropathy is a chronic micro vascular control i.e. maintaining the normal blood sugar levels
complication of poorly controlled diabetes mellitus plays a very significant role in averting the risk of
(DM), leading to end stage renal disease (ESRD).3 The developing both acute and chronic complications.

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Diabetes is a major cause of morbidity and mortality South India. This study was carried out from six month in
throughout the world especially more alarming in the duration of May 2018 to October 2018. 10 ml of
developing countries. Diabetes is among the leading fasting venous blood was collected from the antecubital
causes of kidney failure and screening for early signs of vein of each patient/study subject 5 ml dispensed in
diabetes related to kidney disease is a cost saving clotted vial for estimation of serum creatinine, 2ml in
intervention and feasible for developing countries. ethylene diamine tetraacetic acid (EDTA) vial for
Microvascular complications including nephropathy, estimation of HbA1c by high performance liquid
retinopathy and neuropathy are initiated by chronic chromatography (HPLC); 3 ml in fluride vial for
hyperglycemia.8 estimation of fasting plasma glucose (FPG ).Written
consent taken from each patient before the procedure and
In India, the prevalence of diabetic nephropathy ranges each patient was counseled separately about the
from 32% to 57% and overt proteinuria is found in 5% to procedure and purpose of the study. 20 ml morning urine
28% of diabetic patients.9 Diabetes mellitus contributes to sample was collected from each study subject for the
a third of all patients in dialysis units in India. Diabetic estimation of spot urine ACR. Fasting plasma glucose
nephropathy is a major public health concern, because (FPG) was estimated by glucose oxidase-peroxidase
dialysis and kidney transplantation therapy are almost method.16 Glycated hemoglobin or HbA1c was estimated
completely inaccessible to most diabetic patients in by using HPLC technique and the obtained value is
India.10,11 According to international diabetes federation expressed as percentage (%).17 Urinary microalbumin
(IDF) in 2013, 382 million people had diabetes (Immunotubidimetric method) and urinary creatinine
worldwide of which type 2 makes up about 90% of the (Modified Jaff method) were estimated by Mindray
cases. This is equivalent to 8.3% of the adult people with autoanalyzer using supplied respective reagent kit and
equal rates in both men and women. More than 80% of their ratio i.e., urinary ACR was calculated and expressed
diabetic patient’s deaths obtain in little and middle- in mg/gm (µg/mg) unit.18,19 Serum creatinine (mg/dl) is
income countries. The number of groups with diabetes is measured by Modified Jaff Method.20 eGFR is calculated
estimated to rise to 592 million by 2035.12,13 by using MDRD formula.21

Diabetic nephropathy is the leading cause of chronic MDRD formula = eGFR (mL/min/1.73 m2) = 186 ×
kidney disease (CKD) in United States and other Western (Scr)-1.154 × (Age)-0.203 × (0.742 if female) × (1.212 if
Societies. Diabetes is responsible for 30-40% of all black).
ESRD cases in United States.13 The estimated overall
incidence rate of CKD and end-stage renal disease Statistical analysis
(ESRD) in India is currently 800 per million population
(pmp) and 150-200 pmp, respectively. It has made The data were analyzed using SPSS software program,
observation that DM as the cause of CKD found in 31.2% version 20.0. The mean and standard deviation were
of patients. The estimation of microalbumin levels in measured. Analyzed and interpreted using descriptive and
urine has been the gold standard for monitoring the inferential statistics. The correlations of HbA1c with
diabetic nephropathy progression and is also predictive of urinary ACR, eGFR and serum creatinine were calculated
high HbA1C levels.14 Microalbuminuria (MAU) is a by Pearson’s correlation test and relevant ‘p’ value was
preliminary manifestation of diabetic nephropathy which calculated as level of significance. The probability value
initiates as a result of microvascular changes. Long term is less than 0.05 (p <0.05) and it was considered as
control of diabetes is monitored by estimation of glycated statistically significant.
hemoglobin (HbA1c). There are two important markers
to asses renal impairment-glomerular filtration rate RESULTS
(GFR) and microalbuminuria. Microalbuminria is better
reflected by spot urine albumin-creatinine ratio (urinary The result of the study samples was included 125 type 2
ACR). There are some formula-based calculations of DM patients. The age of the participants ranges from 35
GFR, called estimated GFR or eGFR cockroft-Gault (C- to 70 years (mean age 54.25±6.92). A total of 125
G) formula and modification of diet in renal disease patients in which majority of 85 (68%) patients were
Study (MDRD). In the present study, to evaluation of male and 40 (32%) were females. The clinical parameter
HbA1c with urinary ACR, serum creatinine and eGFR in of diabetic patients is shown in (Table 1).
type-2 diabetes mellitus were measured.
Out of 125 patients 87 are residing in rural area and 38
METHODS are residing in urban area. The distribution of the Type 2
DM patients based on education and there are 74 patients
A cross-sectional study carried out the evaluation of with high education levels and 51 patients with Low
HbA1c with urinary ACR, serum creatinine and eGFR education levels. It reveals the distribution of the patients
among 125 type 2 diabetic mellitus patients in around based on economic status.
Puducherry. The study was analyzed in type 2 diabetic
mellitus patients of 35-70 years of age in practice area at Out of 125 patients 44 are good, 33 patients medium and
Department of Medicine, AVMC and H, Puducherry and 48 are low. The mean duration of diabetes is 9.27±2.34 in

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years. Most patients (60%) had never smoked, 12% were and II (p values are 0.042, 0.005 and <0.001 respectively.
current smokers and 35% were smoking stopped at the The p value is less than 0.05 is the level of significance.
time of data collection. The majority of patients (64%)
were classified as overweight and 24% were in normal Table 2: Correlation of HbA1c with and S. creatinine,
weights. The most of these patients (74%) were found as ACR and eGFR.
hypertension.
Diabetic P
Parameters R value
Table 1: Clinical parameters of diabetic patients value
patients (N=125). Serum 0.001S
0.825
creatinine
‘P’ N=125 HbA1c Urinary
Parameters Mean value ± SD 0.654 0.001S
value ACR
Age (range 35-70 years) 54.25±6.92 0.965 eGFR -0.742 0.042S
Male (85) 42.5±38.89 Serum 0.420
Gender Group I 0.001S
Female (40) 20±16.97 0.825 creatinine
Rural (87) 43.5±44.54 HbA1c
HbA1c Urinary
Residence 0.486 <8%, 0.335 0.050S
Urban (38) 19±11.31 ACR
N= 80
High eGFR -0.402 0.005S
education 37±46.66 Serum 0.001S
level (74) Group II 0.744
creatinine
Education 0.739 HbA1c
Low HbA1c Urinary
education 25.5±9.19 ≥8%; 0.632 0.001S
ACR
level (51) N = 45
eGFR -0.708 0.001S
Good (44) 22±25.45 P<0.05 level of significant.
Economic
Medium (33) 16.5±10.60 0.650
status
Low (48) 24±19.79 DISCUSSION
DOD (Duration of
9.27±2.34 0.967 In cross-sectional study, out of 125 type 2 DM patients of
diabetes in years)
Present 15 12 % age range between 35-70 years (54.25±6.92) and p value
Smoking 0.965. The mean duration of diabetes is 9.27±2.34 in
Never 75 60 %
status years with p value is 0.967. Venugopal S et al, and Layer
Stopped 35 28 %
UM et al, have reported that the significant correlation of
Underweight 13 10 %
HbA1c with microalbuminuria type 2 diabetes mellitus
BMI Normal 32 26 %
patients.22 Haque N et al, has also reported significant
Overweight 80 64 % positive correlation of HbA1c with S. creatinine and
Hypertension 115 74 % urinary ACR in type 2 diabetic patients (p values are
Unknown 10 26 % 0.008 and <0.001 respectively.23 The similar studies were
FPG (mg/dl) 110.25±18.50 0.007 reported by Sheik et al.24 They have found significant
HbA1c (%) 8.24±1.18 0.215 positive correlation of HbA1c with microalbuminuria (p
Serum creatinine (mg/dl) 1.12±0.29 0.426 <0.05) and S. creatinine (p <0.001) in type 2 DM
eGFR (ml/min/1.73sq. m) 74.65±22.55 0.324 patients. These positive correlations remained significant
Urinary ACR (mg/gm) 52.24±82.15 0.050 when HbA1c ≥8% (p values are 0.04 and <0.001) and
when HbA1c <8%, they found only significant positive
The evaluation of HbA1c was assessed with serum correlation between HbA1c and ACR (p value 0.005) but
creatinine, urinary ACR and eGFR among total study not between HbA1c and S. Creatinine where p value is
subjects (N=125), group I with HbA1c < 8% (N=80) and 0.614. Haque N et al.23 have found that the positive
group II with HbA1c ≥ 8% (N=45) were presented in correlation of HbA1c with eGFR although this positive
(Table 2). correlation is not statistically significant (p value=0.158).
In this study, negative correlation is statistically
There is significant positive correlation of HbA1c with significant between HbA1c with eGFR (p value=0.036).
urinary ACR and serum creatinine in 125 type 2 DM They have also found that the mean years of duration of
patients (r value= 0.654 and 0.825 respectively. The diabetes was 6.36±1.65 in their study, whereas in present
probability value both is less than 0.001 at level of study the mean years of duration of diabetes are
significance and only with serum creatinine in group I, 9.27±2.34. Glomerular hyperperfusion and renal
HbA1c <8% (‘p’ value =0.001). The significant positive hypertrophy occur in the first years after the onset of
correlation of HbA1c remained with serum creatinine and type-2 diabetes mellitus and are associated with an
ACR in group II, HbA1c ≥8% (p value is <0.001). There increase of the GFR. During the first 5 years of type-2
is also significant negative correlation is found between diabetes mellitus, thickening of the glomerular basement
HbA1c and eGFR in all type 2 DM patients in group I membrane, glomerular hypertrophy and mesangial

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 Sivasubramanian V et al. Int J Res Med Sci. 2019 May;7(5):1924-1928

volume expansion occurs as the GFR returns to normal. 5. Van Dijk C, Berl T. Pathogenesis of diabetic
Diabetic nephropathy is a chronic microvascular nephropathy. Rev Endocr Metab Disord.
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There is a spectrum of changes in chronic kidney disease, 6. Locatelli F, Canaud B, Eckardt KU. The importance
with well-defined functional progression from of diabetic nephropathy in current nephrological
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failure.25 In early renal impairment, classical markers 7. Damsgaard, EM, Froland A, Jorgensen OD,
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intervention. So, newly detected or known type 2 DM mellitus. IOSR J Dental Med Sci. 2018;17(9):79-84.
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