Anaemia among primary care patients with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD): a multicentred cross-sectional study

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Abstract

Objectives

This study aimed to determine the prevalence of anaemia among patients with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD) at primary care settings and its associated factors.

Design, setting and participants

This cross-sectional study involved 808 adult patients with T2DM and CKD who were recruited via systematic sampling from 20 public primary care clinics in Peninsular Malaysia. Their sociodemographic, clinical and biomedical profiles were collected through interviews, examination of medical records and blood testing.

Results

The prevalence of anaemia was 31.7% (256/808). The anaemia was mainly mild (61.5%) and normocytic normochromic (58.7%). About 88.7% of the patients with anaemia were not known to have anaemia prior to the study. Among 36 patients with documented history of anaemia, 80.6% were still anaemic, and only a half received iron therapy. Multivariate regression analysis showed that women (adjusted odd ratio (AOR): 1.57, 95% CI: 1.12 to 2.21, p=0.009) and those with older age (AOR: 1.04, 95% CI: 1.01 to 1.06, p<0.001), CKD stage 3a (AOR: 2.47; 95% CI: 1.25 to 4.87, p=0.009), CKD stage 3b (AOR: 4.36; 95% CI: 2.14 to 8.85, p<0.001), CKD stage 4 (AOR: 10.12; 95% CI: 4.36 to 23.47, p<0.001), CKD stage 5 (AOR: 10.80; 95% CI: 3.32 to 35.11, p<0.001) and foot complication (AOR 3.12, 95% CI: 1.51 to 6.46, p=0.002) were more likely to have anaemia. Having higher body mass index (AOR 0.95, 95% CI: 0.92 to 0.99, p=0.012) and higher diastolic blood pressure (AOR 0.97, 95% CI: 0.95 to 0.99, p<0.001) were associated with lower odds to have anaemia.

Conclusion

Anaemia among patients with T2DM and CKD in primary care was common, and the majority was unrecognised. Inadequate treatment of anaemia was also prevalent. Therefore, screening of anaemia should be incorporated into the routine assessment of diabetic complications particularly for those with significant associated factors. It is hoped that such strategy could lead to early treatment and hence improve their overall care.

Trial registration number

NMRR-15-660-24324.

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Most cited references 27

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Unrecognized anemia in patients with diabetes: a cross-sectional survey.

David Power, Con Tsalamandris, George Jerums … (2003)

Anemia is common in diabetes, potentially contributing to the pathogenesis of diabetes complications. This study aims to establish the prevalence and independent predictors of anemia in a cross-sectional survey of 820 patients with diabetes in long-term follow-up in a single clinic. A full blood count was obtained in addition to routine blood and urine test results for all patients over a 2-year period to encompass all patterns of review. Predictors of the most recent Hb concentration and anemia were identified using multiple and logistic regression analysis. A total of 190 patients (23%) had unrecognized anemia (Hb 2 times (odds ratio [OR] 2.3) and macroalbuminuric patients >10 times (OR 10.1) as likely to have anemia than normoalbuminuric patients with preserved renal function (GFR >80 ml/min). Anemia is a common accompaniment to diabetes, particularly in those with albuminuria or reduced renal function. Additional factors present in diabetes may contribute to the development of increased risk for anemia in patients with diabetes.

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Anemia and end-stage renal disease in patients with type 2 diabetes and nephropathy.

S. Shahinfar, Z. Zhang, F Keane … (2004)

Diabetic nephropathy is the leading cause of end-stage renal disease (ESRD). Anemia is common in diabetics with nephropathy; however, the impact of anemia on progression to ESRD has not been carefully examined. We studied the relationship between baseline hemoglobin concentration (Hb) and progression of diabetic nephropathy to ESRD in 1513 participants enrolled in Reduction in Endpoints in NIDDM with the Angiotensin II Antagonist Losartan study and followed for an average of 3.4 years. Multivariate Cox proportional hazards models were used to analyze the relationship between Hb and ESRD, after adjusting for predictors for ESRD. Analyses were performed with Hb stratified by quartile: first quartile /=13.8 g/dL (reference) and as a continuous variable. Baseline hemoglobin concentration was correlated with subsequent development of ESRD. After adjustment for predictors of ESRD, the hazard ratios for the first, second, and third Hb quartiles were 1.99 (95% CI, 1.34-2.95), 1.61 (95% CI 1.08-2.41), and 1.87 (95% CI 1.25-2.80). With hemoglobin as a continuous variable, the adjusted hazard ratio was 0.90 (95% CI 0.84-0.96, P= 0.0013). The average increase in adjusted relative risk was 11% for each 1 g/dL decrease in hemoglobin concentration. Our data suggest that even mild anemia, Hb <13.8 g/dL increases risk for progression to ESRD. Hemoglobin is an independent risk factor for progression of nephropathy to ESRD in type 2 diabetes.

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Is Open Access

Haemoglobinopathies in Southeast Asia

Suthat Fucharoen, Pranee Winichagoon (2011)

In Southeast Asia α-thalassaemia, β-thalassaemia, haemoglobin (Hb) E and Hb Constant Spring (CS) are prevalent. The abnormal genes in different combinations lead to over 60 different thalassaemia syndromes, making Southeast Asia the locality with the most complex thalassaemia genotypes. The four major thalassaemic diseases are Hb Bart's hydrops fetalis (homozygous α-thalassaemia 1), homozygous β-thalassaemia, β-thalassaemia/Hb E and Hb H diseases. α-Thalassaemia, most often, occurs from gene deletions whereas point mutations and small deletions or insertions in the β-globin gene sequence are the major molecular defects responsible for most β-thalassaemias. Clinical manifestations of α-thalassaemia range from asymptomatic cases with normal findings to the totally lethal Hb Bart's hydrops fetalis syndrome. Homozygosity of β-thalassaemia results in a severe thalassaemic disease while the patients with compound heterozygosity, β-thalassaemia/Hb E, present variable severity of anaemia, and some can be as severe as homozygous β-thalassaemia. Concomitant inheritance of α-thalassaemia and increased production of Hb F are responsible for mild clinical phenotypes in some patients. However, there are still some unknown factors that can modulate disease severity in both α- and β-thalassaemias. Therefore, it is possible to set a strategy for prevention and control of thalassaemia, which includes population screening for heterozygotes, genetic counselling and foetal diagnosis with selective abortion of affected pregnancies.

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Author and article information

Journal

Journal ID (nlm-ta): BMJ Open

Journal ID (iso-abbrev): BMJ Open

Journal ID (hwp): bmjopen

Journal ID (publisher-id): bmjopen

Title: BMJ Open

Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )

ISSN (Electronic): 2044-6055

Publication date Collection: 2018

Publication date (Electronic): 22 December 2018

Volume: 8

Issue: 12

Electronic Location Identifier: e025125

Affiliations

[1 ] Klinik Kesihatan Ampangan, Jalan Seremban-Kuala Pilah , Seremban, Malaysia

[2 ] departmentDepartment of Family Medicine , Faculty of Medicine, Universiti Kebangsaan Malaysia , Kuala Lumpur, Malaysia

[3 ] departmentDepartment of Family Medicine, Faculty of Medicine and Health Sciences , Universiti Sains Islam Malaysia , Nilai, Malaysia

[4 ] Klinik Kesihatan Lukut, Jalan Seremban , Port Dickson, Malaysia

[5 ] Klinik Kesihatan Masjid Tanah , Masjid Tanah, Malaysia

[6 ] Klinik Kesihatan Bandar Seri Putra , Kajang, Malaysia

[7 ] Klinik Kesihatan Batu 13 1/Jalan Hulu Langat , Selangor, Malaysia

Author notes

[Correspondence to ] Dr Hizlinda Tohid; hizlinda2202@ 123456gmail.com

Article

Publisher ID: bmjopen-2018-025125

DOI: 10.1136/bmjopen-2018-025125

PMC ID: 6307578

PubMed ID: 30580276

SO-VID: c0015d0a-77e4-475e-8074-baee25cb96c7

License:

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

History

Date received : 20 August 2018

Date revision received : 25 October 2018

Date accepted : 16 November 2018

Funding

Funded by: Roche Malaysia;

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ScienceOpen disciplines: Medicine

Keywords: anaemia,diabetes mellitus,chronic kidney disease,primary care

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ScienceOpen disciplines: Medicine

Keywords: anaemia, diabetes mellitus, chronic kidney disease, primary care

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Anaemia among primary care patients with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD): a multicentred cross-sectional study

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Abstract

Objectives

Design, setting and participants

Results

Conclusion

Trial registration number

Related collections

Negative Pressure Wound Therapy

Most cited references 27

Unrecognized anemia in patients with diabetes: a cross-sectional survey.

Anemia and end-stage renal disease in patients with type 2 diabetes and nephropathy.

Haemoglobinopathies in Southeast Asia

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Cited by 28

Most referenced authors 253