Association of HbA1Cwith Microalbuminuria in Type 2 Diabetes Anwarullah et al.

Original Article
Anwarullah**
Association of HbA1C with Abdullah*
Jamila*
Microalbuminuria in Type 2 Diabetes Usman Waheed**
Asim Ansari***
Najam Farooq***
Abstract
Introduction: Microalbuminuria is often the first sign of renal dysfunction
*
(nephropathy) in diabetes mellitus. The current study was aimed at Islamabad Diagnostic Centre,
Islamabad, Pakistan;
determining the microalbuminuria levels in type 2 diabetes and to correlate **Department of Biochemistry,
changes in microalbuminuria levels with the glycosylated hemoglobin Faculty of Biological Sciences,
(HbA1c) levels in type 2 diabetic patients. Quaid-i-Azam University,
Materials and Methods: The study was conducted at the Islamabad Islamabad, Pakistan;
***Department of Bioinformatics
Diagnostic Centre, Islamabad, Pakistan. Patients with type 2 diabetes aged and Biotechnology, International
between 30-60 years were included in the study. Patients with systemic Islamic University, Islamabad,
diseases like cardiovascular diseases, cerebrovascular diseases and Pakistan.
urinary tract infection was excluded from the study. Fasting blood samples
were used to analyze HbA1c levels for the estimation of diabetic control
and subsequently random urine specimens to investigate microalbumin Address for Correspondence
level of all the individuals under study. The statistical software SPSS 19.0 Anwarullah
was used for the analysis of the data. Department of Biochemistry
Faculty of Biological Sciences
Results: The study showed that microalbuminuria levels were linearly Quaid-i-Azam University
correlated to those of HbA1c levels. Islamabad.
Conclusion: Impaired glycemic control is associated with significant Email: anwarbch@gmail.com
elevations in urinary microalbumin levels which suggest that the
monitoring of microalbuminuria levels at the early stages of diabetes can
avert and reduce the clinical and economic burden of auxiliary
complications (nephropathy etc.) in the developing countries like Pakistan.
Key words: HbA1c, Microalbuminuria, Type 2 diabetes mellitus.
deaths occur in low- and middle-income countries.5
Introduction According to an estimate by WHO, diabetes will be the
Diabetes is an important metabolic disorder worldwide 7th leading cause of death in 2030.6 The overall risk of
and is characterized by variable degree of insulin dying among people with diabetes is at least double the
resistance, impaired insulin secretion, and increased risk of their peers without diabetes.7
1
glucose production. The effects of diabetes mellitus As in other developing countries, the prevalence of
include longterm damage, dysfunction and failure of diabetes in Pakistan has increased rapidly in recent
various organs. The two main types of the syndrome are years and is likely to continue to increase in the future,
Type 1 (usually develops in childhood and adolescence with important implications for health policy. Diabetes is
and patients require lifelong insulin injections for increasing at an alarming rate in Pakistan as there are
survival) and Type 2 which is the commonest type approximately 7.1 million diabetic patients and around
(usually develops in adulthood and is related to obesity, 120,000 die every year as a result of diabetes related
lack of physical activity, and unhealthy diets).2 The complications and many more are being incapacitated.
cause of type 1 diabetes is not known and it is not Diabetes is among the leading causes of kidney failure8
preventable with current knowledge. and screening for early signs of diabetes-related kidney
347 million people worldwide have diabetes3 In 2004, an disease (nephropathy) is a cost saving intervention and
estimated 3.4 million people died from consequences of feasible for developing countries. Microvascular
high fasting blood sugar.4 More than 80% of diabetes complications including nephropathy, retinopathy and

Ann. Pak. Inst. Med. Sci. 2014; 10(1):93-96 93

Association of HbA1Cwith Microalbuminuria in Type 2 Diabetes Anwarullah et al.

neuropathy are initiated by chronic hyperglycemia. Many
association studies suggested a strong correlation
between level of hyperglycemia and the progression of
micro vascular complications in diabetic patients.9
Estimation of microalbumin levels in urine has been the
gold standard for monitoring the diabetic nephropathy
progression10 and is also predictive of high HbA1c
levels. According to a study by Tobe et al, reduction of
HbA1c level by 1% (7.5 to 6.5%) also significantly
decreases microalbumin levels, even to normal.11
The current study was conducted to evaluate the
prevalence of microalbuminuria and renal impairment in
patients with type 2 diabetes without known proteinuria.
In addition, we investigated the association of
microalbuminuria withHbA1c levels for indicating risk of
diabetic nephropathy in poorly controlled diabetic
patients.
Materials and Methods
This cross-sectional study was conducted at the
Islamabad Diagnostic Centre (IDC), Islamabad,
Pakistan. Ethical approval was granted by the ethical
review committee of IDC. 174 type-2 diabetes patients
were enrolled in the study. Patients with systemic
diseases like cardiovascular diseases, cerebrovascular
diseases and urinary tract infection were excluded from
the study. A sample of blood was drawn after overnight
fasting of 10-12 hours to test for HbA1c levels. The
fasting blood sample with EDTA was used to estimate
HbA1c levels. The sample was incubated with
pretreatment reagent to lyse red blood cells. The
pretreated samples were again incubated with magnetic
microparticles coated with silica. Hb and HbA1C were
bound to the silica surface of the microparticles. After
washing, anti-HbA1C acrydinium, labeled conjugate was
added to create a reaction mixture. Following another
wash cycle, pre-trigger and trigger solution were added
to the reaction mixture. The resulting chemiluminescent
reaction was measured as relative light units. The result
was calculated as a percentage of total hemoglobin
concentration (Architect Si 1000 Abbott International).
A morning urine sample was used for estimating the
microalbumin levels by Immunoturbidity method. The
multigent microalbumin immunoturbiditimetric that uses
polyclonal antibodies against human albumin was used
for the determination of urine microalbumin urea. The
specimen was mixed with the reagents. Albumin in the
specimen combined with the anti-human albumin
antibody, in the reagent to yield an insoluble aggregate
that causes increased turbidity in the solution. The
degree of turbidity is proportional to the albumin in the
specimen, which was measured optically. A <7.0%
HbA1c level was considered to be normal while
<20mg/L microalbuminwas considered as normal. The
data were analyzed using SPSS version19.0. Pearson
correlation coefficient was calculated to find the linear
relation between HbA1C and microalbuminuria. T test
was also used to find out relationship between HbA1c
and microalbuminuria. P value was taken as significant
at 5 percent confidence level (P<0.05).
Results
Among 174 known diabetic patients, 41.3% (n=72) were
females and 58.62% (n=102) were males. The mean
age was 51.8 years for both gender groups. The mean
results for HbA1c was 8.56% with SD of 2.63 (Table I)
and the mean microalbumin results was 66.67mg/L with
SD 2.14 (Table 1).
Table I: Mean HbA1c and microalbuminurea value
Std.
N Minimum Maximum Mean Deviation
Glycosylated Hb 174 5.0 19.4 8.556 2.6259
value
<5.0 2550 66.67 2.14
Miroalbuminuria
value
The study revealed that out of 174 diabetic patients59
%( n=99) had HbA1c value of >7.0% and 43% (n=75)
had less than 7.0%. Collectively microalbuminuria was
seen in33% (n=57) patients (Figure 1).
Figure: 1 Association of HbA1c and
microalbuminurea
The prevalence of microalbuminuria among both
genders was same, i.e. 43% in females and 46% in
males. A positive correlation was found between the two
variables at the level of significance (0.05) and this was
evidenced by Pearson correlation coefficient (r=0.190)

Ann. Pak. Inst. Med. Sci. 2014; 10(2): 93-96 94

Association of HbA1Cwith Microalbuminuria in Type 2 Diabetes
and T test. (P<0.05) was considered statistically
significant. (Table II).
Table II: Pearson correlation coefficient.
Glycocylated Microalbuminur
HB in %age ea in mg
*
Glycosylated HB Pearson 1 .190
in %age Correlation
Sig. (2-tailed) .012
N 174 174
*
Microalbuminuria Pearson .190 1 In the present study statistically significant correlation
in mg Correlation
Sig. (2-tailed) .012
N 174 174
*. Correlation is significant at the 0.05 level (2-tailed).
Discussion
In the present study, 174 diabetic patients of type 2
were studied. The overall prevalence of
microalbuminuria has been establishedas 33% with a
minimal gender difference. A statistically significant
correlation was found between the prevalence of
microalbuminuria and HbA1c level. The study explicitly
indicates that poor diabetic control is the leading cause
of diabetic nephropathy as evidenced by elevated
microalbuminuria. Many complications arise due to
uncontrolled or poorly controlled diabetes mellitus
amongst which the most destructive is diabetic
nephropathy.12. The prevalence of microalbuminuria has
been reported as 36.3% [13] from India, 16.8% [14] in
Saudi Arabia, 22.7% [15] in Hong Kong 14.2% [16] in Iran
29% in Pakistan. 20 .
Several works have been done on the significance of
microalbuminuria in the early diagnosis of diabetic
nephropathy with correlation to other parameters like
albumin to creatinine ratio in urine[17].Differences in the
prevalence of microalbuminuria in different populations
can be due to factors like the methods of urine collection
and methodology of detecting microalbumin and
ethnicity[16]. No statistically correlation was found
between the prevalence of microalbuminuria and the
age of patients in the present study which was similar to
findings reported by Allawiet al.18 However, the study
from India by Varghese et al13 reported a statistically
significant correlation between the prevalence of
microalbuminuria and the age among 1425 type 2
diabetic patients. Similar results were also found from
Pakistan Naz et al reported the finding from the patients
from Rawalpindi/Islamabad.21 These variations are
probably related to the different distributions of patients'
ages in the different studies.
Ann. Pak. Inst. Med. Sci. 2014; 10(2): 93-96
Anwarullah et al.
In the present study, prevalence of microalbuminuria
among males and females was 43% and 46%
respectively. Thus the prevalence of microalbuminuria
was not statistically different for the two genders which
were similar to the findings reported by Mather et al. in
European diabetic patients19 and Sheikh et al from
Pakistan[22 However, Varghese et al. reported an
increased prevalence of microalbuminuria in Indian men
compared with Indian women.
was found between the prevalence of microalbuminuria
and the fasting blood HbA1c levels which was similar to
findings reported from India and Iran.13,16
Conclusion
The prevalence of microalbuminuria in diabetic patients
was found to be high, which advocate the need of
therapeutic and preventive measures from the
Clinicians, Diabetic Associatios and overall the Ministry
of Health.
Being a developing country, Pakistan needs to formalize
an early testing strategy for microalbuminuria and
HbA1c estimation in both poorly controlled and
uncontrolled type 2 diabetic patients as an early marker
for renal risk factor.
Conflict of interest: None
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