Chronic Kidney Disease Management in the Middle East and Africa: Concerns, Challenges, and Novel Approaches

The burden of chronic kidney disease (CKD) and other comorbidities, such as hypertension and diabetes, which increase the risk of developing CKD, is on the rise in the Middle East and Africa. The Middle East and Africa CKD (MEA-CKD) steering committee, comprising eminent healthcare specialists from the Middle East and Africa, was formed to identify and propose steps to address the gaps in the management of CKD in these regions. The current article lists the MEA-CKD steering committee meeting outcomes and evaluates the available evidence supporting the role of novel therapeutic options for patients with CKD. The need of the hour is to address the gaps in awareness and screening, early diagnosis, along with referral and management of patients at risk. Measures to bring about appropriate changes in healthcare policies to ensure access to all benefit-proven protective therapies, including novel ones, at community levels are also vital for reducing the overall burden of CKD on the healthcare system as well as governing bodies, especially in developing countries of the Middle East and Africa.

Diabetic nephropathy and proton pump inhibitors – Pilot case-control study

Introduction:

Methods:

Results:

Conclusion:

Perilipin 5 ameliorates high-glucose-induced podocyte injury via Akt/GSK-3β/Nrf2-mediated suppression of apoptosis, oxidative stress, and inflammation

Hyperglycemia-induced podocyte damage contributes to the onset of diabetic nephropathy, a severe complication of diabetes. Perilipin 5 (Plin5) exerts a vital role in numerous pathological conditions via affecting cell apoptosis, oxidative stress, and inflammation. However, whether Plin5 plays a role in regulating podocyte damage of diabetic nephropathy has not been fully determined. This work aimed to explore the role of Plin5 in mediating high glucose (HG)-induced injury of podocytes in vitro. Our results demonstrated that Plin5 expression was markedly decreased in mouse podocytes challenged with HG. Plin5 overexpression markedly suppressed HG-induced apoptosis, reactive oxygen species (ROS) production, and the pro-inflammatory response in podocytes. On the contrary, Plin5 silencing produced the opposite effects. Further mechanistic analysis demonstrated that Plin5 upregulation remarkably increased the levels of phospho-Akt and phospho-glycogen synthase kinase-3β (GSK-3β) in HG-exposed podocytes. Moreover, Plin5 overexpression increased the levels of nuclear factor erythroid 2-related factor 2 (Nrf2) and enhanced the activation of Nrf2 signaling. Akt inhibition markedly blocked Plin5-mediated activation of Nrf2, while GSK-3β inhibition reversed Plin5-silencing-induced suppressive effects on Nrf2 activation. Notably, Nrf2 suppression significantly blocked Plin5-mediated protective effects against HG-induced podocyte injury. In summary, our work indicates a vital role for Plin5 in protecting against HG-induced apoptosis, oxidative stress, and inflammation in podocytes via modulation of Akt/GSK-3β/Nrf2 signaling. This study suggests that Plin5 may participate in modulating podocyte damage in diabetic nephropathy.

DUSP6 protects murine podocytes from high glucose‑induced inflammation and apoptosis

Diabetic nephropathy (DN) is one of the most severe complications that can occur in patients with diabetes, and without effective and timely therapeutic intervention, can gradually progress to renal failure. Previous studies have focused on investigating the pathogenesis of DN; however, the role of dual‑specificity phosphatase 6 (DUSP6) in DN is not completely understood. Therefore, the present study aimed to investigate the role of dual‑specificity phosphatase 6 (DUSP6) in DN. DN model mice were established and the expression levels of DUSP6 in the kidney tissues and high glucose (HG)‑induced murine podocytes (MPC5 cells) were determined using immunohistochemistry, reverse transcription‑quantitative PCR and western blotting. In addition, the levels of reactive oxygen species (ROS) and inflammatory cytokines in MPC5 cells were analyzed using commercial assay kits or ELISA kits, respectively, and flow cytometric analysis was performed to analyze the rate of cell apoptosis. The present study indicated that DUSP6 expression levels were significantly decreased in DN model mice compared with control mice, and in HG‑induced MPC5 cells compared with normal glucose‑induced MPC5 cells. DUSP6 overexpression enhanced MPC5 cell viability and increased protein expression levels of cell markers, such as synaptopodin and nephrin, compared with the negative control group. DUSP6 overexpression also reduced the levels of ROS and inflammatory cytokines, including interleukin (IL)‑1β, IL‑6 and tumor necrosis factor‑α secreted by MPC5 cells under HG conditions. Moreover, compared with the HG group, cell apoptosis was inhibited by DUSP6 overexpression under HG conditions, which was further indicated by decreased expression levels of cleaved caspase‑3 and Bax. Thus, these findings indicated that DUSP6 mediated the protection against HG‑induced inflammatory response.

Microvascular complications among patients with diabetes: An emerging health problem in Saudi Arabia

Diabetes mellitus, besides disrupting the carbohydrate metabolism process, also induces vascular disease and impacts nearly all the types and sizes of blood vessels. In fact, vascular complications cause majority of the morbidity, hospitalizations and mortality of patients with diabetes mellitus. Retinopathy, nephropathy and neuropathy (microvascular complications) impact hundreds of millions of diabetics and normally target those having long-term or uncontrolled forms of the disease; however, these disorders can also exist at the time of diagnosis or in those yet to be diagnosed. The Kingdom of Saudi Arabia is the biggest country in the Middle East that occupies around four-fifths of the Arabian Peninsula supporting a population of more than 33.3 million people. The prevalence of diabetes mellitus is increasing at an alarming rate in Saudi Arabia. Over 25% of the adult population is suffering and that figure is projected to more than double by 2030. In fact, diabetes mellitus has approximately registered a 10-fold upsurge in the past three decades in Saudi Arabia. However, the prevalence and risk factors of microvascular complications in diabetes mellitus patients have not yet been clearly documented in Saudi Arabia. Hence, in this review, we aim to provide an overview of the microvascular complications among patients with diabetes in Saudi Arabia, utilizing data from the currently available published literature. This is an attempt to facilitate the government and healthcare systems aware of the enormous worth of prevention, early detection and appropriate management of such microvascular complications.

A Systematic Review of Childhood Diabetes Research in the Middle East Region

Background: Diabetes mellitus (DM) is a common chronic disorder in children and is caused by absolute or relative insulin deficiency, with or without insulin resistance. There are several different forms of childhood DM. Children can suffer from neonatal diabetes mellitus (NDM), type 1 diabetes (T1DM), type 2 diabetes (T2DM), Maturity Onset Diabetes of the Young (MODY), autoimmune monogenic, mitochondrial, syndromic and as yet unclassified forms of DM. The Middle East has one of the highest incidences of several types of DM in children; however, it is unclear whether pediatric diabetes is an active area of research in the Middle East and if ongoing, which research areas are of priority for DM in children. Objectives: To review the literature on childhood DM related to research in the Middle East, summarize results, identify opportunities for research and make observations and recommendations for collaborative studies in pediatric DM. Methods: We conducted a thorough and systematic literature review by adhering to a list recommended by PRISMA. We retrieved original papers written in English that focus on childhood DM research, using electronic bibliographic databases containing publications from the year 2000 until October 2018. For our final assessment, we retrieved 429 full-text articles and selected 95 articles, based on our inclusion and exclusion criteria. Results: Our literature review suggests that childhood DM research undertaken in the Middle East has focused mainly on reporting retrospective review of case notes, a few prospective case studies, systemic reviews, questionnaire-based studies, and case reports. These reported studies have focused mostly on the incidence/prevalence of different types of DM in childhood. No studies report on the establishment of National Childhood Diabetes Registries. There is a lack of consolidated studies focusing on national epidemiology data of different types of childhood DM (such as NDM, T1DM, T2DM, MODY, and syndromic forms) and no studies reporting on clinical trials in children with DM. Conclusions: Investing in and funding basic and translational childhood diabetes research and encouraging collaborative studies, will bring enormous benefits financially, economically, and socially for the whole of the Middle East region.

The rate of progression of type 2 diabetes mellitus to end stage renal disease - A single centred retrospective study from Malaysia

INTRODUCTION

In Malaysia, 61% of dialysis cases are secondary to diabetes. To date, we are still lacking of data on the rate of progression of type 2 diabetes mellitus (T2DM) to end stage renal disease (ESRD) in Malaysia.

MATERIALS AND METHODS

This was a retrospective study conducted at nephrology unit of a tertiary hospital in Kedah. All diabetic ESRD patients who fulfilled the inclusion criteria were identified and recruited for analysis.

RESULTS

The mean duration of DM to ESRD was found to be 14.37 ± 4.42 years. Mean duration for the onset of diabetic nephropathy was 8.73 ± 3.37 years. There was a relative short duration from diabetic nephropathy to ESRD noted, which was 5.63 ± 2.06 years. The mean duration of DM to ESRD for patients receiving RAAS blocker was found to be 18.23 ± 2.38 years as compared to 11.41 ± 2.94 years for those who did not (95% CI: -0.64 to -2.46). For different type of RAAS blockers, namely ACE inhibitor and angiotensin receptor blocker (ARB), there was no significant difference observed pertaining to mean duration of DM to ESRD; 17.89 ± 1.97 years for ACEi and 19.00 ± 4.16 years for ARB (95% CI: -4.74 to 2.52).

DISCUSSION

Time frame from diabetic nephropathy to ESRF among Malaysian population was shorter as compared to findings from other countries with an average period of 15 to 25 years. RAAS blockers should be initiated early in diabetic patients.

Effect of berberine on the renal tubular epithelial-to-mesenchymal transition by inhibition of the Notch/snail pathway in diabetic nephropathy model KKAy mice

Renal tubular epithelial-to-mesenchymal transition (EMT) and renal tubular interstitial fibrosis are the main pathological changes of diabetic nephropathy (DN), which is a common cause of end-stage renal disease. Previous studies have suggested that berberine (BBR) has antifibrotic effects in the kidney and can reduce apoptosis and inhibit the EMT of podocytes in DN. However, the effect of BBR on the renal tubular EMT in DN and its mechanisms of action are unknown. This study was performed to explore the effects of BBR on the renal tubular EMT and the molecular mechanisms of BBR in DN model KKAy mice and on the high glucose (HG)-induced EMT in mouse renal tubular epithelial cells. Our results showed that, relative to the model mice, the mice in the treatment group had an improved general state and reduced blood glucose and 24-h urinary protein levels. Degradation of renal function was ameliorated by BBR. We also observed the protective effects of BBR on renal structural changes, including normalization of an index of renal interstitial fibrosis and kidney weight/body weight. Moreover, BBR suppressed the activation of the Notch/snail pathway and upregulated the α-SMA and E-cadherin levels in DN model KKAy mice. BBR was further found to prevent HG-induced EMT events and to inhibit the HG-induced expression of Notch pathway members and snail1 in mouse renal tubular epithelial cells. Our findings indicate that BBR has a therapeutic effect on DN, including its inhibition of the renal tubular EMT and renal interstitial fibrosis. Furthermore, the BBR-mediated EMT inhibition occurs through Notch/snail pathway regulation.

Association of depression and sleep quality with complications of type 2 diabetes in geriatric patients

BACKGROUND

Diabetes mellitus (DM) is highly prevalent and increasing in geriatric population. Depression and sleep disorders occur at a higher rate in patients with diabetes compared with controls.

AIM

The purpose of this study was to demonstrate whether diabetic complications influence the sleep quality and depression in elderly patients.

METHODS

154 geriatric diabetic patients (male/female: 69/85) were enrolled in this study. Patients were investigated for microvascular and macrovascular complications. The Pittsburgh Sleep Quality Index (PSQI) and Geriatric Depression Scale (GDS) were performed for assessment of sleep quality and depression, respectively. Linear regression analysis was performed to identify significant independent related factors for GDS and PSQI scores.

RESULTS

Microvascular and macrovascular complications were found in 47.4 % and 29.2 of study population. PSQI and GDS scores of patients with microvascular complications were significantly higher than those of patients without microvascular complications (8.23 ± 3.83 vs 5.76 ± 3.04, p 0.001; 11.07 ± 6.07 vs 6.94 ± 5.35, p 0.001), respectively. There was no difference in GDS scores between the patients with and without macrovascular complications. There was a positive correlation between DM duration and PSQI, GDS scores. Neuropathy was an independent variable for poor sleep quality (OR 1.362, 95 % CI 0.032-2.692, p 0.045) and depression (OR 2.909, 95 % CI 0.610-5.209, p 0.014).

CONCLUSION

Depression status and sleep quality are strongly influenced by diabetic complications and DM duration in elderly patients.

Prevalence of chronic complication among type 2 diabetics attending primary health care centers of Al Ahsa district of Saudi Arabia: a cross sectional survey

Background:

The morbidity and mortality related to diabetes is a great global concern. The knowledge of chronic complications of diabetes and associated co morbidity factors is very important for formulating the necessary policies and action plan.

Aims:

To determine the prevalence of chronic complications and comorbidity among the type 2 diabetics attending the primary health care centers of Al Ahsa district of Saudi Arabia.

Material and Methods:

This cross sectional retrospective survey was carried out on 506 type 2 diabetic patients attending the different primary health care centers of ministry of health, Al Ahsa. Data regarding the co morbidity factors and chronic complications were recorded from the health records of the selected diabetic patients. Data analysis was done by SPSS version 16. A p<0.05 was considered significant for all statistical calculations.

Results:

Overall 72.72% (95% CI 69.78-74.45) of the study subjects were suffering from one or more complications of diabetic mellitus. Among them 33.39% (165) were suffering from single, 25.29% (128) with two and 15% (75) from more than two complications. The overall prevalence of complication among the female subjects was significantly higher than the male (78.16%, 95% CI 76.76-84.40 Vs 65.76%, 95% CI 61.63-69.89, p=.038). The chronic complication was higher among the urban population than the rural population (77.3% 95% CI 72.88-80.26 Vs 69.78% 95% CI 66.1%-76.92%, p=.035).

Conclusion:

The result showed a high percentage of chronic complications among the diabetic patients of this region. The high percentage of obesity, hypertension and dyslipidaemia among them are important co morbidity factors which if not controlled can cause further increase in the number of chronic complications.

Is there a link between neutrophil-lymphocyte ratio and microvascular complications in geriatric diabetic patients?

BACKGROUND

Chronic inflammation plays an important role on development and progression of Type 2 diabetes (T2DM) through immunologic inflammatory mechanisms. Neutrophil to lymphocyte ratio (NLR) is a new, simple and cheap marker of subclinical inflammation. NLR has recently been used as a systemic inflammation marker in chronic diseases as well as a predictor of prognosis in cardiovascular diseases and malignancies.

AIM

The objective of the present study was to investigate the relationship between NLR and microvascular complications of diabetes mellitus (DM) in elderly population.

SUBJECTS AND METHODS

Two hundred and forty-two patients with DM (145 diabetic patients with complications, 97 diabetic patients without complications) and 218 control subjects were enrolled in this study. NLR and microvascular complications because of DM were evaluated and compared with other inflammatory markers.

RESULTS

NLR was higher in the diabetic group (2.21±1.14) than in the controls (2.18±0.76). Furthermore, there was a statistically significant difference between NLR levels in diabetic patients with and without complications (2.46±1.26 vs 2.04±0.51, respectively; p<0.001). The results of themultiple logistic regression analysis depicted that NLR is also an independent predictor for microvascular complications (odds ratio 2.217; 95%confidence interval 1.086-4.526, p=0.029). Receiver operating curve analysis suggested that the optimum NLR cutoff point for microvascular complication was 2.89 with 96.72% specificity, 94.4% positive predictive value.

CONCLUSION

Increased NLR levels may be associated with microvascular complications of DM in the elderly population.

Effects of magnoline on P-selectin's expression in diabetic rats and its reno-protection

BACKGROUND AND OBJECTIVE

Magnoline is an active ingredient of magnolia fargesii with anti-inflammatory and anti-platelet effects. The objective is to explore the renoprotection of magnoline in diabetic rats and its effects on P-selectin.

METHODS

Thirty-six rats were randomized into 4 groups-normal control group (C), diabetic group (D), small-dose magnoline treatment group (M1) and large-dose magnoline treatment group (M2) (n=9 in each group). Streptozotocin was selected to construct diabetic rat model, and group M1 and group M2 were treated with magnoline 0.5mg/Kg.d and 2mg/Kg.d respectively. Urinary albumin excretion rate, renal function, levels of P-selectin and TGF-β1 were observed after 16 weeks.

RESULTS

Levels of albuminuria and serum creatinine of group M1 (1078.9 ± 77.3μg/24h, 29.7 ± 3.9μmol/L) and M2 (852.9 ± 80.1μg/24h, 30.9 ± 2.9μmol/L) were lower than group D (1572.8 ± 176.2μg/24h, 39.4 ± 4.1μmol/L) (P <0.05). Serum levels of P-selectin in group M1 and M2 were lower than group D (P <0.05). The renal expression of P-selectin and TGF-β1 in group M1 and M2 were significantly attenuated respectively.

CONCLUSIONS

Magnoline has reno-protective effects on diabetic rats which may be related to the inhibition of P-selectin.

Chronic kidney disease in the type 2 diabetic patients: prevalence and associated variables in a random sample of 2642 patients of a Mediterranean area

Background

Kidney disease is associated with an increased total mortality and cardiovascular morbimortality in the general population and in patients with Type 2 diabetes. The aim of this study is to determine the prevalence of kidney disease and different types of renal disease in patients with type 2 diabetes (T2DM).

Methods

Cross-sectional study in a random sample of 2,642 T2DM patients cared for in primary care during 2007. Studied variables: demographic and clinical characteristics, pharmacological treatments and T2DM complications (diabetic foot, retinopathy, coronary heart disease and stroke). Variables of renal function were defined as follows: 1) Microalbuminuria: albumin excretion rate & 30 mg/g or 3.5 mg/mmol, 2) Macroalbuminuria: albumin excretion rate & 300 mg/g or 35 mg/mmol, 3) Kidney disease (KD): glomerular filtration rate according to Modification of Diet in Renal Disease < 60 ml/min/1.73 m² and/or the presence of albuminuria, 4) Renal impairment (RI): glomerular filtration rate < 60 ml/min/1.73 m², 5) Nonalbuminuric RI: glomerular filtration rate < 60 ml/min/1.73 m² without albuminuria and, 5) Diabetic nephropathy (DN): macroalbuminuria or microalbuminuria plus diabetic retinopathy.

Results

The prevalence of different types of renal disease in patients was: 34.1% KD, 22.9% RI, 19.5% albuminuria and 16.4% diabetic nephropathy (DN). The prevalence of albuminuria without RI (13.5%) and nonalbuminuric RI (14.7%) was similar. After adjusting per age, BMI, cholesterol, blood pressure and macrovascular disease, RI was significantly associated with the female gender (OR 2.20; CI 95% 1.86–2.59), microvascular disease (OR 2.14; CI 95% 1.8–2.54) and insulin treatment (OR 1.82; CI 95% 1.39–2.38), and inversely associated with HbA1c (OR 0.85 for every 1% increase; CI 95% 0.80–0.91). Albuminuria without RI was inversely associated with the female gender (OR 0.27; CI 95% 0.21–0.35), duration of diabetes (OR 0.94 per year; CI 95% 0.91–0.97) and directly associated with HbA1c (OR 1.19 for every 1% increase; CI 95% 1.09–1.3).

Conclusions

One-third of the sample population in this study has KD. The presence or absence of albuminuria identifies two subgroups with different characteristics related to gender, the duration of diabetes and metabolic status of the patient. It is important to determine both albuminuria and GFR estimation to diagnose KD.

Vascular access in patients receiving hemodialysis in Libya

PURPOSE

A native arteriovenous fistula (AVF) represents the optimal form of Vascular Access (VA) for patients receiving hemodialysis (HD). In Libya there are several barriers to AVF creation including lack of adequate preparation for dialysis and surgical services. We aimed to conduct the first comprehensive study of VA utilisation in HD patients in Libya.

METHODS

A prospective observational study included all adult patients receiving HD treatment in 25 HD facilities in Libya from May 2009 to Nov 2011. Researchers gathered data regarding VA through interviews with staff and patients as well as medical records. Patients with definitive VA were re-interviewed after 1 year.

RESULTS

At baseline the majority of patients (91.9%; n=1573) were using permanent VA in the form of AVF or arteriovenous graft. Patients with permanent VA were more likely to be male and less likely to be diabetic than those with CVCs. Most patients had commenced HD using a temporary CVC (91.8%). VA-related complications were: thrombosis (46.7%), aneurysm (22.6%), infection (11.5%) and haemorrhage (10.2%). Incident VA thrombosis was reported by 14.7% in 1 year. Independent risk factors for incident thrombosis were female gender and diabetes. Hospitalisation for VA related complications was reported by 31.4%.

CONCLUSIONS

Few patients in Libya initiate HD with definitive VA, but most achieve it thereafter. Improved dialysis preparation and increased provision of surgical services are required to increase the proportion of patients initiating HD with definitive VA and should be a priority in rebuilding health services in Libya after the recent conflict.

Epidemiology and aetiology of dialysis-treated end-stage kidney disease in Libya

Background

The extent and the distribution of end stage kidney disease (ESKD) in Libya have not been reported despite provision of dialysis over 4 decades. This study aimed to develop the first comprehensive description of the epidemiology of dialysis-treated ESKD in Libya.

Methods

Structured demographic and clinical data were obtained regarding all adult patients treated at all maintenance dialysis facilities (n=39) in Libya from May to September 2009. Subsequently data were collected prospectively on all new patients who started dialysis from September 2009 to August 2010. Population estimates were obtained from the Libyan national statistics department. The age and gender breakdown of the population in each region was obtained from mid-2009 population estimates based on 2006 census data.

Results

The prevalence of dialysis-treated ESKD was 624 per million population (pmp). 85% of prevalent patients were aged <65 years and 58% were male. The prevalence of ESKD varied considerably with age with a peak at 55–64 years (2475 pmp for males; 2197 pmp for females). The annual incidence rate was 282 pmp with some regional variation and a substantially higher rate in the South (617 pmp). The most common cause of ESKD among prevalent and incident patients was diabetes. Other important causes were glomerulonephritis, hypertensive nephropathy and congenital or hereditary diseases.

Conclusions

Libya has a relatively high prevalence and incidence of dialysis-treated ESKD. As the country prepares to redevelop its healthcare system it is hoped that these data will guide strategies for the prevention of CKD and planning for the provision of renal replacement therapy.