A total of 658 patients attended renal, hypertensive, diabetic and general MOPD clinics during the 4 months of enrollment. Of the 658 patients who attended the medical outpatient clinic during the study period, 306 patients were excluded from the study including 234 patients who didn’t have CKD, 69 patients had Advanced CKD (CKD stage 4 & 5) and 3 patients didn’t provide consent. A total of 206 (58.5%) enrolled patients had hypertension, of whom 120 (58.3%) patients had uncontrolled hypertension (Figure 1).
Baseline and demographic characteristics of study patients
A total of 352 patients with median age of 54 (47-59) years met the criteria to be included in this study; 182 (51.7%) were male, 252 (71.6%) were married, 205 (58.2%) living in urban areas and 258 (73.3) had at-least secondary level education. A total of 206 (58.5%) patients had hypertension, of whom 120 (58.3%) patients had uncontrolled hypertension. For those with uncontrolled hypertension the median age was 55(50-60) years, 48(45-56) years for those with controlled hypertension and 54(48-59) years for normotensive participant. The median systolic blood pressure (SBP) was 146(142-150) mmHg for those with uncontrolled hypertension and 125(120-128) mmHg for those with controlled hypertension, the median diastolic blood pressure (DBP) was 86 (82-90) mmHg for those with uncontrolled hypertension and 80(76-84) mmHg for those with controlled hypertension. The median body mass index (BMI) was 26.1(24.0-27.5) kg/m2 for those with uncontrolled hypertension and 24.4(23.4-26.0) kg/m2 for those with controlled hypertension while the median waist circumference was 97(90-104) cm for those with uncontrolled hypertension and 90(84.5-103.0) mmHg for those with controlled hypertension. The median eGFR was 48(43-55) mil/min/1.73m2 for those with uncontrolled hypertension and 53(45-62) mil/min/1.73m2 for those with controlled hypertension (Table 1).
Table 1: Socio-demographics and Clinical data of patients with early CKD by their hypertensive status (n=352)
Variables
|
Uncontrolled hypertension
(n=120)
|
Controlled hypertension
(n=86)
|
Normotensive (n=146)
|
p-value
|
|
Median (IQR) or Proportion
|
Median (IQR) or Proportion
|
Median (IQR) or Proportion
|
|
Age (years)
|
55 (50-60)
|
48 (45-56)
|
54(48-59)
|
0.001
|
Sex
Male
Female
|
61(50.8%)
59(49.2%)
|
48(55.8%)
38(44.2%)
|
73(50%)
73(50%)
|
0.631
|
Marital status
Married
Single
|
87(72.5%)
33(27.5%)
|
57(66.3%)
29(33.7%)
|
111(76.0%)
35(24.0%)
|
0.399
|
Level of education
Primary or less
Secondary and above
|
38(31.7%)
82(68.3%)
|
19(22.1%)
67(77.9%)
|
50(34.2%)
96(65.8%)
|
0.221
|
Residence
Rural
Urban
|
58(48.3%)
62(51.7%)
|
32(22.1%)
54(77.9%)
|
58(39.7%)
88(60.3%)
|
0.232
|
Occupation
Employed
Self-employed
|
49(40.8%)
71(59.2%)
|
30(34.9%)
56(65.1%)
|
41(28.1%)
105(71.9%)
|
0.712
|
NHIF status
Insured
Not insured
|
47(39.2%)
73(60.8%)
|
31(36.0%)
55(64.0%)
|
70(47.9%)
76(52.1%)
|
0.093
|
SBP (mmHg)
|
146(142-150)
|
125(120-128)
|
122(120-128)
|
0.001
|
DBP (mmHg)
|
86(82-90)
|
80(76-84)
|
78(76-82)
|
0.001
|
BMI (Kg/m2)
|
26.1(24.0-27.5)
|
24.4(23.4-26.0)
|
25.5(24.4- 30.8)
|
0.001
|
Waist circumference (cm)
|
97(90-104)
|
90(84.5-103.0)
|
91.5(81.0-104.0)
|
0.003
|
Hb (g/dl)
|
12.4(10.9-13.2)
|
12.6(11.4-13.2)
|
12. 3(11.0- 13.2)
|
0.289
|
FBG (mmol/L)
|
5.3(4.9-6.2)
|
5.1(4.9-5.7)
|
5.0(4.8-5.5)
|
0.001
|
HbA1c (%)
|
6.2(5.8-6.7)
|
5.6(5.0-6.0)
|
5.8(5.7-6.2)
|
0.020
|
Creatinine (umol/L)
|
130.9(123.0-138.9)
|
124.2(120.5-137.7)
|
119(116.4-132.2)
|
0.025
|
eGFR (mil/min/1.73m2)
|
48(43-55)
|
53(45-62)
|
55(53-61)
|
0.001
|
BUN (mmol/l)
|
8.0(7.2-8.9)
|
7.4(6.9-8.3)
|
6.7(6.4-7.4)
|
0.013
|
uPCR
|
0.025(0.025-0.130)
|
0.025(0.02-0.027)
|
0.025(0.025-0.120)
|
0.001
|
Total Cholesterol(mmol/l)
|
5.4(4.5-6.0)
|
4.8(4.1-5.9)
|
4.0(4.1-4.7)
|
0.164
|
Triglycerides(mmol/l)
|
4.6(1.5-5.4)
|
1.6(1.5-5.0)
|
1. 3(1.5-4.8)
|
0.251
|
HDL-C(mmol/l)
|
1.2(0.8-1.4)
|
1.3(0.9-1.7)
|
1.3(0.8-1.5)
|
0.008
|
LDL-C(mmol/l)
|
3.8(3.1-4.4)
|
3.3(3.0-4.0)
|
3.5(3.1-4.2)
|
0.200
|
Abbreviations: BMI, Body mass index; BUN, blood urea nitrogen; CKD, chronic kidney disease; DBP, diastolic blood pressure; eGFR, estimated glomerular filtration rate; FBG, Fasting blood glucose; Hb, Hemoglobin; HbA1c, glycosylated hemoglobin; HDL, high density lipoprotein; IQR, Interquartile range; LDL, Low density lipoprotein; NHIF, national health insurance fund; SBP, systolic blood pressure; uPCR, urine protein-creatinine ratio.
Clinical profile of study participants
Of the 120 patients with uncontrolled hypertension, 88.3% patients had CKD stage 3, 80.0% patients reported non-adherence to antihypertensives, 76.7% patients had overweight/obesity, 72.5% patients reported current alcohol use, 60.0% patients had dyslipidemia, 43.3% patients reported current smoking, 36.7% patients presented with significant proteinuria and 26.7% patients had diabetes mellitus (Table 2)
Table 2: Clinical profile of patients with early CKD by their hypertensive status (n=206)
Variables
|
Uncontrolled hypertension
(n=120), Proportion (%)
|
Controlled hypertension
(n=86), Proportion (%)
|
p-value
|
Age (years)
<50
>_50
|
26 (21.7%)
94(78.3%)
|
47(54.7%)
39(45.3%)
|
0.001
|
Current alcohol use
No
Yes
|
33(27.5%)
87(72.5%)
|
56(65.1%)
30(34.9%)
|
0.001
|
Current smoking
No
Yes
|
68(56.6%)
52(43.3%)
|
61(70.9%)
24(29.1%)
|
0.028
|
Diabetes mellitus status
No
Yes
|
88(73.3%)
32(26.7%)
|
73(84.9%)
13(15.1%)
|
0.048
|
Adherence to antihypertensives (Morisky score)
<_2
>2
|
24(20.0%)
96(80.2%)
|
51(59.3%)
35(40.7%)
|
0.001
|
Overweight or obesity
No
Yes
|
28(23.3%)
92(76.7%)
|
45(52.3%)
41(47.7%)
|
0.001
|
Anemia status
No
Yes
|
70(58.3%)
50(41.7%)
|
56(65.1%)
30(34.9%)
|
0.326
|
CKD stage
Stage 2
Stage 3
|
14(11.7%)
106(88.3%)
|
29(33.7%)
57(66.3%)
|
0.001
|
Lipid profile
Normal
Impaired
|
48(40.0%)
72(60.0%)
|
48(55.8%)
38(44.2%)
|
0.025
|
uPCR
<0.03
>_0.03
|
76(63.3%)
44(36.7%)
|
75(87.2%)
11(12.8%)
|
0.003
|
Abbreviations: CKD, chronic kidney disease; uPCR, urine protein-creatinine ratio.
Factors associated with uncontrolled hypertension
We divided the patients into two subgroups [(uncontrolled hypertension ≥140/90mmHg) vs. (controlled hypertension <140/90mmHg)]. A total of 15 potential variables were identified after performing univariate logistic regression analyses. Backward elimination reduced this to 10 parameters; the factors independently associated with uncontrolled hypertension on multivariate logistic regression analysis included: age ≥ 50 years (OR =5.17, 95 % CI 2.37-13.33, P = 0.001), alcohol use (OR = 11.21, 95% CI 3.83-32.84, P = 0.001), Overweight and Obesity (OR=6.28, 95% CI 2.54-15.53, P = 0.001), non-adherence to antihypertensives (Morisky score >2) (OR =10.19, 95% CI 4.22-24.61, P = 0.001) and CKD stage 3 (OR=3.52, 95% CI 1.32-9.42, P = 0.012). Current history of smoking, proteinuria, and dyslipidemia were statistically significantly associated with uncontrolled hypertension on the univariate logistic regression analysis but this association was lost on multivariate logistic regression analysis (Table 3).
Table 3: Factors associated with uncontrolled hypertension (n=120)
Variables
|
No of patients
|
Univariate
|
Multivariate
|
|
|
COR (95% CI)
|
P-value
|
AOR (95% CI)
|
P-value
|
Age
<50
≥ 50
|
26
94
|
Ref
4.36 (2.37-8.01)
|
<0.001
|
5.62 (2.37-13.33)
|
0.001
|
Residence
Urban
Rural
|
58
62
|
Ref
1.50(0.86-2.64)
|
0.156
|
Ref
1.43 (0.64-3.18)
|
0.379
|
Alcohol
No
Yes
|
33
87
|
Ref
7.85 (3.70-16.64)
|
<0.001
|
Ref
11.21(3.83-32.84)
|
0.001
|
Smoking
No
Yes
|
68
52
|
Ref
1.94(1.07-3.52)
|
0.028
|
Ref
1.76 (0.77-4.03)
|
0.179
|
Diabetes mellitus status
No
Yes
|
88
32
|
2.04(0.99-4.18)
|
0.050
|
1.32(0.45-3.81)
|
0.613
|
Overweight or Obesity
Normal
Increased
|
28
92
|
Ref
3.61 (1.98-6.56)
|
<0.001
|
Ref
6.28 (2.54-15.53)
|
0.001
|
Adherence to antihypertensives
≤ 2
>2
|
24
96
|
Ref
5.83(3.13-10.84)
|
<0.001
|
Ref
10.19 (4.22-24.61)
|
0.001
|
CKD stage
Stage 2
Stage 3
|
14
106
|
Ref
3.85(1.89-7.87)
|
<0.001
|
Ref
3.52(1.32-9.42)
|
0.012
|
Proteinuria
No
Yes
|
76
44
|
Ref
2.74(1.40-5.35)
|
0.003
|
Ref
2.24(0.81-6.24)
|
0.121
|
Lipid profile
Normal
Impaired
|
48
72
|
Ref
1.90(1.08-3.32)
|
0.026
|
Ref
1.39(0.61-3.12)
|
0.432
|
Abbreviations: 95% CI, 95% Confidence interval; AOR, Adjusted odds ratio; CKD, chronic kidney disease; OR, odds ratio.