Prevalence of Microalbuminuria and Associated Factors Among Type 2 Diabetes Mellitus Patients in Jigjiga Town Public Hospitals, Somali Regional State, Ethiopia, 2020

Under The aim of this study is to assess the prevalence of micro-albuminuria and associated factors among adult type two diabetes mellitus clients in public hospitals of Jigjiga town, Somali region, Ethiopia, from April 1 to July15, 2020 Methods: Institutional based cross-sectional study design was used from April 1 to July 15, 2020. A pretested structured questionnaire was used to collect a data from 204 Type 2 diabetes mellitus patients visiting at Karamara general and Jigjiga University referral hospitals for follow up. Descriptive statistics was computed. Logistic regression model was used to identify covariates using SPSS version 20. The direction and strength of statistical association was measured by odds ratio with 95 % CI and a P-value < 0.05 was considered as statistically signicant. Results: The prevalence of micro-albuminuria was 48.0% with [95% CI (41.2, 54.9)] Duration of DM between 11-20 years [AOR=3.71; 95% CI (1.45, 9.49)] Family history of hypertension [AOR=2.24; 95% CI: (1.02, 4.70)] Systolic blood pressure [AOR=3.36; 95% CI:(1.39, 8.13)], Low density lipoprotein [AOR=5.60; 95%CI: (2.22,14.11)] High density lipoprotein [AOR=5.210;95%CI:(2.067,13.131)] and Glycated hemoglobin [AOR = 3.246; 95% CI (1.356, 7.78)] were signicantly associated with micro-albuminuria Conclusion: There is a signicant level of micro-albuminuria among type 2 diabetes mellitus patients.


Introduction
Diabetes mellitus, (DM) a condition that is seen when the person's blood glucose rises because of complete absence of insulin (hormone that regulates blood glucose), or enough of it cannot be produced, or in certain conditions body is not able to use insulin when in fact it is being produced in the body. In type 2 diabetes, blood glucose rises due to the inability of the body's cells to respond fully to insulin, Though majority cases of Type 2 diabetes are commonly seen in older adults, nowadays children and younger adults are involved due to factors related to lifestyle [1]. Whatever its form (type I and II), diabetic mellitus may lead to many clinical complications including kidney failure that can lead to premature death, [2].It is also possible to categorize complications from both forms of diabetic mellitus that cause serious morbidity as nephropathy, neuropathy and retinopathy [3].
Under normal circumstances, a urine albumin excretion (UAE) of 5-10 mg/L is considered to be normal [4].
Microalbuminuria is , However, de ned as a level of albumin in the urine that is between 20 mcg/min, and 200 mcg/min (30-300mg/24h) with normal urine ow of 1 ml/min, below and above this range is called normo-albuminuric and macro-albuminuria, respectively [5,6] Nearly half of patients with diabetes develop diabetic nephropathy, the single leading cause of end-stage renal disease (ESRD). Microalbuminuria is a marker for the development of diabetic nephropathy in type II diabetes mellitus. After some period of living with DM, a patient with microalbuminuria may go to another stage called macroalbuminuria ,(albuminuria above 200mg/min) which necessitates the risk of progressing to ESRD [7].
Furthermore, the presence of microalbuminuria determines increased risk for heart disease as well as vascular damage due to arterial defects and endothelial dysfunction [8]. Diabetic nephropathy, initially marked by microalbuminuria may be the result of various underlying risk factors with individual glycemic control and excess weight being the leading ones [9][10][11].The fact that microalbuminuria can pose a huge threat to life by progressing to more serious stages like proteinuria, it is recommended that an individual with DM early checks for albuminuria in a period that is one year apart [12] According to international diabetic federation (IDF), globally, from a total of 5 billion, an estimated 463 million adults between the ages of 20-79 years (9.3%) have diabetes, and a total of 4.2 million deaths due to it. More than three fourth of these people live in countries considered to be low and middle income, with prevalence rate of (9.5% and 4%) respectively. By the year 2030 it is projected worldwide that the number of patients with DM will increase and climb 578.4 million, about (2.26%) increase in the prevalence of DM to the current rate. More than 310 million (10.8%) of diabetic patients live in urban settings, whereas almost 153 million (7.2%) live in rural areas [1]. Over the past three decades, globally the prevalence of DM has been gaining momentum with an estimated 4.7% in the year 1980 to 8.5% in 2014 [2] In 2019 China and India (the two most populous countries in the world) are the leading in the number of people living with DM (more than 116 million and 77 million, respectively) [1].
A recent report from over fty countries shows that 55% of individuals living with DM, develop an end stage renal disease [2].In western countries one fourth of patients with T2DM develop diabetic nephropathy with recent study showing that diabetic nephropathy (DN) is the single leading cause of end stage renal disease and replacement [13].
In the United Kingdom Prevalence of microalbuminuria (MA) among T2DM patients was reported to be less than 10% compared with Hispanic Americans in which the prevalence was 35% [14].Another report also states that the prevalence of microalbuminuria was high among individuals from South Asia (31%) when compared with white Europeans (20%) [15].
More than 19 million (3.9%) people in Africa between the age of 20-79 have DM of which nearly 75% die due to it. More than 55% of these people live in four countries with highest population which are South Africa (4.6), Nigeria (2.7), DRC (1.8)and Ethiopia(1.7million people) [1]. The prevalence of DM in Africa has been increasing over the last 3 decades, and even becoming the leading region per population of DM in the years to come. The reasons behind this increase may be due to scarce screening and diagnostics resources which may in turn delay early diagnosis and treatment [16]. Diabetic nephropathy is characterized by an increased albumin in the urine (UAE) without primary kidney problems [17]. Although Diabetic Nephropathy has been generally increasing with an increase in DM[16], its prevalence was reported to be higher in blacks [18,19]. That much studies are not available showing microalbuminuria prevalence at Africa level, however, some studies con rm variations in the prevalence of microalbuminuria from 9.2% in Tanzania [20] to47% in Uganda [21]. In Ethiopia almost 1.7 million (3.2) individuals have been reported to have DM and it is expected that this number to rise in the years to come [1],An available literature from Gondar town, northern Ethiopia indicates that the prevalence of microalbuminuria in Ethiopia was 37% [22].
Various risk factors have been related to microalbuminuria. In a study conducted in Albania by Pasko.N. and colleagues stated an increase in the level microalbuminuria as the duration with which the individual lives with DM increases, it also reported that macroalbuminuric clients had an increase in their blood pressure (both systolic and diastolic) compared to those who were normoalbuminuric [23]. A similar study conducted in Southern India showed macroalbuminuric individuals had an increased fasting blood glucose and glycated hemoglobin (HbA1c) when compared with their normoalbuminuric counterparts [24].
Being at older age, obese, overweight, hypertriglyceridemia and hypercholesterolemia were all associated with microalbuminuria[6].Different studies have outlined intervention for microalbuminuria, among those is a study involved in systematic review by Frederik Persson and fellows which reported treating with angiotensin converting enzyme inhibitor (ACEi), has yielded less compared to placebo in preventing the development of microalbuminuria [25]. Similar study but conducted in a large scale-cluster randomization revealed restrictions in the dietary sodium intake to have signi cantly reduced albuminuria [26].
Several studies which measures the prevalence of microalbuminuria and its associated factors; have been done elsewhere, conversely, only few studies were done in Ethiopia, on the prevalence of microalbuminuria among T2DM, therefore the aim of this study was to determine the prevalence and associated factors of microalbuminuria among T2DMpatients in Jigjiga town public hospitals, Somali Regional state, Eastern Ethiopia, 2020 using a cross sectional study design.
Public and private health care institutions in Somali region, only screen for overt proteinuria (macroalbuminuria) which is considered to be a marker for advanced stages of renal disease or some other physiological conditions, like fever and infections particularly urinary tract by using dipsticks(qualitative methods that cannot detect small amount of protein in the urine), However, microalbuminuria needs to be screened so that it can be treated before it becomes macro-albuminuria and diabetic nephropathy.
The rst and major importance of this study will therefore be generating valuable evidences regarding the associated factors of microalbuminuria, a clinical marker of renal involvement in T2DM patients in the context of Somali region, eastern Ethiopia. Secondly, the results of the study will be much useful to the actual diabetic clients, health care facilities (Hospitals, health centers etc.), and in setting appropriate preventive and therapeutic measures in addressing diabetic nephropathy and this study may become a baseline data for researchers who are interested in this topic.

General objective
To assess the prevalence and associated factors of microalbuminuria among type2 diabetes mellitus patients in Jigjiga town public hospitals, Somali Regional State, Eastern Ethiopia, from April 1 to July 15, 2020 Study area and Study period Study area Somali Regional State is one of 10 regional states of the Federal Democratic Republic of Ethiopia located in the Eastern part of Ethiopian lowlands. The region has 11 zones and more than 90 Woreda administrations. The study was conducted in Jigjiga town, capital of Somali Regional State located 635 km from Addis Ababa to the East. The town has one referral Hospital, one general hospital, 3 health centers and 20 health posts (government), 27 higher clinics, 10 medium clinics. This study was, however, be speci cally conducted in Jigjiga University Sultan Sheik Hasan Referral Hospital (JJUSSHRH) and Karamara General Hospital (KGH) where 500 T2DM clients make regular visits for follow up.

Study period
The study was conducted from April 1 to July 15, 2020

Study design
Institutional based cross-sectional study design was used.
Inclusion and exclusion criteria Inclusion criteria All T2DM clients willing to provide information and take part in the survey

Exclusion criteria
Menstruating women, those who have urinary tract infection, Hematuria, critically ill, those who present with acute febrile illnesses (AFI), Pregnancy, Suspected/diagnosed renal or hepatic or any systemic disorders i.e., sickle cell anemia Sample size determination Sample size for the rst objective The sample size was calculated by using single population proportion formula considering a 95% con dence interval, 5% margin of error and prevalence of micro-albuminuria 37% [22].
The total sample size =358 Since, the source population was 500, which is below 10,000, population correction formula was used. The nal sample size of this study was = 222 Sampling technique All 222 study units were consecutively selected upon arrival and included in the study

Sampling procedure
The study participants were allocated for the two hospitals in a manner that was proportional to their number of clients registered and come for follow up. JJUSHRH had a total of 350 T2DM clients while KGH had a total of 150.
To proportionate the number of study subject for each hospital, the formula = was used. Where n=number of clients registered for follow up in each hospital, nf = total sample size and N= the total number clients registered for follow up in the two hospitals.
The proportional size For JJUSHRH was as follows The proportional size For KGH was as follows Data collection methods and materials A structured questionnaire was used to interview clients in order to collect data on socio -demographic and clinical variables. Anthropometric measurements such as, Weight of the client in kilograms(kg)was measured to the nearest 0.1 kg using calibrated weighing scale and Height of the client in meters (m)was measured in standing position with shoes removed using stadiometer to the nearest 0.1 cm. Body mass index of the client in (kg/m2) was also measured and then classi ed based on the WHO reference values as underweight if less than 18.5, Normal if 18.5-24.99, overweight 25-29.99 and obese if greater than 30kg/m2 [2].
Routine physical examination was done on clients by the physicians available at the chronic clinics or outpatient departments (OPDs) as the clients visited the hospitals and those found to have signi cant complications of systemic disorders like cardiovascular disorders and hepatic enlargement (through palpation) were excluded from the study.
Blood pressure in millimeter mercury (mmHg) in sitting position was measured using Sphygmomanometer and stethoscope from the left arm after the individual rested for about 5 minutes, in order to record the data, an average of two measurements which are 5 minutes apart were done and nally taken as the blood pressure results of the clients. Clients were classi ed as hypertensive if they had systolic blood pressure of > 140 mmHg and/or diastolic blood pressure of >90mmHg or known to be hypertensive on medications (antihypertensive).
Venipuncture (venesection) was performed through aseptic technique and 8 ml of blood was collected in test tube, then the blood was analyzed within the day of collection, for complete blood count (CBC).
Serum creatinine, low density lipoprotein (LDL), high density lipoprotein (HDL)and blood urea nitrogen (BUN)was measured using Biosystems A25 chemistry analyzer. Glycosylated hemoglobin (HbA1c) which represents glycemic control for the last three months with the aid of EDTA containing test tubes was also analyzed using Fine care HbA1c analyzer, and the results of the test were categorized as good control if the HbA1c value was<7% and poor control if it was >7%.FBS was measured using Prodigy Auto Code which displays the readings quantitatively and the result was categorized as normal if <80-130mg/dl (only for known DM patients) and high if > 130mg/dl. All sample were analyzed with in the day of collection.
A morning spot mid-stream urine specimen of 10 ml was collected using pre-treated containers, 5ml was taken from the 10ml using a syringe to another container for urine analysis using dipstick to check the presence of proteins, glucose, red and white blood cells. Presence of the above-mentioned substances in the urine, were dealt with an appropriate treatment through the available physicians. Microalbuminuria was checked using HemoCue ® 201 albumin analyzer (HemoCue®, Ängelholm, Sweden) and its microcuvettes, HemoCue ® 201 albumin analyzer is a factory calibrated electronic device that employs immunoturbidimetry and quantitatively measures a slight amount of albumin in the urine that the dipsticks cannot detect.
Microalbuminuria was measured three times one month apart then microalbuminuria was considered positive if two out of three tests within 3 months read 20-199mg/L [27].
Since all patients having the follow ups in these two hospitals were mainly residents of Jigjiga town and its surrounding (rural kebeles), upon meeting with the clients for the rst visit, personal address like telephone and possible way of communication like neighborhood and house number were asked so that it becomes easier for the data collectors to reach/visit those who do not (if any) make a visit to the hospitals in the next follow up.

Data collectors
The data was collected by four diploma laboratory technologists and two BSc nurses (3 for each hospital) who were under the guidance of one BSc nurse holder supervisor for each hospital.
Procedure for data collection Before data collection, four days of training were given for both the data collectors and supervisors by a senior laboratory technologist. Before interviewing, the data collectors informed the clients about the aims/purposes, possible risks (from physical discomfort to potential in ammation of the veins) and possible bene ts of the study (potential change in the treatment protocol of their chronic disorder), the right and refusal to participate in the study. The collected information was kept con dential. Participants who were willing and sign the voluntary consent form were interviewed. Data was collected through faceto-face interviews using unstructured and pretested questionnaire. Four days of training were provided for the data collectors and supervisors. Pre testing of questionnaire was done at two selected private clinics in the same town and calibration of instruments was made to ensure the quality of data, to assess the reliability, clarity, sequence, consistency, and the total time that it will take to nish the questionnaire before the actual data collection begins. Then after, the necessary feedbacks were incorporated in the nal tool to improve its quality. Principal investigator and supervisors made spot-checking and reviewing all the completed questionnaires and specimens to ensure completeness and consistency of the information collected. Data entry was done by the principal investigator to keep accuracy of the data. The specimen was labeled with codes that match with the codes of the questionnaires to prevent mismatch of specimen and respective questionnaires. Data processing and analysis

Operational de nitions
The data was entered into statistical software Epi data version 3,1, double data entry was made and then, exported to SPSS version 20after exporting the prepared data. Descriptive statistics such as frequency distribution was computed to describe variables of the study. The data was described and presented using narrative text, tables, and chart.
Logistic regression model was used to analyze the outcome variable. It was performed in two stages; in rst stage a bivariate analysis was conducted to identify a candidate's covariates for multivariate analysis at p-value less than 0.25. In the second stage, multivariate analysis was done to see the association between the outcome variable and independent variables which were signi cant at bivariate stage. The direction and strength of statistical association was measured by odds ratio with 95 % CI. In this study P-value < 0.05 was considered as statistically signi cant.
The model adequacy and tness were checked using Hosmer-Lemeshow goodness of t test and all assumptions of regression analysis (model adequacy and multi collinearity of the independent variables) was also checked. Multi-collinearity was checked using variance in ated factor (VIF)/ tolerance and no multi-collinearity was found between variables.

Ethical considerations
All methods were done in accordance with the declaration of Helsinki. Ethical clearance was obtained from the Institutional Health Research Ethics Review Committee (JJU-IHRERC College of Medicine and health sciences,) of Jigjiga University. For Karamara General Hospital, a formal letter of permission and support was written to regional health bureau which is responsible for regional controlled hospitals and for Sheik Hasan Referral Hospital, Jigjiga University has written a letter to it as it's under the control of the university. All the study participants were informed about the purpose of the study, their right to refuse was stressed and written and signed voluntary consent was obtained from all study participants prior to data collection. The respondents were assured that the information as well as specimens obtained from them will not be used for any other purpose and treated with complete con dentiality. Clients who test positive for microalbuminuria during data collection were linked back to their OPD for an appropriate treatment.

Plan for Information dissemination
The ndings of this study will be submitted and presented to the School of Graduate Studies, College of Medicine and Health Sciences, of Jigjiga University. The ndings of this study will also be disseminated to JJUSHRH and KGH. Furthermore, publication of this thesis will be tried as one major dissemination strategy.

Socio-Demographic Characteristics of the Study Participants
Out of the 222 study participants primarily sampled for the study, 204 have participated making the response rate 91.9%. The mean age of the study participants was 55.90 with SD of ±13.33, the minimum and maximum age of the study participants was 24 and 82 years respectively ( Table 1)   were 181(88.7%) and about 108(52.9%) of the participants had a normal fasting blood sugar. Concerning glycated hemoglobin (HbA1c) 118(57.8%) were having a poor control over their diabetes (Table 3). In the multivariable analyses, duration of DM between 11-20years signi cantly associated with microalbuminuria with AOR of4times [AOR=3.708; 95%CI : ( 1.449, 9.490)] compared to <5 and 5-10 years.

Discussion
In this study the prevalence of microalbuminuria was found to be 48.0% This study also reports that Duration of DM, Family history of hypertension, systolic blood pressure, Low density lipoprotein, High density lipoprotein and Glycated/glycosylated were signi cantly associated with Microalbuminuria The prevalence of this study is much higher than the prevalence reported in the study conducted in Singapore which was14.2% [33], the prevalence of 17.2% in northern Iran [34]and that of 20.3% reported in Kathmandu, Nepal [35].These variations may be attributed mainly to differences between study areas, period, sample size and the tools and devices used to measure microalbuminuria which was Dako and Albumin-Creatinine ratio (ACR) In this study, however, we used HemoCue albumin analyzer.  [37], and 37% reported in Gondar, Ethiopia [22],all of which may be due to differences in study period, sample size, measuring tools, methods used, and also de nitions of microalbuminuria where microalbuminuria was de ned by these studies as albumin to creatinine ratio ranging from 30 to 300 mg/g in a 24-hour urine collection, (ours de ned as ranging 20-199mg/l in a morning spot urine collection).were also markedly lower than the prevalence rate of this study.
This study has found a prevalence that is comparable with other cross-sectional studies conducted in India, Turkey, and Botswana which have reported prevalence rate of41.5%, 43.2% and 44.6%, respectively [18,38,39]. It is also consistent with the prevalence of the institutional based cross-sectional study that was conducted in Mulago National referral hospital, Uganda which reported a prevalence of 45.7% [21] This nding is however much smaller than the prevalence of another similar study conducted at Warri, Nigeria which revealed a prevalence of 58% [40]. Possible difference may be due to the inclusion of higher age groups in the study (45-80years) which seem to focus on older ages and in turn may increase the prevalence of the microalbuminuria, in this study we used age between 18-82years, nally, of course the use of MICRAL test which may also increase the prevalence rate and other possible factors including study period were detected as vital differences.
Micro-albuminuria was nearly 4 times more likely to affect those patients with longer duration of DM. This is in line with various similar studies conducted in Malaysia, Taiwan, Northern Iran, Palestine and Botswana [6, 10,18,34,41].This study found that duration of DM between 11-20 years associated with microalbuminuria. This is also supported by the study conducted at Ekiti, Nigeria which revealed a signi cant association between microalbuminuria and duration of DM greater than 10 years. Possible reason for this association may include, the fact that people living with diabetes for a longer period of time encounter renal involvement due to high persistent sugar concentration in the blood vessels over time and due to the degenerative nature of aging affecting kidneys and blood vessels leading up to the kidneys.
Family history of hypertension was signi cantly associated with microalbuminuria, this study revealed that microalbuminuria was2times more likely to affect those patients with family history of hypertension. This is supported by the study conducted in Egypt, which revealed a signi cant association between microalbuminuria and family history of hypertension [42]. This may be attributed to genetical and hereditability means, or on the other hand, family history of hypertension may cause renal damage to the family member (parents) and that may affect the offspring's kidneys Systolic blood pressure (SBP) was signi cantly associated with microalbuminuria, in this study, patients with high systolic blood pressure were reported to be 3 times more vulnerable to encountering microalbuminuria. This is in line with the study conducted in Tirana, Albania which reported a signi cant association between SBP and microalbuminuria [23]. This is also supported by the study conducted in India and Taiwan which both found a signi cant association between SBP and microalbuminuria [41,43].
This association may due to fact that an increased blood pressure puts the kidney in a strangulated manner due to Vaso-constriction which makes di cult for the kidneys to nd oxygen and nutrient (through blood) which is vital for kidneys' normal functioning including prevention of protein loss through urine.
Another factor that was found to be signi cantly associated with microalbuminuria was Low density lipoprotein (LDL), in these study patients with higher LDL were almost 6times more likely to have microalbuminuria. The same is true for the study conducted by Vaidya and colleagues which found signi cant correlation between LDL and microalbuminuria [43]. This is also supported by the studies conducted in Kerala, Nigeria and Cameroon which all stated the signi cant association between LDL and micro-albuminuria [40,44,45].
This association may be attributed to the fact that an increased LDL may nally bring about atherosclerosis or fatty deposition of the arterial walls which makes the blood vessels narrower in diameter and that could interrupt blood supply to the kidneys, impairing the kidney's functions and eventually kidneys 'start releasing proteins (Albumin).
This study found that Lower High-density lipoproteins (HDL)was associated with microalbuminuria. This is in line with a previous study conducted in Wari, Nigeria which also reported a signi cant association between HDL and microalbuminuria [40]. This association may be justi ed as the HDL also known as good cholesterol helps us remove excess cholesterol (bad cholesterol) from our cells, tissues and sometimes plaques in the blood vessels, and then returns to the liver for subsequent removal, when it becomes lower, microalbuminuria may be seen.
Glycosylated/glycated hemoglobin (HbA1c) was found in this study to have also signi cantly associated with microalbuminuria, according to this study, patients with poor glycemic control were 3times more likely to have microalbuminuria. This is consistent with various similar studies including ones conducted in the cities of Islamabad and Peshawar in Pakistan, Albania, Taiwan and some from sub-Saharan Africa [11,23,41,[44][45][46][47][48].
Possible justi cation to this association may be the fact that continuous high sugar levels can damage the small blood vessels across the body and in particular the kidneys, poorly controlled glycemic can also cause damage to the tiny lters of the kidney called glomeruli which lter the blood. Due to the presence of special function called reabsorption, the kidneys have the ability to release waste products while retaining the important substances like macronutrients, of which albumin, a plasma protein is a member when however, blood glucose is poorly controlled the kidneys are damaged and as a result of that kidneys begin leaking proteins (Albumin) through the urine.

Limitations of these study
Due to nancial resource constraints in this study, large enough sample size could have not been determined and that may affect the overall prevalence of this study and may widen the con dence intervals as well.

Conclusions
There exists a signi cant level of microalbuminuria among type 2 diabetes mellitus patients with relatively longer duration of diabetes, Family history of hypertension, higher-Low density lipoprotein and lower-High density lipoprotein. Poorly controlled systolic blood pressure and glycemic were identi ed as two important major modi able risk factors for microalbuminuria. Prevalence of microalbuminuria and Associated Factors among type 2 diabetes mellitus patients in Public Hospitals of Jigjiga town, Somali Region, Ethiopia, 2020.