|Year : 2018 | Volume
| Issue : 3 | Page : 59-67
Prevalence of diabetic kidney disease before and after renal transplantation in Arab countries
Osama Gheith1, Nashwa Othman2, Aymen Maher1, Suzann Rida3, Medhat A Halim4, Heba Abduo5, Torki Al-Otaibi4
1 Department of Internal Medicine and Nephrology, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
2 Department of Public Health Nursing, Faculty of Nursing, Mansoura University, Mansoura, Egypt
3 Department of Public Health and Nephrology, Hamed Al-Essa Organ, Transplant Center of, Kuwait
4 MRCP of Internal Medicine and Nephrology, Hamed Al-Essa Organ, Transplant Center of, Kuwait
5 Dasman Diabetes Institute of, Kuwait
|Date of Submission||18-Jun-2018|
|Date of Acceptance||06-Sep-2018|
|Date of Web Publication||09-Nov-2018|
Dr. Osama Gheith
Department of Internal Medicine and Nephrology, Urology and Nephrology Center, Mansoura, Safat 13001
Source of Support: None, Conflict of Interest: None
Introduction The Arab world contains 22 countries with a total population of 362.5 million people. The prevalence of diabetes around the world has reached epidemic proportions. It already affects nearly more than 350 million people and is predictable to grow to more than 550 million people by 2035. The prevalence of diabetic kidney disease (DKD) in Arab countries is not well studied. The aim of the study was to review and present the prevalence of DKD among the Arabian population.
Materials and methods We reviewed most of the published data − since the 1980s − in different Arabic countries regarding the prevalence of diabetes and DKD.
Results The Arab countries with the highest prevalence of T2DM are: the Kingdom of Saudi Arabia (31.6%), Oman (29%), Kuwait (25.4%), Bahrain (25.0%), and the United Arab Emirates (25.0%). The lowest prevalence was found in Mauritania (4.7%) and Somalia (3.9%). Arab countries with high prevalence of micro-albuminuria included UAE, KSA, Bahrain, and Lebanon while KSA, Kuwait, Bahrain, and Egypt represented countries with the highest prevalence of macro-albuminuria. Low prevalence of DM and DKD was found in Iraq and Tunisia. These differences could be attributed to the genetic predisposition and the change in lifestyle. The cumulative incidence of PTDM at 12 months post-transplant was 17.6% in Sudan, 27% in KSA, 27% among the Egyptian liver transplants, 22.2% among the Egyptian kidney recipients, and 33% in Bahrain. There is no data available regarding diabetic kidney disease in renal transplant recipients in Arab countries.
Conclusion Diabetic nephropathy is not an uncommon complication of diabetes (types 1 and 2) in Arab countries. Rapid economic growth in some Arabic speaking countries improved the infrastructure, but carries with it the burden of risk factors of DM. Large prospective collaborative studies are critically needed to explore this medical and socioeconomic problem among the Arab people before and after renal transplantation.
Keywords: Arab countries, diabetic kidney disease, prevalence
|How to cite this article:|
Gheith O, Othman N, Maher A, Rida S, Halim MA, Abduo H, Al-Otaibi T. Prevalence of diabetic kidney disease before and after renal transplantation in Arab countries. J Egypt Soc Nephrol Transplant 2018;18:59-67
|How to cite this URL:|
Gheith O, Othman N, Maher A, Rida S, Halim MA, Abduo H, Al-Otaibi T. Prevalence of diabetic kidney disease before and after renal transplantation in Arab countries. J Egypt Soc Nephrol Transplant [serial online] 2018 [cited 2018 Dec 11];18:59-67. Available from: http://www.jesnt.eg.net/text.asp?2018/18/3/59/245126
| Overview|| |
Diabetic kidney disease (DKD) developed in 20–40% of diabetic patients. In the Western world, DKD is the primary single cause of end-stage kidney disease (ESKD) . Both type 1 and type 2 diabetes can lead to nephropathy, but in type 2 diabetes, a smaller proportion of patients progresses to ESKD. Owing to the higher prevalence of type 2 diabetes, these patients represent more than 50% of diabetics on dialysis  and the incidence of DKD as a cause of ESKD is increasing each year . DKD is characterized by elevated urine albumin excretion or reduced glomerular filtration rate (GFR), or both .
The prevalence of diabetes around the world has reached epidemic proportions. It already affects nearly more than 350 million people (8% of the global population), and is predictable to grow to more than 550 million people by 2035 . More than 40% of diabetics will develop chronic kidney disease (CKD) , with a significant number who will develop end-stage kidney disease (ESKD) requiring renal replacement therapies (dialysis and/or transplantation).
The highest incidence rate of DKD is 3% per year on average, seen 10–20 years after diabetes onset, after which the rate of nephropathy tapers off. Therefore, a diabetic patient for 20–25 years without clinical signs of DKD has a low chance to develop such complication (only a 1% year) . There is marked racial/ethnic and international difference in the epidemiology of diabetic kidney disease  with a higher risk of development of ESKD among the Native Americans, Hispanics, and African Americans compared with non-Hispanic whites with type 2 diabetes. Internationally, there is considerable variability among countries, with percentages fluctuating from 9% in Russia to 49% in Malaysia. This discrepancy could be explained by the differences in economic viability and governmental infrastructures .
| Stages of and prediction of diabetic kidney disease|| |
Diabetic nephropathy is a chronic complication of both type 1 DM (beta cell damage, absolute lack of insulin) and type 2 DM (insulin resistance and/or decreased secretion of insulin) . Five stages had been recognized in the development of diabetic kidney disease: In stage I, the GFR is either normal or increased and lasts around 5 years from the onset of diabetes. The size of the kidneys is increased by nearly 20% and renal plasma flow is increased by 10–15%, but without albuminuria or hypertension. Stage II starts more or less 2 years after the onset of the disease with thickening of the basement membrane and mesangial proliferation with normalization of GFR, but without clinical signs of the disease. Many patients continue in this stage for life. However, stage III represents the first clinically detectable sign of glomerular damage and micro-albuminuria (albumin 30–300 mg/day). It usually occurs 5–10 years after the onset of the disease with or without hypertension. Approximately 40% of patients reach this stage. Stage IV is the stage of CKD with irreversible proteinuria (>300 mg/day), decreased GFR below 60 ml/min/1.73 m2, and sustained hypertension. Stage V is defined when ESKD with GFR less than 15 ml/min/1.73 m2 is detected. Nearly 50% of patients will need renal replacement therapy in the form of peritoneal dialysis, hemodialysis, or kidney transplantation . In the early stages of diabetic nephropathy, nephromegaly and changed Doppler indicators may be the early morphological signs of renal damage; however, proteinuria and GFR are the best indicators of the degree of damage . Micro-albuminuria can predict the progression of kidney damage in patients with type 1 or 2 DM and this was confirmed in the early 1980s . Approximately20–30% of the patients progress to micro-albuminuria after 15 years of disease duration and less than half develop real nephropathy. The European Diabetes (EURODIAB) Prospective Complications Study Group  and an 18-year Danish study  reported the overall occurrence of micro-albuminuria (after 7.3 years) in patients with type 1 and 2 DM as 12.6% and 33%, respectively. However, in the United Kingdom Prospective Diabetes Study (UKPDS), the incidence of micro-albuminuria in patients with type 2 DM in Great Britain is 2% per year and the prevalence is 25% 10 years after the diagnosis . Proteinuria develops more frequent in patients with type 1 diabetes (15–40%), usually after 15–20 years of DM duration, but in patients with type 2 DM, the prevalence varies between 5 and 20% .
A classification of type 1 and type 2 diabetic nephropathy was developed by the research committee of the Renal Pathology Society . Four classes of glomerular lesions were defined:
- Class I: showed isolated glomerular basement membrane thickening. Basement membranes are greater than 430 nm in men older than age 9 years and 395 nm in women. There is no evidence of mesangial expansion, increased mesangial matrix, or global glomerulosclerosis involving greater than 50% of glomeruli.
- Class II: mild (class IIa) or severe (class IIb) mesangial expansion. A lesion is considered severe if areas of expansion larger than the mean area of a capillary lumen are present in greater than 25% of the total mesangium.
- Class III: at least one Kimmelstiel–Wilson lesion (nodular intercapillary glomerulosclerosis) is observed on biopsy and there is less than 50% global glomerulosclerosis.
- Class IV: advanced diabetic sclerosis. There is greater than 50% global glomerulosclerosis that attributable to diabetic nephropathy.
The severities of interstitial and vascular lesions were also assigned scores according to the degree of interstitial fibrosis, tubular atrophy, lymphocyte infiltrates, and vascular haylinosis. Although this classification scheme is helpful to pathologists, its clinical utility is unknown.
| Risk factors for kidney disease in type 1 diabetes|| |
Hyperglycemia is a well-known risk factor for DKD and it was recognized that tight glucose control reduces the risk of DKD . Specifically, during the Diabetes Control and Complications Study (DCCT), near normalization of blood sugar decreased the risks of incident micro-albuminuria and macro-albuminuria by 39% (95% CI: 21–52%) and 54% (95% CI: 29–74%), respectively, compared with conventional therapy. Even with long-term follow-up in observational Epidemiology of Diabetes Interventions and Complications (EDIC) Study, formerly assigned patients to DCCT-intensive therapy study continued to experience lower rates of incident micro-albuminuria and macro-albuminuria with risk reductions of 45% (95% CI: 26–59%) and 61% (95% CI: 41–74%), respectively . Beneficial effects of intensive therapy on the worsening of GFR have become evident in the long term combined DCCT/EDIC follow-up, with a risk reduction of 50% (95% CI: 18–69%). Other risk factors for DKD in diabetics include male sex, obesity, hypertension, inflammation, resistance to insulin, hypovitaminosis D, and dyslipidemia . Moreover, a hereditary component to DKD has long been recognized as some genetic loci and polymorphisms in specific genes have been associated with DKD.
| Diabetic kidney disease in type 1 diabetes|| |
Innovative studies of type 1 diabetes considered the natural history of DKD as progressive increase of urine albumin excretion followed by GFR loss and the development of ESKD. Micro-albuminuria was defined as an albumin excretion rate (AER) of 30–299 mg/24 h ‘incipient nephropathy’, which has progressed steadily to macro-albuminuria with an AER greater than or equal to 300 mg/24 h ‘diabetic nephropathy’. Micro-albuminuric patients are commonly noted to have higher GFR ‘hyperfiltration’, while macroalbuminuric patients showed rapid GFR loss leading steadily to ESKD. Frequent exceptions had been observed. Specifically, albuminuria has been observed to revert, while GFR loss has been observed without albuminuria and is not always progressive. Therefore, albuminuria and impaired GFR are not necessary complementary, overlapping manifestations of DKD .
| Incidence of kidney disease in type 1 diabetes|| |
Nearly half of patients with type 1 DM develop diabetic kidney disease over the course of their lifetime. However, albuminuria and reduced GFR both are infrequent during the first 10 years after type 1 diabetes diagnosis. In more recent studies, the lifetime increasing incidence of macro-albuminuria has been defined as 15–25%, and the cumulative incidence of micro-albuminuria has been reported as 25–40%. In early studies, up to 35% of participants developed ESKD. In Finland and in the Pittsburgh Epidemiology of Diabetes Cohort (Pittsburgh, Pennsylvania, USA), the long-term cumulative incidence of ESKD has dropped to less than 10%, though the rate of ESKD has remained higher in the Joslin type 1 diabetes cohort (Boston, Massachusetts, USA) .
| Progression of kidney disease in type 1 diabetes|| |
The progression of DKD in type 1 diabetes is unpredictable. In the Joslin type 1 diabetes cohort, 29% of participants with micro-albuminuria showed reduced GFR within 12 years’ average follow-up. The EURODIAB type 1 diabetes study reported that 14% of micro-albuminuric patients developed macro-albuminuria above 7.3 years’ follow-up. Steno type 1 diabetes cohort showed that 34% of participants with micro-albuminuria went on to develop macro-albuminuria over 7.5 years’ average follow-up. In the DCCT/EDIC cohort, the participants who had incident micro-albuminuria, the 10-year cumulative incidence of macro-albuminuria was 28% .
In the DCCT/EDIC cohort, patients with macro-albuminuria lost GFR at a mean rate of 5.7% per year, and the 10-year cumulative incidence of impaired GFR was 32%, while in patients with micro-albuminuria, the mean rate of estimated GFR loss was 1.2% per year, and the 10-year cumulative incidence of diminished GFR was 15%. Interestingly, in the Joslin type 1 diabetes cohort, ‘early renal function decline’ developed in nearly one-third of micro-albuminuric participants and also occurred occasionally in persistent normoalbuminuric participants with an AER less than 30 mg/24 h. Such findings suggest that albuminuria and GFR loss are interrelated but are not essentially indicative of a single, homogeneous underlying disease process .
| Regression of kidney disease in type 1 diabetes|| |
Micro-albuminuria commonly regresses to normo-albuminuria as reported in the Joslin type 1 diabetes cohort. They showed that 58% of patients with persistent micro-albuminuria regressed to persistent normo-albuminuria over the following 6 years, frequently without inhibitors of the renin–angiotensin–aldosterone system (RAAS) . Similar results were observed in the DCCT/EDIC . Therefore, better control of diabetes, hypertension, and lipids were associated with a greater likelihood of micro-albuminuria regression. Of the DCCT/EDIC participants who developed macro-albuminuria, 52% regressed to sustained micro-albuminuria or normo-albuminuria within 10 years, but many were managed with RAAS inhibitors . Moreover, regression of macro-albuminuria was associated with an 89% lower risk of progressing to reduced GFR. In the same direction, longitudinal studies of pancreas transplantation demonstrate that the pathological lesions of diabetic glomerulopathy can regress with euglycemia .
| Kidney disease in type 2 diabetes|| |
The incidence of DKD and rates of DKD progression are less clear in type 2 diabetes compared with type 1 diabetes, mainly due to the highly variable age of onset, complexity of defining the exact time of diabetes onset, and the relative shortage of long-term type 2 diabetes cohorts. Therefore, two of the best characterized type 2 diabetes cohorts are the United Kingdom Prospective Diabetes Study (UKPDS) and the Pima Indian population. The UKPDS enrolled more than 5000 participants with new-onset type 2 diabetes and after a median 15 years of follow-up, they found that micro-albuminuria (defined as persistent urine albumin concentration ≥50 mg/l) occurred in 38% of participants, and reduced GFR (defined as persistent estimated creatinine clearance ≤60 ml/min/1.73 m2) occurred in 29% of participants. Among Pima Indians, for whom the onset and duration of diabetes are more precisely determined due to systematic diabetes screening, the cumulative incidence of heavy proteinuria (≥1 g per gram creatinine) was 50% at 20 years’ duration, prior to widespread use of RAAS inhibitors. The high rate of proteinuria in the Pima population has remained stable over time, though the incidence of ESKD has declined .
In most type 2 diabetics, the prevalence of DKD at any point in time is ∼30–50%. Among the US adults with diabetes (>90% type 2), the overall prevalence of DKD was approximately 35% ranging from nearly 25% in patients younger than 65 years old to nearly 50% with age older than 65 years . At younger ages, micro-albuminuria predominates while in older age reduced GFR is increasingly prevalent among cases with DKD. This finding could be explained by the trend in using medications that reduce albuminuria, such as glucose-lowering medications and RAS inhibitors.
However, the phenotype of reduced GFR with normo-albuminuria has been increasingly recognized in type 2 diabetes. In population-based studies of diabetes in the United States and Australia, 36–55% of individuals with reduced GFR did not have concurrent micro-albuminuria or macro-albuminuria. Frequently, nonalbuminuric reduced GFR was observed in the absence of diabetic retinopathy, suggesting the underlying processes other than diabetic glomerulopathy. In the UKPDS, female gender, increased age, and insulin resistance were risk factors for reduced GFR but not micro-albuminuria, while male gender, adiposity, hyperglycemia, and dyslipidaemia were risk factors for micro-albuminuria but not reduced GFR . Higher blood pressure was a risk factor for both reduced GFR and micro-albuminuria.
| Progression of kidney disease in type 2 diabetes|| |
The progression and regression of established DKD is highly variable in type 2 diabetes. In the UKPDS, evolution from micro-albuminuria to macro-albuminuria occurred at a rate of 2.8% per year, and change over from macro-albuminuria to elevated plasma creatinine or ESKD occurred at a rate of 2.3% per year. Similar to what happened with type 1 diabetes, loss of GFR can occur at any level of urine albumin excretion but tends to be more rapid with greater urine albumin excretion. At diagnosis of type 2 diabetes, 7.3% of patients had micro-albuminuria or worse rising to 17.3% after 5 years, 24.9% after 10, and 28.0% after 15 years .
| Health consequences of diabetic kidney disease|| |
The high mortality risk observed among people with types 1 and 2 diabetes is largely confined to those with evidence of DKD because it is associated with a number of interrelated cardiovascular diseases, including microangiopathies and macroangiopathies.
| Prevalence of diabetes in Arab countries|| |
The Arab world contains 22 countries with a total population of 362.5 million people with a $2.55 trillion economy .
Arab world countries with the highest prevalence of T2DM are: the Kingdom of Saudi Arabia (31.6%), Oman (29%), Kuwait 25.4%, (Bahrain (25.0%) and the United Arab Emirates (25.0%). The lowest prevalence was found in Mauritania (4.7%) and Somalia (3.9%). The highest prevalence was observed in the Gulf Cooperation Council (GCC) countries 25.45% while the non-GCC countries had the lowest prevalence (12.69%). The combined mean prevalence of T2DM in both GCC and non-GCC Arab countries was 16.17% ([Table 1]) .
|Table 1 Prevalence of diabetes and diabetic kidney disease in Arab countries |
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Arab countries with high prevalence of micro-albuminuria included UAE, KSA, Bahrain, and Lebanon while KSA, Kuwait, Bahrain, and Egypt represented countries with the highest prevalence of macro-albuminuria. Low prevalence of DM and DKD was found in Iraq and Tunisia ([Table 2]). These differences could be attributed to genetic predisposition and change in lifestyle.
|Table 2 Distribution of diabetes and albuminuria in different Arab countries|
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In 2007, four out of the top five countries worldwide with diabetes were high-income countries from the Arab Gulf countries. Data have shown that the five countries with the highest diabetes prevalence in the adult population are Nauru (30.7%), the United Arab Emirates (UAE) (19.5%), Saudi Arabia (16.7%), Bahrain (15.2%), and Kuwait (14.4%) . As of 2014, Saudi Arabia, Kuwait, and the UAE had the highest prevalence of diabetes, 24, 23, and 19%, respectively .
About half of all diabetes-related mortality in this region occurs in people under the age of 60 years. Saudi Arabia has the largest number of cases (65 000) of T1DM in children aged 0–14 years, while Kuwait has the highest incidence rate of 22 cases per 100 000 per year .
In a survey that provided a snapshot of the status of diabetes control and the related complications, and the quality of diabetes management in the Gulf countries − Saudi Arabia, Kuwait, and the UAE − end-stage kidney failure were reported in less than 10% of patients. Serum creatinine level greater than 2 mg/dl was seen in 4.4% of patients. Proteinuria was less than 15 mg/dl in 55.2% of patients, between 15 mg/dl and 30 mg/dl in 14.8%, and greater than or equal to 30 mg/dl in 30.0% of patients. Micro-albuminuria was observed in 34.4% of patients, it was absent in 60.4% of the population, and about 5.3% of patients were unable to provide information on this parameter .
Alsuwaida and his colleagues in 2007 reported that the most common cause of ESKD in the Arabian Gulf Countries was diabetic nephropathy . Moreover, Farag et al.  reported that diabetes was the first leading cause of ESKD in Egypt, Jordan, Kuwait, and Tunisia and was the second leading cause in KSA, UAE, and Qatar.
Al Arrayed and coworkers, 2004 estimated the incidence of glomerular diseases in Bahrain by examining 498 renal biopsies from patients with proteinuria, hematuria, and mild to moderate renal impairment during the period between January 1990 and December 2002 at a tertiary care hospital. They found that lupus nephritis represented the commonest lesion (38.9%) followed by diabetic nephropathy (31.9%), hypertension (20.4%), and finally tubulointerstitial diseases representing 13.1% of all renal biopsies .
Al-Hermi et al.  found that diabetic nephropathy represented 31% among pediatric patients with type 1 DM of more than 5 years and were followed by pediatricians in Bahrain. We did not find any available studies on diabetic nephropathy in adults in Bahrain.
Al Sarraf et al.  assessed Kuwaiti diabetic patients in three primary healthcare centers. The study revealed that the prevalence of diabetic nephropathy was 22.1% and micro-albuminuria alone was 11.1%.
Rashed and Aboud in 2004  realized that diabetic nephropathy was the most common cause of ESRD among patients who received renal transplants between 1986 and 2002 in Qatar.
In a cross-sectional analysis assessing the prevalence of micro-albuminuria among diabetic patients in the UAE, the overall prevalence rate of micro-albuminuria was 61% and of them 12.5% had proteinuria which was higher among men. Moreover, in the UAE, 23.3% of patients with ESRD had diabetes as the cause .
Most of the diabetic patients in Saudi Arabia (90%) suffer from type 2 DM. The prevalence of DM was higher in urban areas (men 12%, women 14%) than rural areas (men 7%, women 7.7%). The highest prevalence (49%) was in urban women aged 51–60 years. In 1994, 12.8% of Saudi diabetic patients had proteinuria (detected by urine dipstick) and 41.3% had micro-albuminuria . Ten years later, a study in Abha City, Saudi Arabia, showed that more than half of the diabetic patients had proteinuria .
Badran and Laher  showed that diabetic nephropathy was the major contributor to the need for dialysis in Saudi Arabia, where the number of diabetic patients entering renal replacement therapy increased dramatically from 4% in the early 1980s to 14.8% in the mid-1990s and shockingly to 40% in the late 1990s.
Micro-albuminuria was found to be 27% in outpatient type 2 DM in Oman .
In Jordan, Jbour et al.  reported that 45% of diabetic patients at a national diabetes center had retinopathy, 33% had nephropathy, and 5% had amputations. At a diabetic clinic in Libya, 30% of patients had retinopathy, 25% had nephropathy, and 45% had neuropathy .
Abu Al-Halaweh reported that 16.3% had macrovascular disease (previous myocardial infarction or stroke) and 25.9% had microvascular complications among Palestinians with T2DM. Moreover, 4.9% had advanced kidney disease with serum creatinine greater than 1.4 mg/dl .
Sudan and Egypt
The prevalence of diabetes varied across the Northern African countries ranging from 2.6% in rural Sudan to 20% in urban Egypt . Diabetic albuminuria prevalence ranged from 21% in Egypt to 22% in Sudan. In a cross-sectional study from Egypt, 42% of diabetic patients had nephropathy, 22% had peripheral neuropathy, 0.8% had foot ulcers, and 5% were blind .
Afifi et al.  evaluated a sample of ESKD patients enrolled in the Egyptian renal data system during the period 1996–2001 for the prevalence of diabetic nephropathy. They found that the prevalence gradually increased from 8.9% in 1996 to 14.5% in 2001. The mean age of patients with diabetic nephropathy was significantly higher than that of patients with ESKD from other causes. Mortality was also significantly higher in diabetic patients with ESKD .
Elbagir et al.  reported that the prevalence of diabetic nephropathy in diabetic Sudanese patients (with a median duration of diabetes of 9 years) was 22% and also they reported an overall prevalence of long-term complications as 67% in their previous report.
In 1987, Osman et al.  reported that diabetes was the fourth common cause of renal failure in Khartoum after chronic glomerulonephritis, obstructive nephropathy (stone disease), and hypertension. Two years later, Abboud et al.  reported a 9% prevalence of diabetic nephropathy. In 1995, Elbagir et al.  investigated the pattern of long-term complications in Sudanese insulin-treated diabetic patients and reported a higher prevalence (22%) of diabetic nephropathy. In another study, DN represented the third most common cause of patients being on dialysis therapy in Sudan, which accounts for 10.4% of all cases .
From the Libyan report by Kadiki and Roaed  it has been recorded that that the prevalence of DN was 25.2%.
Bouaziz et al.  reported that the prevalence of micro-albuminuria was 11% among type 2 diabetic patients. However, Bouzid et al.  (in a larger study including type 2 diabetics) reported that the prevalence of CKD, micro-albuminuria, and macro-albuminuria were 19.8, 13, and 10.1%, respectively.
The prevalence of diabetes in Algeria has increased from 6.8% in 1990 to 12.29% in 2005. In 2005, diabetes was the second most common chronic disease (8.78%) among the 35-to-70- year-olds, preceded only by hypertension (16.23%). The national prevalence of diabetes in Algeria in 2013, according to the IDF, is estimated at 6.63% . The prevalence of type 2 diabetes (initially non-insulin-dependent diabetes mellitus) was 10.5% and type 1 diabetes (insulin-dependent diabetes mellitus) was 3.7%. One in five patients had micro-albuminuria and a little over a third of patients had macroproteinuria. End-stage renal disease was found in 0.52% of type 2 diabetes patients .
In a study from Morocco including type 1 diabetic patients, 48.6% has been reported with micro-albuminuria, 36.1% with macro-albuminuria but only 15.35 with nephrotic range proteinuria. However, the incidence of ESKD after 5 years was 34.7% .
The WHO STEPwise chronic disease risk factor surveillance program reported the prevalence of diabetes in Mauritania to be 6% .
The prevalence rate of T2D was three times higher in Iraqi as well as in the Swedish study participants as compared with the prevalence rates reported from Iraq (7.4–7.8%) . Abdulkader and Al Lami  reported that only 16.1% of type 2 diabetic patients in Bagdad (Iraq) had micro-albuminuria with defined micro-albuminuria as albumin/creatinine ratio 30–300 mg/g on two occasions. In another study by Al Ani, diabetic neuropathy, nephropathy, and retinopathy were detected in 18.13, 17.03, and 12.64% of the studied patients, respectively .
Syria and Lebanon
The prevalence of type 2 diabetes was 8.5% among the Lebanese people (95% CI: 7.3–9.7).The most common complications included heart disease (27.8%), retinopathy (16.6%), and nephropathy (7%) . Taleb et al.  concluded in their Lebanese diabetic cohort that micro-albuminuria and macro-albuminuria were present in 33.3% and 12.7% of the 222 patients (the mean age was 56.4 years, mean deviation of diabetes was 8.6 years, 58.7% were women, and 43.8% were obese), respectively. In a cross-sectional study under the auspices of Aleppo University, Moukeh et al.  evaluated the epidemiology of hemodialysis patients in Aleppo city and they reported a comparable prevalence of hypertension (21.1%), glomerulonephritis (20.5%), and diabetes (19.5%) among these populations.
The overall prevalence of diabetic nephropathy among type 2 diabetic Yemeni patients in this study was 33.6% (21.2% had MA and 12.4% had MAA) .
| Post-transplant diabetes in Arab countries|| |
The cumulative incidence of PTDM at 12 months post-transplant was 17.6% in Sudan , 27% in KSA , 27% among the Egyptian liver transplants , 22.2% among the Egyptian kidney recipients , and 33% in Bahrain .
The majority of diabetic transplant recipients have developed histological changes of recurrent diabetic nephropathy, in some cases within 1 year after transplantation . However, the incidence of diabetic nephropathy is rare . There is no data available regarding diabetic kidney disease in renal transplant recipients in Arab countries. De-novo nephropathy caused by post-transplant DM seems to occur as frequently as recurrent diabetic nephropathy. Histologic diabetic nephropathy develops in a mean of 5.9 years after new-onset diabetes . However, the longer the duration of post-transplant diabetes, the higher the risk of developing diabetic nephropathy. The histologic abnormalities resemble those abnormalities observed in the classic diabetic nephropathy in native kidneys .
| Conclusion|| |
Diabetic nephropathy is not an uncommon complication of diabetes (type 1 and 2) in Arab countries. Rapid economic growth in some Arabic speaking countries improved the infrastructure but carries with it the burden of risk factors of DM. Large, prospective collaborative studies are critically needed to explore this medical and socioeconomic problem among the Arab people before and after renal transplantation.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]