The Importance of Microalbuminuria as a

Target Therapy in Patients with

Hypertension and Diabetes?

Name
Dept.
 Diabetes Prevalence Facts
• 190 million people worldwide1
– Diabetes type 1 and 2
• 97% have diabetes type 21
• Numbers expected to double by year 20251
• 80% of diabetics have hypertension2

• Sources:
• (1). IDF Diabetes Atlas: International Diabetes Federation. E-Atlas 2001,
www.idf.org/e.atlas (last date of consultation: Jan 2004)
• (2). Tarrow L et Al Diabetes Care 1997, 17: 1247-1251
Top ten countries for estimated number of
adults with diabetes, 1995 and 2025
Country 1995 (millions) Country 2025 (millions)

Rank
1 India 19.4 India 57.2
2 China 16.0 China 37.6
3 U.S. 13.9 U.S. 21.9
4 Russian Fed. 8.9 Pakistan 14.5
5 Japan 6.3 Indonesia 12.4
6 Brazil 4.9 Russian Fed. 12.2
7 Indonesia 4.5 Mexico 11.7
8 Pakistan 4.3 Brazil 11.6
9 Mexico 3.8 Egypt 8.8
10 Ukraine 3.6 Japan 8.5
All other countries 49.7 103.6

Total 135.3 300.0

Progression to End Stage Renal Disease
(ESRD)
• A rise in blood pressure often affects kidneys
• Diabetes + Hypertension = increased chance of end-stage
renal disease (ESRD)

• Stage1- Early hypertrophy-hyperfunction

• Stage2- Glom. lesions w/out clin. dis, normoalbuminuria
• Stage3- Incipient Diab. Nephropathy, microalbuminuria
• Stage4- Overt diab. nephropathy, proteinuria
• Stage5- End-stage renal failure/ disease
 The Situation in Southeast Asia
• Diabetes affects some 49 million people in the South-East
Asian (SEA) Region*
• This is thus the largest region in terms of diabetic
population
• Diabetes not yet considered a national problem with high
priority in almost all the countries of the region
• Only diabetes associations give focus to the disease

• Source:
• IDF Diabetes Atlas – IDF E-Atlas, 2001, www.idf.org/e-atlas. Date of last
consultation: Jan 2004
• * Refers to Hong Kong, Indonesia, Malaysia, Philippines, Singapore and
Thailand
 Statistics on Diabetes in Southeast Asia
(2001)
• Total population
– 1.2 billion adult population (20 - 79 year age group)
– 65.8 million number of people with diabetes (20 - 79
year age group)
– 49 million (estimated) type-2 diabetes prevalence (20 -
79 year age group)

• Information from International Diabetes Federation www.idf.org.

• Date of last consultation: Sept 2004
American Diabetic Association Guidelines
• At the time of diagnosis of type 2 diabetes
– All patients should be tested for microalbuminuria1
• A simple dipstick test will highlight the problem
• Microalbuminuria an early indicator of vascular injury
– Marker for both kidney and heart disease
• In Asia2:
– 40% of hypertensive diabetic type 2 (HD) patients have
microalbuminuria
– 59% of HD type 2 have diabetic nephropathy, a kidney disease that
results from diabetes
• Antihypertensive therapy slows progression of renal disease
and reduces cardiovascular risk

• Sources:
• (1). American Diabetes Association. Diabetes Care, 2004 Vol 27, Suppl 1.
• (2). Data on file: Sanofi Aventis (MAPS, 2002; DEMAND-registry, 2003)
Prevalence of Diabetes in Southeast Asia
• Ranges from a low of 3.1% in the Philippines to a high of
12.1% in Hong Kong1.
• 80% of all diabetics are hypertensive2
• Up to 10% will develop renal complications within three to
five years3

• Sources:
• (1). Diabetes Atlas, International Diabetes Federation – E-Atlas 2001,
www.idf.org/e-atlas. Date of last date of consultation: Jan 2004
• (2). Tarrow et al. Diabetes Care 1994: 17: 1247-1251
• (3). Hasslacher C et al. Nephrol Dial Transplant 1982, Vol 4 (10): 859-63.
 Diabetes and Hypertension
in South East Asia
Philippines Thailand Singapore Malaysia Hong Kong Indonesia Total SEA

Prevalence of Diabetes in 3.10% 3.70% 11.30% 6.30% 12.10% 4.60%

Population
Prevalence of Hypertension
in Diabetic Patient 80%
Population

Estimated Population of
Diabetic Hypertensive 1.0 1.2 0.3 0.6 0.5 4.6 8.1
(mil)
Philippines Thailand Singapore Malaysia Hong Kong Indonesia Total SEA
Prevalence of 21%(3) 15%(4) 27.3%(5) 31.2%(6) 7.3%(7) 15%(4)
Hypertension

Prevalence of Diabetes
7.8% 9.3% 28.3% 15.8% 30.3% 11.5%
in Hypertensive
Population(8)

Estimated
Population of
1.3 0.9 0.3 1.1 0.2 3.9 7.6
Hypertensive
Diabetic

Ref:
• (1). IDF Diabetes Atlas 2001 (2). Tarrow et al. Diabetes Care 1994; 17: 1247-1251. (3). Food & Nutrition ResearchInstitute, Part IV, Hypertension,
www.fnri.dost.gov.ph/facts/p4hypnat.html. (4). WHO Fact Sheets: www.who.int/inf-fs/en/fact106.html. (5). Highlights of the 1998 National Health Survey,
Statistics Singapore Newsletter. (6). Five year prevalence in coronary risk factors in rural Malaysia, www.kenes.com/73eas/program/abstracts/383.doc
(7).Department of Health, HK, www.info.gov.hk/dh/diseases/ncd/eng/hyperten.html (8).Tarrow L et al. Diabetes Care 1994; 17:1247-1251. Date of last
consultation of websites: November 2003
Regional Survey by Isis Research Aug 2004
• Six Southeast Asian countries
– Hong Kong (n=201)
– Indonesia (n=255)
– Philippines (n=250)
– Malaysia (n=250)
– Singapore (n=202)
– Thailand (n=250)

– The sample size provides 95% confidence interval that it is

representative of the diabetic hypertensive population

• 1,408 diabetic hypertensive respondents interviewed in

August 2004

• Source: Isis Research on behalf of Sanofi Aventis

 Percent of Respondents
Who Took Annual Urine Test

100.0 92.0
90.0
85.6
Percent of Respondents

80.8
80.0 75.9 74.6
68.0
70.0
60.0
56.1
50.0
40.0
30.0
20.0
10.0
0.0

SEA Hong Kong Indonesia Malaysia Philippines Singapore Thailand

Average

• Source: Isis Research on behalf of Sanofi Aventis

 Percent of Screened Respondents*
Who Did Not Know the Purpose of the Urine Test

60.0
48.7 50.4
Percent of Respondents

50.0
42.4
40.0 36.5 35.0

30.0
22.5
19.8
20.0

10.0

0.0

SEA Hong Kong Indonesia Malaysia Philippines Singapore Thailand

Average
* Screened respondents refer to respondents who have gone for annual urine test.

• Source: Isis Research on behalf of Sanofi Aventis

 Percent of Screened Respondents*
Who Indicated Urine Test is for Detecting
Protein in Urine

80.0
69.9
65.8
Percent of Respondents

70.0
60.0 53.9 51.0 51.8
50.0 45.3
40.4
40.0
30.0
20.0
10.0
0.0

SEA Hong Kong Indonesia Malaysia Philippines Singapore Thailand

Average
* Screened respondents refer to respondents who have gone for annual urine test.

• Source: Isis Research on behalf of Sanofi Aventis

 IDNT1: Summary
• Irbesartan (300mg once daily) successfully reduced the
risk of progression of renal disease and total mortality,
independent of its blood pressure-lowering effects
– 20% reduction in the primary endpoint vs. control (p=0.02)
– 23% reduction vs. amlodipine, despite similar BP reduction (p=0.006)
– Irbesartan was well tolerated

• Treating 16 patients for three years would prevent one

from developing doubling of creatinine, ESRD or
death2

• Sources:
• (1). Lewis EJ et al. N Engl J Med 2001;345:851-860.
• (2). Adapted from IDNT
 Use of Irbesartan :
• In recent clinical trial on hypertensive type 2 diabetics with
microalbuminuria, Irbesartan 300mg once daily has been
shown to reduce the risk of patients progressing from
microalbuminuria to proteinuria1

• In 34% of such patients, their level of albumin returns to

normal level2

• Irbesartan is indicated for the treatment of hypertension as

well as treatment of renal disease in patients with
hypertension and type 2 diabetes.

• Sources:
• (1). Lewis EJ et al. N Engl J Med 2001;345:851-860.
• (2). Parving H-H, et al. N Engl J Med 2001;345:870-878.
 Key Findings
• Nearly 25% of the sample did NOT go for an annual urine test
to detect the presence of protein in urine.

• 36.5% of those tested did not know why they were tested

• Only 53.9% of the tested knew that the urine test is for
detecting protein in urine

• As diabetic hypertensives are clearly predisposed to renal

insufficiency and resultant renal failure, many are therefore
putting themselves at unnecessary risk.
 Conclusions
• Progress has been made in the testing for Microalbuminuria in South East
Asia
– we are seeing positive increases in annual testing.

• There is however a need for doctors to educate patients on the

importance of being tested annually for the presence of protein in urine

• End-stage Renal Disease (ESRD) is a grave complication of diabetes.

There is no pharmacological cure for ESRD, but hemodialysis and renal
transplant are possible

• Diabetics should take a microalbuminuria test annually – simple,

affordable

• Early treatment with the class of drugs known as angiotensin receptor

blocks (eg, Irbesartan) should be instituted in patients with hypertension
and type 2 diabetes.