Awareness Of Chronic Kidney Disease Among Diabetic Patients In Erbil City

Introduction

The kidneys are very important organs that perform essential functions, some of which are filtering wastes, excess water, and acids from the body's cells' waste products. They also regulate the body's balance of water, salts, and essential minerals such as sodium, potassium, phosphorus, and calcium. Given the kidney's intricate structure and function, kidney-related diseases are equally complex. Kidney dysfunction can lead to various disorders, primarily categorized into two types: acute kidney injury (AKI), a sudden but often reversible loss of kidney function, and chronic kidney disease. Although AKI is reversible with appropriate treatment, it can potentially increase the risk of progression to CKD in later life (Digital, n.d.). Chronic Kidney Disease (CKD) is a major worldwide health concern affecting more than 10% of the global population (Ibitoba et al., 2022). As defined by current international standards, chronic kidney disease (CKD) is diagnosed when the Glomerular Filtration Rate (GFR) remains below 60 mL/min per 1.73 m² for a period exceeding three months (Vaidya & Aeddula, 2025). Chronic kidney disease (CKD) is categorized into five progressive stages based on Glomerular Filtration Rate (GFR). Stage 1 indicates mild kidney dysfunction, whereas Stage 5, referred to as End-Stage Renal Disease (ESRD) represents the most advanced and critical stage of chronic kidney disease (CKD). At this critical stage, kidney function declines to less than 10% of normal capacity, marking an irreversible loss of renal function (Asmelash et al., 2020). Progression of chronic kidney disease can be initiated by various risk factors that result in permanent renal harm Key contributors include advanced age, genetic predisposition, diabetes mellitus, hypertension, uncontrolled blood sugar levels, and tobacco use (Asmelash et al., 2020). Data on global health from 2017 places chronic kidney disease (CKD) as the 12th foremost cause of death across the globe. Epidemiological research indicates that around 9.1% of the worldwide population experienced CKD in 2017, resulting in 1.2 million deaths that year. Current projections indicate a concerning upward trend, with CKD-related deaths expected to reach 2-4 million annually by 2040 (Alobaidi, 2021).

A recent study caried out in Bangladesh revealed significant gaps in public awareness about chronic kidney disease (CKD). The findings showed that merely 11% of participants demonstrated adequate knowledge about CKD, while a substantial majority (60%) possessed very limited understanding of the condition (Ghimire et al., 2021). Diabetes mellitus and hypertension remain the primary etiological factors for chronic kidney disease (CKD) across both developed and developing nations globally (Asmelash et al., 2020). Among these, diabetic nephropathy stands out as the most common cause of CKD. Both conditions exhibit considerable mortality and morbidity rates resulting from their advancing decline in kidney function. Worldwide, kidney replacement therapy continues to be the main treatment option for advanced CKD cases caused by diabetes (Banerjee et al., 2022). For individuals with end-stage renal disease (ESRD), the main treatment options consist of kidney transplantation or hemodialysis (Tegegne et al., 2020).

Prompt recognition and prompt treatment of chronic kidney disease (CKD) can greatly reduce or lessen complications associated with the illness. CKD cases frequently stay asymptomatic during the initial stages, mainly because patients have limited awareness about kidney diseases, chronic illnesses, and their related risk factors (Kumela Goro et al., 2019). This research examines the understanding and awareness of CKD within diabetic groups, seeking to uncover gaps that could guide future educational and preventive measures.

Methods

A quantitative, descriptive study design was conducted to assess the aweareness of chronic kidney disease among diabetic patients at Layla Qasm center in Erbil City, Iraq. The sample size of the study was 397 diabetic patients. The population is N = 49340 patients according to data from Directorate of Health-Erbil (DOH Erbil) in 2024. The sample size was calculated using the following statistical Yamane formula (Yamane, 1967).           where the n= sample size, N= population size and e= level of precision or sampling error = 0.05. The study included all patients who have diabetic mellitus (type I & type II), both gender, all age categories and patients who accept to participate in the study. A non-probability purposive sampling technique was used to select the samples.

The data was gathered by asking questions to the participants during interviews. Containing three parts: part 1: Sociodemographic characteristic of the patient, part 2: Medical information and part 3: Assessment of awareness of CKD among Diabetic patients attending Layla Qasm center at Erbil city. A semi-structured questionnaire was employed as the study's instrument to collect medical and demographic data. A total of eleven structured yes-or-no questions were used to evaluate the awareness of chronic kidney disease in patients with diabetes. Each of the patient’s correct answer was given a score of 1 and therefore the maximum total score was 11. Awareness scouring was leveled as; no awareness = 0 score, low awareness = 1 - 5, moderate awareness = 6 - 9 and high awareness = 9 - 11 score. Individuals who correctly answered 5 or fewer questions were deemed to have low awareness of chronic kidney disease, while those who got 6 to 8 questions right were classified as having moderate awareness. Those who answered between 9 and 11 questions correctly were regarded as having high awareness of CKD. The tool was validated by two nephrologist, two internalist and three medical and dialysis nursing experts. The reliability of the awareness tool was checked using the test-retest method. The reliability score was 0.83.

Institutional ethical committee approval was obtained. After obtaining informed consent from the patients, data were collected by the researcher. It took approximately 30 minutes to collect the data from each sample. Anonymity was maintained.

The data was analyzed by using Statical Package for Social Sciences (SPSS version 27). Results were presented as the frequencies and percentage to assess the level of awareness. Paired t-test was used to test statistical significance of some sociodemographic variables with awareness of CKD.

Results

Table 1 Sociodemographic characteristics of patients with Diabetes Mellitus.

The table 1 shows that the majority of participants are in the 62-72 (34.3%) age groups with average age is 55.34 years, with a standard deviation of ±14.465. Few participants are in the youngest (7-17 and 18-28, each 3.3%) categories. Female (58.1%) participants outnumber males (41.9%). In addition, residents from urban areas make up the majority at 62.6%, while those from rural areas account for 20.7%, and sub-rural residents represent 16.7%. Nearly half (48.2%) are illiterate. Only 10.1% have a college degree, and 2.5% have postgraduate education. A majority of participants are married (87.1%), with only small portion of single (12.1%) individuals. The diabetic individuals is predominantly Muslim, with 99% identifying as such, while only 1% belongs to the Christian faith. The largest demographics are housewives at 44.4% followed by unemployed at 25%. The highest percentage of housewives aligns with the female predominance in the sample.

Table 2 Medical information of patients with Diabetes Mellitus 

The table 2 shows that the average participant has had diabetes for over 11 years, with a wide variation (high standard deviation). Regarding the type of diabetic, Type 2 (52.3%) is the most common. Additionally, the use of medication, accounting for 73.2%, stands out as the primary method for managing the disease. A significant portion of participants (67.4%) have comorbid conditions, emphasizing the connection between diabetes and other health problems. Nearly half (49.8%) have high blood pressure, a common diabetes comorbidity followed by cardiac problems (31.4%) which reflects high cardiovascular risk in diabetics. Furthermore, a significant proportion (89.4%) of participants are knowledgeable about the general complications of diabetes, with the majority of this information sourced from medical professionals (52.5%).

Table 3 Assessment of awareness of chronic kidney disease among Diabetic patients.

Table 3 indicate that a majority of diabetic patients (63.9%) are aware concerning chronic kidney disease, while (36.1%) are not. Only (45.8%) of those aware can define chronic kidney disease. Regarding the symptoms, about (40.7%) can list chronic kidney disease symptoms, but (59.3%) cannot. The majority of patients (70.2%) do not know chronic kidney disease can be asymptomatic in the early stage. The heist percentage (65.9%) know that the diabetes can cause chronic kidney disease, but lowest percentage (34.1%) are unaware. A significant portion (60.1%) of individuals with diabetes recognize that managing blood sugar levels can lower the risk of chronic kidney disease. Only (38.9%) are convinced that chronic kidney disease can be prevented, while (61.1%) feel it is inevitable. More than half of diabetic patients (52%) agree with the diabetics should get periodic kidney function tests. Moreover, more than half of participants (53%) knows that the early treatment can prevent kidney failure and (53.3%) of them recognize that medical adherence delays CKD progression. The majority of patients (76%) have had a kidney function test. 

Table 4 Level of awareness of chronic kidney disease among diabetic patients.

Table 4 reveals that among 396 diabetic patients, 5.8% (23 individuals) were completely unaware of chronic kidney disease (CKD). The majority (42.4%) demonstrated low awareness. At the same time, 27.5% demonstrated a moderate level of awareness, while just 24.2% displayed a high level of awareness regarding CKD.

Table 5 Association of level of awareness and sociodemographic variables.

Table 5 examines the statistical significance (p-value) of associations between sociodemographic variables (age, gender, residence, education, etc.) and levels of CKD awareness (No aware, Low aware, Aware, High aware). Statistically analysis was conducted to examine the potential association using chi-square test. The results show a statistically significant association (p < 0.05) between chronic kidney disease awareness levels and all sociodemographic variables studied—except for gender, which did not demonstrate a significant relationship.

Discussion

In the present study, the study population is mostly middle-aged to elderly, urban-dwelling, married Muslim women with low education levels. These findings align with research by Nahlah Fahad et al. (Nahlah Fahad et al., 2023) which assessed diabetic patients awareness of chronic kidney disease in community. Their study also found that most participants were over 40 years old, with married women accounting for 52.3% of the sample and 38% being employed.  These findings are similar with Ghimire et al.'s (Ghimire et al., 2021) research, which reported that most diabetic adult were women aged 51–60 years with limited level of education.

The study revealed that most patients had been diagnosed with type 2 diabetes mellitus for more than 11 years. Previous study done by Nahlah Fahad et al. (Nahlah Fahad et al., 2023) which explored that patients with type 2 diabetes were reported and had a DM duration of 5–15 years. However, nearly half of diabetic patients have high blood pressure, a common diabetes comorbidity. This mirrors previous research on CKD prevalence in diabetic and hypertensive populations, where a majority of diabetics had coexisting hypertension, and about half of hypertensive patients also had diabetes. A high proportion of respondents (89.4%) demonstrated awareness of diabetes-related complications, consistent with Ghimire et al.'s (Ghimire et al., 2021) earlier observations on patients' understanding of diabetic health risks.

The finding of the study revealed that the largest group (42.4%) has inadequate awareness about chronic kidney diseases. Where the significant portion (27.5%) has moderate awareness about chronic kidney disease. Approximately one-fourth of the population (24.2%) exhibits significant awareness, suggesting familiarity with kidney disease dangers, warning signs, and appropriate health precautions. The results parallel with other studies conducted by Nahlah Fahad et al. (Nahlah Fahad et al., 2023), Alghamdi et al. (Alghamdi et al., 2022), Albujays et al.(Albujays et al., 2018), Susanjalee et al. (Susanjalee et al., 2023) concerning that the nearly half of participants were considered as a poor level of awareness, followed by a moderate, and good awareness level of awareness regarding chronic kidney disease.

Furthermore, the results of the present study show a statistically significant association (p < 0.05) between chronic kidney disease awareness levels and all sociodemographic variables studied like (age, marital status, level of education, area of residence, religion and occupation) except for gender, which did not demonstrate a significant relationship. These results are similar with the work of Mondal et al. in Bangladesh (Mondal et al., 2021) which revealed that the knowledge of chronic kidney disease was significantly associated with sex, level of education, occupation. However, Al-qahtani et al. (Al-qahtani et al., 2024) have reported that higher awareness was associated with patient’s age and education, which align with our finding. Similar to the results reported by Ghimire et al. (Ghimire et al., 2021) the present study found that gender showed no statistically significant association with awareness levels. The study done by Hussain et al. (Hussain et al., 2019) showed that there is no association was observed between the knowledge about CKD and gender.

Conclusion

The study indicated that among 397 diabetic individuals, the awareness of chronic kidney disease (CKD) was generally limited, with about one quarter demonstrating high awareness, while nearly half of diabetic individuals had low awareness. A notable relationship (p < 0.05) was identified between the levels of CKD awareness and various sociodemographic factors, including age, location, marital status, and education; however, gender did not exhibit a significant correlation. These findings highlight the need for targeted educational interventions to improve CKD awareness, particularly among diabetic patients with lower education levels and older age groups, to facilitate early detection and management of CKD complications.