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MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
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Aug 2018




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Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
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Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2012 | Month : May | Volume : 6 | Issue : 3 | Page : 369 - 371 Full Version

Exploration of the Clinico-Biochemical Parameters to Explain the Altered Renal Mechanisms in Gestational Diabetes Mellitus


Published: May 1, 2012 | DOI: https://doi.org/10.7860/JCDR/2012/.1987
Nagalakshmi C.S., Devaki R.N., Akila P., Suma K.B., Prashant V., Suma M.N., Parveen D., Sujatha P.

Department of Biochemistry and Department of Obstetrics and Gynaecology, JSS Medical College and Hospital, JSS University, Mysore-570015, Karnataka, India.

Correspondence Address :
Dr. Nagalakshmi C.S.
PG in Biochemistry, JSS Medical College
S S Nagar, Bannimantap, Mysore – 570015
Karnataka, India.
E-mail: nagu.smile@gmail.com; nagu_kolar@yahoo.co.in

Abstract

Context:
Gestational diabetes mellitus (GDM) is a common metabolic abnormality which affects ~2-5% of the pregnancies annually. Various risk factors such as advanced maternal age, previous infants with macrosomia, a strong family history of non-insulin dependent diabetes mellitus (NIDDM) or GDM, poor glycaemic control and a high pre-pregnancy body mass index (BMI) have been implicated for the development of GDM.
Aims:
To compare the serum creatinine, uric acid and the albumin levels in patients with GDM and in normal pregnant women and to see if there existed any correlation between these biochemical markers and certain clinical parameters in the study groups.
Settings and Design:
Hospital based prospective study. Methods and Material: The study group consisted of 40 patients with gestational diabetes mellitus and 40 normal healthy pregnant women who served as the controls. We evaluated the biochemical and the metabolic alterations in these women by measuring their serum creatinine, uric acid and albumin levels. We also concentrated on the maternal complications and the perinatal outcomes.
Statistical analysis used:
The independent samples t-test and the PearsonÂ’s correlation test. Results: There was a significant increase in the serum creatinine and the uric acid levels and a significant decrease in the serum albumin levels in the GDM patients. The incidence of GDM in the studied groups was influenced by factors such as maternal age, gravidity, pre-pregnancy BMI and blood pressure. We observed quite a number of complications such as pre-eclampsia, polyhydramnios, hyperbilirubinaemia, RDS, etc. in the GDM women and their foetuses.
Conclusions: The estimation of serum creatinine, uric acid and albumin can help us in predicting the metabolic alterations which occur in the GDM patients and their foetuses. Further, it is quite essential to identify and manage the complications which are associated with GDM and to prevent its recurrence by considering the modifiable risk factors, since such women would in all probability be prone for GDM in their future pregnancies.

Keywords

Gestational diabetes mellitus, Serum creatinine, Uric acid, Albumin, Maternal age, Gravidity, BMI, Blood pressure, Foetal birth weight, Complications

Introduction
Gestational diabetes mellitus (GDM) affects ~2-5% of all the pregnancies annually (1). During pregnancy, the glomerular filtration rate (GFR) increases by ~50%, thereby decreasing the serum creatinine and the uric acid levels. However, the creatinine levels towards the upper limit of the normal range is a warning sign of impending renal disease in GDM. The raised uric acid levels in GDM are a component of the metabolic syndrome that reflects insulin resistance (2). Haemodilution and the diminished liver functions may alter the serum albumin levels in GDM. So, we aimed to see whether the changes in serum creatinine, uric acid and albumin, together with maternal age, body mass index (BMI), blood pressure and foetal birth weight could help in a better understanding of the pathophysiology and the biochemical and metabolic abnormalities in GDM, with special reference to the renal system.

Material and Methods

Methods After obtaining the institutional ethical clearance and a written consent from all the subjects, pregnant women between the gestational ages of 24-28 weeks, who attended the Department of Obstetrics and Gynaecology at a tertiary care hospital, who had a negative history of a pre-pregnancy diabetic status were subjected to a 50g oral glucose challenge test (OGCT). Those who met the criteria of ≥140mg/dl of venous plasma glucose after 1 hour were Original Article then subjected to a 75g oral glucose tolerance test (OGTT) to confirm GDM by using the criteria of Carpenter and Coustan (3). We enrolled 40 diagnosed cases of GDM and 40 age-matched, normal pregnant women and labeled them as the cases and controls respectively. Venous blood samples were collected aseptically from both the groups of patients for estimating serum creatinine, uric acid and albumin. The data on the maternal age, the obstetric score, blood pressure, the pre-pregnancy weight, the weight gain in pregnancy, the gestational age at delivery, the foetal birth weight and maternal and foetal complications if any, were also collected. Plasma glucose was estimated by the glucose oxidase method, serum creatinine by Jaffe’s method, uric acid by the uricase method and albumin by the bromo-cresol green dye binding method by using a Randox Daytona fully automated clinical chemistry analyzer (Furuno electric Co., Ltd, Japan). The exclusion criteria for the present study included a history of diabetes before pregnancy, essential hypertension, thyroid disorder, multiple pregnancy, renal disease and liver disease.
Statistics
The data was expressed as mean ± standard deviation (SD). SPSS for windows (version 16) was used for all the statistical calculations by applying the independent samples t-test and the Pearson’s correlation test. A p-value of <0.05 was considered as statistically significant

Results

The maternal age in the study groups ranged between 18–37 years. The mean maternal age was significantly higher in the cases as compared to the controls, with a p-value of 0.03. Out of 29 subjects who were aged ≥ 25 years, 19 had GDM, while only 10 had a normal pregnancy course i.e., as the age of the subjects increased above 25 years, the ratio of the incidence of GDM to normal pregnancy increased. Our findings, in association with those of other studies indicated that the risk of GDM progressively increased from the age of 25 years onwards. The incidence of GDM was higher in the primigravida as compared to the multigravida women. Significantly higher blood pressure values were recorded in the GDM patients as compared to the controls. Pregnant women with more pre-pregnancy BMI had a higher incidence of GDM than those with normal pre-pregnancy BMI. There was a significant increase in the serum creatinine and the uric acid levels and a significant decrease in the levels of serum albumin in the GDM patients as compared to the controls. The foetuses of the GDM mothers had a higher birth weight as compared to that of the foetuses of the controls (Table/Fig 1).
In addition, the complications which were encountered in the GDM group were: pre-eclampsia (n=8), polyhydramnios (n=7), hyperbilirubinaemia (n=5), respiratory distress syndrome (n=5), shoulder dystocia (n=2), birth injury (n=1), perinatal mortality (n=4), polycythaemia (n=2) and congenital anomalies (n=1). Caesarean section was performed in 24 GDM cases and 4 controls. However, 13 GDM cases and 36 controls delivered through the vaginal route. The rest of the 3 GDM cases delivered still born babies. On performing correlation analysis, we found that the serum creatinine levels correlated significantly and positively with those of serum uric acid, while the serum creatinine and serum uric acid levels correlated significantly but negatively with those of serum albumin (Table/Fig 2).

Discussion

Like type 2 diabetes and metabolic syndrome, GDM is characterized by insulin resistance, glucose intolerance, hyperlipidaemia, impaired beta cell function and endothelial dysfunction (4). This study was thus designed to compare the levels of serum creatinine, uric acid and albumin, as they are usually affected by GDM. Perhaps such studies add little to the complex decision making for delivery; however, the chosen biochemical parameters are simple, inexpensive and readily available tests and they should be additionally evaluated.
A maternal age of ≥ 25 years is the factor which is the most predictive for GDM and according to the American Diabetes Association (ADA) recommendations; it should replace the older cut-off value of ≥ 35 years as a risk factor for GDM (5). Advanced maternal age is a known risk factor for the pregnancy complications including preterm delivery, low birth weight, perinatal death, GDM, gestational hypertension, placenta previa, intra-uterine growth retardation (IUGR) etc. (6).
Gestational hypertension which accompanies GDM is associated with a higher frequency of complications, since it aggravates the course (7). The rate of pre-eclampsia and even its severity may be influenced by the severity of GDM and pre-pregnancy BMI. Hyperglycaemia associated insulin resistance, together with an activated sympathetic nervous system, changes in lipids and lipoproteins, circulating cytokines and other metabolic processes such as hyperinsulinaemia and hyperuricaemia, can contribute to the pathogenesis of preeclampsia in GDM (8).
Higher pre-pregnancy BMI is a risk factor for developing GDM, since maternal obesity is an independent risk factor for pregnancy induced hypertension, GDM, post-partum haemorrhage, foetal macrosomia, congenital malformations and operative delivery (4). Thus, maintaining the optimal weight before and during the pregnancy is very much essential. Further, the independent association of BMI with gestational hypertension addresses the topic of the correlation between insulin resistance, obesity and hypertension (7).
Higher creatinine levels or even those towards the upper limit of the normal range can act as a warning sign of the impending renal disease in the GDM pregnancies, since chronic renal disease is often clinically silent until at an advanced stage and as serum creatinine may change only slightly until its clearance falls below 50ml/min (2). As reported by the current study, Tarim et al., reported that the patients with GDM had higher levels of creatinine, but they reported that this association did not reach statistical significance (9), (10).
The hyperuricaemia in GDM has been explained to be a component of the metabolic syndrome which reflects insulin resistance and it has been shown to have a positive correlation with the creatinine levels. Further, hyperuricaemia has been correlated with obesity, dyslipidaemia and diabetes mellitus (2). In a univariate analysis, gestational hyperuricaemia was found to be significantly associated with a high rate of maternal and foetal complications, along with proteinuria and hypertension (11). Hyperinsulinaemia may activate the sympathetic nervous system and both of them may be independently associated with a reduced urinary excretion of uric acid. Thus, the raised serum uric acid levels may reflect both these mechanisms (12). There are very few studies which have measured the uric acid levels in GDM women, which have shown higher serum uric acid levels (2).
The protein metabolism is altered to a great extent in GDM and since albumin signifies the synthetic function of the liver, it has been reported to have shown decreased levels in GDM. Microalbuminuria in GDM may well be a sign of early renal disease and a long-term follow-up of all the GDM patients for the markers of renal disease have been strongly indicated (13). We found a very significant correlation among all the three biochemical parameters, which was in accordance with the findings of few other studies.
Foetal macrosomia, a well known problem which has been associated with GDM, leads to many complications like respiratory distress syndrome (RDS), shoulder dystocia, birth injuries, etc. and it can be prevented by maintaining a strict glycaemic control (14).
We observed quite a few maternal and neonatal complications in the GDM cases such as pre-eclampsia, polyhydramnios, hyperbilirubinaemia, RDS, shoulder dystocia, birth injuries, perinatal mortality, polycythaemia, caesarean delivery and congenital anomalies. Many of these were associated with an increased risk of perinatal morbidity and mortality (15). A likely explanation for polyhydramnios was foetal polyuria which resulted from foetal hyperglycaemia (16). If polyhydramnios is encountered during an ultrasound evaluation, consideration should be given to the possibility of latent or uncontrolled diabetes mellitus or foetal macrosomia or anomalies. Foetal surveillance and a genetic evaluation should also be considered (17). Hyperbilirubinaemia in the GDM foetuses may be due to prematurity and polycythaemia with haemolysis. Renal vein thrombosis has also been reported to result from polycythaemia. The foetal lung maturation will be delayed in diabetic pregnancies. The gestational age, rather than overt diabetes, is likely to be the most significant factor which governs the development of RDS (16). Further, RDS, shoulder dystocia and birth injuries can be explained on the basis of the foetal macrosomia, as has been already mentioned (14).
The limitation of our study could be the relatively small sample size. Further studies with a larger sample size and those which incorporate newer biochemical markers such as cystatin C, urinary NGAL (neutrophil gelatinase-associated lipocalin), etc., can be interesting.

Conclusion

Biochemical parameters such as serum creatinine, uric acid and albumin, can help in predicting the early onset and progression of GDM. Further, such an early diagnosis will help the clinicians in the proper treatment of GDM and its attendant complications, both maternal and neonatal, and will thus improve the quality of life of the GDM patients and their offsprings. Further studies with additional biochemical and clinical markers can be interesting.

References

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Koivunen RM, Juutinen J, Vauhkonen I, Morin-Papunen LC, Ruokonen A, Tapanainen JS. Metabolic and steroidogenic alterations which are related to an increased frequency of polycystic ovaries in women with a history of gestational diabetes. J Clin Endocrinol Metab 2001; 86:2591-99.
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Kale SD, Kulkarni SR, Lubree HG, Meenakumari K, Deshpande VU, Rege SS, et al., Characteristics of the gestational diabetic mothers and their babies in an Indian diabetic clinic. J Assoc Physicians India. 2005; 53: 857-63.
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Megahed MA, Taher IM. Folate and homocysteine levels in pregnancy. Br J Biomed Sci. 2004; 61(2): 84-87.
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Brown MA, Buddle ML. Hypertension in pregnancy: maternal and fetal outcomes according to the laboratory and clinical features. Med J Aust 1996;165:360-65.
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Verdecchia P, Schillaci G, Reboldi G, Santeusanio F, Porcellati C, Brunetti P. The correlation between serum uric acid and the risk of cardiovascular disease in essential hypertension – The PIUMA study. Hypertension 2000; 36(6): 1072-78.
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DOI and Others

DOI: JCDR/2012/3812:1987

Financial OR OTHER COMPETING INTERESTS:
None.


Date of Submission: Dec 12, 2011
Date of peer review: Jan 19, 2012
Date of acceptance: Feb 09, 2012
Date of Publishing: May 01, 2012

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