According to Li et al. [1] and Fraser and Maarten [2], chronic kidney disease (CKD) is a serious public health challenge due to its growing burden. Chronic kidney disease is defined as the progressive loss of kidney function that can occur over a period of time ranging from several months to years; the condition occurs due to the gradual change in the normal structure of the kidney with glomerular filtration rate (GFR) of <60 mL/min per 1.73m² for over 3 months [3, 4]. Thus, resulting in a continuous reduction in the ability of the kidney to process waste in the blood and perform other functions [4].

Diabetes mellitus (DM) stated a chronic, metabolic disease characterized by an increase in blood glucose levels that can result in severe damage to several organs in the body, such as the heart, eyes, kidneys, and nerves, with diabetes nephropathy if not controlled [5]. There are two major DM types: Type 1 diabetes (insulin-dependent) and Type 2 diabetes. According to Tannor et al. [6], DM is the principal risk factor and foremost cause of CKD, as diabetic nephropathy occurs in about 40% of persons diagnosed with Type 2 DM [1, 6]. Diabetes nephropathy is also known as diabetic kidney disease. It is clinically diagnosed clinically based on the value of the projected albuminuria and albumin creatinine ratio (UACR) ≥30 mg/g (or ≥ 3.4 mg/mol) with or without a progressive decrease in eGFR below 60 mL/min per 1.73 m² caused by damage to the small renal blood vessels [6].

Hypertension is the persistent increase of blood pressure (BP) which can be diagnosed based on elevated systolic and diastolic BP or either [7]. There is a bidirectional link between hypertension and CKD; also, hypertension has been stated to be a major contributor to the progression of CKD as it accounts for about 28% of CKD causes among hypertensive patients [3]. A study conducted in Nigeria by Olanrewaju et al. (2020) identified hypertension as a traditional cause of CKD.

Previous studies by Asmelash et al. [8], Jitraknatee et al. [9], Bahrey et al. [10], and Kumela et al. [4] showed that hypertension and diabetes are the two major causes of CKD globally. Predictors associated with the development of CKD among DM and hypertensive patients include; advanced age, obesity, diabetes nephropathy, uncontrolled DM, poor knowledge of CKD, first-degree relatives and dyslipidemia, preexisting hypertension, long duration of DM, and hypertension. A Nigerian study conducted by Akokuwebe et al. [11] stated that some factors contributing to the burden of CKD include poor literacy level, inadequate knowledge of risk factors, dearth of CKD prevention programs, poor access to healthcare, late presentation, limited renal replacement therapy, and its unaffordability, as well as harmful socio-cultural practices, some lifestyle risk factors such as age, elevated blood pressure (BP), presence of diabetes mellitus, obesity, habitual intake of analgesics and herbs are associated with CKD development or progression.

Fiseha and Tamir [12], Miller et al. [13], and Kumela et al. [4] stated that timely detection and treatment of CKD can prevent or minimize its complications. Yet, most cases of CKD were not clinically recognized early due to a lack of patients’ awareness about CKD and associated risk factors, as CKD is usually silent till the advanced stages. Screening patients at risk of CKD with objective measures revealed that 29% had CKD, with only 7% having prior knowledge that they were suffering from kidney disease [4]. Studies have established that patients’ awareness and understanding of CKD are persistently low, ranging from 23% to 40% [4, 12, 14, 15]. The global burden of CKD is increasing and is projected to become the 5^th most common cause of death worldwide by 2040 [1].

Previous studies conducted by Olanrewaju et al. [16], Fiseha and Tamir [12], and Tegegne et al. [3] have identified diabetes and hypertension as the leading causes of CKD globally. Furthermore, a recent study conducted in Ekiti State, which is the study setting, also confirmed that the leading risk factors for CKD are diabetes and hypertension [17]. Unfortunately, CKD in individuals with these identified risk factors is usually a subtle disease in the early stages, which becomes severe as it progresses. Patients seek care only when severe symptoms are usually manifestations of serious complications. Chronic kidney disease increases mortality risk by 31.1% in patients with diabetes, with the increase based on the severity of the disease, which ultimately imposes a colossal reduction in quality of life and financial burden on the patient, the family, and the society at large. Investigating the factors of CKD in patients with diabetes and hypertension is, therefore, an important initial step in understanding the disease burden and developing additional research priorities, which few studies have done. Thus, the study investigated the prevalence and risk factors of chronic kidney disease among diabetes and hypertensive patients in a tertiary hospital in Ado-Ekiti, Ekiti State.

Of the 200 participants recruited for the study, a response rate of 98% was attained; thus, 198 participants were used for analysis.

The socio-demographic characteristics of the participants revealed that with respect to age, 50% and 57.1% of diabetes and hypertensive participants were above 60 years; this result is similar to findings of a similar study conducted in Northern Thailand by Jitraknatee et al. [9] where the mean age of the study population was 61.6. The majority of the participants were females and married; this is similar to the findings of Tegegne et al. [3] and Bahrey et al. [10]. Furthermore, 36.7% of the diabetes participants have hypertension as a comorbidity; this is consistent with the findings of Asmelash et al. [8] in a study conducted in Ethiopia, where 66.8% of participants had a comorbidity. Only 2% and 3.1% of diabetes and hypertensive participants have a family history of CKD, which is lower than the findings of 19.2% obtained by Fiseha and Tamir [12] in a similar study conducted in Ethiopia.

Participants with GFR below 60mls/min and albuminuria of >30mg/g were considered to have CKD, as mentioned by Tegegne et al. [3] and Kumela et al. [4]. In this study, 39.8% of people with diabetes have CKD, while 56.1% of hypertensives have CKD using CKD epidemiology collaboration (CKD-EPI) to calculate the eGFR. This might be a sequel to the fact that they are already diagnosed with diabetes and hypertension, with some having both disease conditions at 68% and 42%, respectively, with an associated increase in the prevalence of some of the major risk factors identified in herbal concoction use 77.6% and 73.5%, respectively and use of NSAID 74.5% and 78.6%, respectively. Conversely, a higher prevalence of 61.3% was obtained among diabetes patients in Northern Thailand [9].

The study findings were at variance with the prevalence of 18.7% obtained by Fiseha and Tamir [12] among diabetes participants and 26% obtained by Kumela et al. [4] among both DM and hypertensive participants. Correspondingly, a study conducted by Abd ElHafeez et al. [21] in Egypt among high-risk groups obtained a prevalence of 24.7%. The difference observed in the prevalence rates might be related to the variance in study subjects and setting, the formula used to calculate the estimated glomerular filtration rate, the difference in the sample size as well as the fact that CKD staging was determined by both eGFR and albuminuria of greater than 30mg/g. The study was conducted in an outpatient department, and the eGFR was calculated using CKD epidemiology collaboration (CKD-EPI).

Inadequate awareness and knowledge of CKD is the leading barrier to the timely diagnosis and prevention of disease progression [22]. As revealed in the study, the level of CKD awareness among the study participants was inadequate, 57.1% and 40.8% among diabetes and hypertensives patients, respectively. This is consistent with the study conducted in Rwanda by Ngendahayo et al. [19], where low awareness (55%) of CKD was reported among university students. Similarly, a hospital-based study conducted by Kumela et al. [4]) in Ethiopia reported an awareness level of 36.5%; however, the study reported a high level of awareness of 75% among diabetes participants at stage 4 of CKD. Additionally, a systematic study and meta-analysis study conducted by Chu et al. [23] in the USA established a low level of awareness of 19.2%. Furthermore, Asmelash et al. [8], in their community-based study conducted in North West Ethiopia, reported 68.7% good knowledge of CKD. The differences in the results are probably due to the different study settings, sample sizes, and populations. It is expected that hospital-based participants who might have had better access to health education than the general community may have better knowledge than others.

The study participants were diabetes and hypertension patients, the leading risk factors of CKD. In this study, most diabetes patients were also hypertensive, while almost half of the hypertensive participants also had diabetes. These findings corroborate the findings of Ibitoba et al. [17] in a study conducted in Ado-Ekiti, Ekiti State, Southwestern Nigeria, where diabetes (41.9%) and hypertension (64.7%) were identified as the leading risk factors for CKD. This contrasts with another similar study conducted in the Northcentral, Nigeria, by Olanrewaju et al. [16], where only 4.1% and 23.7% of diabetes and hypertension were identified as risk factors for CKD, respectively [24].

In addition, advanced age has been identified as another risk factor for CKD; in this study, 50% and 57.1% of diabetics and hypertensives, respectively, were above the age of 60 years. This is in line with a study conducted in Ethiopia by Bahrey et al. [10], where it was established that an age greater than 60 years is a risk factor for CKD. Additionally, participants in the study were using herbal concoctions and non-steroidal anti-inflammatory drugs (NSAIDs), risk factors for CKD. These findings are similar to the results of Ibitoba et al. [17] and Shiferaw et al. [25], which showed that habitual use of NSAIDS is two times more likely to result in CKD.

The study showed that the average mean score and standard deviation of the identified clinical risk factors include BMI 29.64±4.39 and 30.25±5.49 among diabetes and hypertensive participants, respectively. This is at par with a systematic review and meta-analysis study conducted in Ethiopia by Shiferaw et al. [25], which showed that patients with BMI ≥ 30 kg/m² were 2.51 times more likely to develop CKD than those with BMI 18.5-24.9 kg/m². The study also identified fasting blood sugar as a risk factor with a mean and standard deviation of 156.87±51.10 for diabetes participants. This is consistent with another similar study conducted by Kumela et al. [4], which showed that FBS of >150mg/dl was independently associated with CKD, likewise two of the studies reviewed in the systematic review and meta-analysis study conducted in Ethiopia by Shiferaw et al. [25] which showed that people with FBS >150mg/dl were statistically associated with CKD in patients with diabetes. Likewise, the study showed a mean score and standard deviation of systolic blood pressure for hypertensive participants as 142.49±20.12. This agrees with a study by Kumela et al. [4], which found that 83% of hypertensive participants with a long duration of hypertension and uncontrolled hypertension are independent predictors of CKD. Likewise, four studies reviewed in the systematic review and meta-analysis study conducted in Ethiopia by Shiferaw et al. [25] showed that people with SBP >140mmHg were 3.26 likely to develop CKD.

The relationship between participants’ socio-demographic characteristics and CKD awareness showed a significant relationship between both participants’ socio-demographic factors (level of education) and awareness of chronic kidney disease. This implies that the participants' level of education mirrors their awareness of chronic kidney disease. This is similar to the knowledge level of participants from the studies of Asmelash et al. [8] and Kumela et al. [4], where good knowledge was recorded among participants with higher levels of education. However, the study finding was at variance with Ngendahayo et al. [19] and Asmelash et al. [8]. The relationship observed might be due to the participants' different educational backgrounds ranging from primary to tertiary educational levels.

Furthermore, employment status was found to be significant, with the majority of the participants running their businesses or working in private firms; this could be associated with the level of income which is also significantly associated with awareness of CKD. It is opined that employment status and income level influence better access to health information, thus improving health literacy and awareness of CKD. This was supported by the study of Ngendahayo et al. [19], where a significant relationship between occupation and knowledge of CKD was established. This probably implied that occupation might influence more preventive activities. Duration of hypertension was also found to be significantly associated with awareness of CKD; this may be because people who receive follow-up care might have more access to health information, such as the CKD risk factors and preventive measures. However, this finding was at variance with the study by Kumela et al. [4] that showed no significant relationship between hypertension duration and CKD awareness.

The relationship between participants’ clinical characteristics includes body mass index, systolic and diastolic blood pressure, albuminuria, fasting blood sugar, lipid profile, and development of CKD. Diabetes and hypertension have been established in studies as the two principal causes of CKD. Poorly controlled or untreated diabetes mellitus and hypertension progress rapidly to CKD [24]. According to Shiferaw et al. [25], the predictors of CKD among diabetes and hypertensive patients includes clinical factors, which have also been established in the study. Body mass index (BMI) was significantly associated with the onset of CKD among diabetes participants. This is supported by a previous study by Shiferaw et al. [25], where patients with BMI ≥30 kg/m² were 2.51 times more likely to develop CKD than those with BMI 18.5–24.9 kg/m². Geletu et al. [26] also posited that high BMI was significantly associated with CKD. The possible reason could be that an increased BMI promotes kidney damage through direct mechanisms like hemodynamic and hormonal effects, which might also lead to glomerular hyperfusion and glomerular hyperfiltration; as a result, glomerular capillary pressure increases, which may subsequently result in increased urinary albumin excretion, followed by overt proteinuria and declining GFR.

Additionally, glycemic control seems to be the most important determinant factor of developing diabetes-related complications and CKD risk, particularly among patients with type 2 diabetes. Fasting blood glucose was significantly associated with the onset of CKD among the diabetes respondents. This is in line with the study of Kumela et al. [4], where fasting blood sugar of >150mg/dl was independently associated with CKD. Shiferaw et al. [25]) likewise posited that poor glycemic control (HbA1c >7%) is the most important risk factor for diabetic nephropathy.

The study revealed a significant level of lipid profile components, including triglycerides, high-density lipoprotein, low-density lipoprotein, and total cholesterol. This is supported by Shiferaw et al. [25] who opined that CKD onset can be predicted by the typical atherogenic lipid profile, including high triglycerides, which was directly found to be associated with an increased probability of developing reduced eGFR.

Furthermore, the study established a significant relationship between CKD with uncontrolled blood pressure, particularly among diabetics and hypertensives. This is similar to the finding of Kumela et al. [4], where the long duration of hypertension and uncontrolled blood pressure (BP>140/90 mmHg) were independent predictors of CKD. Shiferaw et al. [25] also showed that systolic blood pressure of more than 140mmHg was a strong predictor of CKD, predominantly in diabetes and hypertensive patients, establishing that early treatment of hypertension is vital in the prevention of cardiovascular disease and the progression of diabetic renal disease and retinopathy. Likewise, the benefit of tight blood pressure control may be as great or greater than stern glycemic control.

The research study determined the prevalence of CKD, assessed the awareness level, and identified the risk factors of chronic kidney disease (CKD) among diabetes and hypertensive patients receiving follow-up treatment in a tertiary hospital. It was revealed in the study that the prevalence of CKD among diabetes and hypertensive participants were 39.8% and 57.1%, respectively. The study established a low level of awareness of CKD among the study population, while the identified risk factors of CKD were; diabetes mellitus, hypertension, herbal concoction, and NSAID. Furthermore, it was observed that there was a significant relationship between participants’ educational background, age, employment status, income level and duration of hypertension, and awareness level of CKD. Body mass index, lipid profile, fasting blood sugar, and blood pressure were the major identified clinical risk factors that significantly predicted CKD development. The study concluded that the prevalence of CKD is high at 39.8% and 57.1% among diabetes and hypertensive participants, respectively, and that body mass index, lipid profile, fasting blood sugar, and blood pressure significantly predicted the development of CKD among the studied population.

Based on the outcomes of this study, prevention is key when it comes to kidney disease; hence, all stakeholders, including nurses and other healthcare providers, should reinforce preventive activities. Community awareness and campaigns on kidney health should be carried out as often as possible, and risk assessment should be done to recognize CKD cases at the initial stages, as this will facilitate early interventions to slow down its progression and thereby reduce the financial burdens and morbidity and mortality associated with CKD.

The most at-risk population, which includes diabetes and hypertensive individuals, should be well counseled on the importance of compliance with the treatment regimen and the need to avoid other risk factors to prevent delayed renal involvement and progression of CKD stages. Finally, nurses and other healthcare professionals should ensure proper monitoring of diabetes and hypertensive patients through adequate health education in compliance with exercise, diet, medications, and regular medical follow-ups. Additionally, blood pressure should be maintained at 130/80mmHg, HbA1c below 7, and BMI 18.5-24.9.