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Finerenone is a new mineralocorticoid receptor antagonist with a different structure, volume of distribution and half-life compared to spironolactone. This drug has been tested in two large, randomized trials including diabetic patients with chronic kidney disease (in terms of glomerular filtration rate and albuminuria) and already treated by renin-angiotensin system blockade. Results are positive on hard renal- and cardiac endpoints. Risk of hyperkalaemia is higher than with placebo but is considered as acceptable. An open question that will be tested in further studies is the role of finerenone in the context of a treatment by gliflozins, drugs that also showed cardiorenal protection.La finérénone est un antagoniste non stéroïdien du récepteur des minéralocorticoïdes avec une structure, un volume de distribution et une demi-vie différents de la spironolactone. Cette molécule a récemment été testée dans deux grands essais randomisés et contrôlés chez des patients avec une néphropathie diabétique avérée (en termes de débit de filtration glomérulaire et d’albuminurie) et un blocage optimal du système rénine-angiotensine-aldostérone (SRAA). Les résultats attestent d’une néphroprotection et d’une cardioprotection conférées par cette molécule, en addition aux bloqueurs du SRAA, sur des critères de jugement durs. Le risque d’hyperkaliémie était supérieur au placebo, mais acceptable. Une question ouverte reste celle de la place de cette molécule par rapport aux gliflozines, ayant aussi prouvé une protection cardiorénale.

Both renin-angiotensin-aldosterone system inhibitors (RAASi) and sodium-glucose cotransporter type 2 inhibitors (SGLT2i, gliflozins) reduce the risk of heart failure and of progressing towards end-stage renal disease, especially in patients with type 2 diabetes (T2D). Positive results reported in patients with T2D have been confirmed in people without diabetes. These two pharmacological classes now occupy a privileged place in international guidelines, in diabetology, cardiology and nephrology. The present article describes similarities and differences between these two types of medications. It emphasizes the importance of combining both approaches in order to optimize the cardiovascular and renal prognosis, while maintaining a good safety profile.Les inhibiteurs du système rénine-angiotensine-aldostérone (iSRAA) et les inhibiteurs des cotransporteurs sodium-glucose de type 2 (iSGLT2, gliflozines) réduisent le risque d’insuffisance cardiaque et de progression vers l’insuffisance rénale terminale, notamment chez les patients avec un diabète de type 2 (DT2). Les effets positifs rapportés chez les patients DT2 ont été confirmés chez les personnes non diabétiques. Ces deux classes pharmacologiques occupent maintenant une place de choix dans les recommandations internationales, en diabétologie, en cardiologie et en néphrologie. Cet article fait le point sur les similitudes et les différences entre ces deux familles médicamenteuses. Il insiste sur l’importance de les combiner pour optimiser le pronostic cardiovasculaire et rénal, tout en maintenant un bon niveau de sécurité.

The relationships between sodium-glucose cotransporter type 2 inhibitors (SGLT2is) and kidney are complex: reduction of the glucose-lowering effect with the decline of glomerular filtration rate (GFR), biphasic effects on GFR along with treatment duration, low risk of acute kidney injury, rapid reduction of albuminuria, and, most importantly in clinical practice, a remarkable nephroprotection, with a decrease of the risk of end-stage renal disease or death from renal cause. This article describes the renal outcomes in the main clinical trials and analyses the impact of treatment with SGLT2is on renal prognosis according to different patient baseline characteristics. A nephroprotection is observed whatever the severity (even if GFR45 ml/min/1,73 m²) and type (with or without albuminuria, with or without diabetes) of renal disease.Les relations entre inhibiteurs des cotransporteurs sodium-glucose de type 2 (iSGLT2) et rein sont complexes: réduction de l’effet antihyperglycémiant avec la diminution du débit de filtration glomérulaire (DFG), effets biphasiques sur le DFG dans le décours du traitement, risque faible d’insuffisance rénale aiguë, diminution rapide de l’albuminurie et, surtout, remarquable néphroprotection à terme, avec une diminution du risque d’insuffisance rénale terminale ou des décès d’origine rénale. Cet article décrit les résultats rénaux dans les grands essais cliniques et analyse l’impact du traitement par iSGLT2 en fonction des caractéristiques des patients à l’inclusion. Une néphroprotection est observée quels que soient la sévérité (DFG45 ml/min/1,73 m²) et le type (albuminurique ou non, diabétique ou non) de la maladie rénale.

To determine the hospital frequency of diabetic patients with a rapid decline in their renal function, to look for the associated factors.Descriptive and analytical cross-sectional study carried out over 12 months (May 1, 2019 to April 31, 2020). Were included all patients aged 18 and over, having achieved at least 3 creatinine during the previous 2 years but spaced at least 6 months apart and having an eGFR calculated from their last creatinine greater than 30 mL/min by the formula of CDK-EPI. We evaluated the eGFR by the CDK-EPI formula using the calculator developed by the Poitiers University Hospital and the Inserm unit of the Francophone Diabetes Society.A total of 80 patients medical files were retained. The rapid decline in renal function was found in 28 patients, either a frequency of 35%. The sex ratio M/F was 1.5. The mean age was 62.93 years (range 18-85 years). Hypertension was the most common comorbidity (92.5%). The very high cardiovascular risk was predominant in 82.5% of cases. The very high renal risk was found in 20 patients, either 25%. Univariate and multivariate analysis showed that the rapid decline in renal function was associated with very high cardiovascular risk (P=0.037) and glomerular filtration rate (P˂0.001).this study showed a high hospital frequency of the rapid decline in renal function in Togo (35%). Our results have identified the very high cardiovascular risk and glomerular filtration rate as risk factors. The originality of our study was the demonstration of the high proportion of very high cardiovascular risk (82.5%) and very high renal risk (25%) in the evaluation of renal and cardiovascular risk.

Sodium-glucose cotransporter type 2 inhibitors (iSGLT2 or gliflozins) exert their antidiabetic action through a specific renal mechanism, by inhibiting tubular glucose reabsorption. These agents have proven their efficacy to reduce major cardiovascular events and hospitalisation for heart failure, but also the progression of chronic kidney disease (CKD), in patients with type 2 diabetes (T2DM) at high risk, independently of glucose control. While the glucose-lowering effect of iSGLT2 is decreasing with the decline of estimated glomerular filtration rate (eGFR), both cardiovascular and renal protections remain present until an eGFR as low as 30 ml/min/1,73 m². These effects were demonstrated in several meta-analyses and in two trials specifically dedicated to renal outcomes in patients with CKD and macroalbuminuria : CREDENCE with canagliflozin and Dapa-CKD with dapagliflozin. In addition, Dapa-CKD showed similar positive results whatever the presence or absence of T2DM. Safety profile of SGLT2is among patients with CKD is good and similar to that of patients with normal renal function. These favourable findings led to a privileged place of SGLT2i in recent international guidelines promoted by diabetologists, cardiologists and nephrologists. Current restrictive criteria for the prescription and reimbursement of SGLT2i in Belgium according to eGFR level (initiation only if eGFR superior to 60 and interruption if eGFR inferior to 45 ml/min/1.73 m²) should be enlarged very soon owing to convincing results of published controlled trials.Les gliflozines (inhibiteurs des cotransporteurs sodium-glucose de type 2 ou iSGLT2) ont un mécanisme d’action antidiabétique spécifiquement rénal, en inhibant la réabsorption tubulaire du glucose. Indépendamment du contrôle glycémique, ces médicaments ont prouvé leur efficacité pour réduire les événements cardiovasculaires majeurs et les hospitalisations pour insuffisance cardiaque, mais aussi la progression vers l’insuffisance rénale chronique (IRC) terminale chez des patients diabétiques de type 2 (DT2) à haut risque. Si l’effet anti-hyperglycémiant des iSGLT2 diminue avec le déclin du débit de filtration glomérulaire (DFG), les effets protecteurs cardiovasculaires et rénaux persistent au moins jusqu’à un DFG de 30 ml/min/1,73 m². Ces effets ont été démontrés dans plusieurs méta-analyses des essais cardiovasculaires et dans deux essais spécifiquement à visée rénale chez des patients avec IRC et macroalbuminurie, CREDENCE avec la canagliflozine et Dapa-CKD avec la dapagliflozine. En outre, Dapa-CKD a montré les mêmes effets positifs en cas d’IRC non diabétique. Par ailleurs, le profil de sécurité des gliflozines chez les patients avec IRC est bon et comparable à celui des patients avec fonction rénale normale. Ces résultats favorables ont donné aux iSGLT2 une place privilégiée dans les dernières recommandations internationales diabétologiques, cardiologiques et néphrologiques. Les critères restrictifs actuels de prescription et de remboursement en Belgique des iSGLT2 en fonction du niveau de DFG (instauration si DFG sup�rieur a 60 et interruption si DFG inf�rieur a 45 ml/min/1,73 m²) devraient être élargis prochainement au vu des résultats convaincants des essais cliniques disponibles.

SGLT2 inhibitors (SGLT2i) will change the clinical practice of nephrology with their therapeutic cardiorenal and antidiabetic properties. By inhibiting proximal tubular sodium and glucose reabsorption, these new drugs decrease intraglomerular pressures. Over the last 5 years several breakthrough studies have demonstrated the SGLT2i protective effects on outcomes such as cardiovascular mortality, hospital admission for heart failure, sustained decreases in eGFR in patients with diabetic nephropathy and the development of ESKD. With the new DAPA-CKD study revealing protective effects of SGLT2i in CKD patients without diabetes, therapeutic recommendations will now have to evolve towards including these drugs in the chronic management of all most proteinuric CKD patients.Les inhibiteurs du cotransporteur du sodium-glucose de type 2 (iSGLT2) révolutionnent la pratique clinique en néphrologie par le biais de leurs effets antidiabétique, cardio et néphroprotecteur. Ces molécules inhibent la réabsorption du glucose et du sodium au niveau du tubule proximal, ce qui résulte en une baisse de la pression intraglomérulaire. Plusieurs grandes études ont démontré l’effet protecteur des iSGLT2 sur la mortalité cardiovasculaire, le taux d’hospitalisation pour une insuffisance cardiaque et le ralentissement de la progression de la néphropathie diabétique. La sortie de DAPA-CKD va certainement modifier les recommandations thérapeutiques pour la prise en charge de l’insuffisance rénale chronique (IRC) non diabétique, en démontrant un effet néphroprotecteur majeur chez les IRC protéinuriques d’origine non diabétique également.

Reunion Island's population is characterized by a multiethnic origin, which makes it impossible to transpose epidemiological data of Metropolitan France. Only REIN Registry provides a macroscopic view of kidney disease, limited to the causes of end stage renal disease.This is a regional retrospective study whose main objective is to describe renal pathologies in Reunion Island's adults over a period of 3 years. Kidney transplants are excluded.Between 2015 and 2017, 338 native adult kidney biopsies performed on the island are collected. The annual biopsy rate is 132/million/year with preponderance in the northern part of the island due to a higher density of nephrologists. Nephrotic syndrome is the first indication with 30% of cases. The four main results are represented by IgA nephropathy (16%), diabetic nephropathy (12.4%), lupus nephropathy (11.2%) and isolated vascular nephropathy (11%). Incidence of glomerulopathies is similar to the worldwide incidence, nevertheless a preponderant place of diabetic nephropathy is found. On the biopsies performed, incidence of complications is evaluated at 7.5%, with no difference between the detection technique used.This is the first study illustrating main renal pathologies in Reunion Island. Diabetes' frequency in general population is a major confounding factor in diagnosis and management of kidney diseases on the island.

Polypharmacy is common in patients with a chronic disease. It is appropriate when both the patient and the physician discuss the goal of each prescribed medication with a motivated patient capable of managing his/her medication. It can however be inappropriate when treatment becomes too complex for the frail patient. The risk is non-adherence to therapy, which often results in an intensification of treatment due to unmet therapeutic goals. Collaboration between physicians and pharmacists is therefore essential for the educational support of patients with polypharmacy. In this article, we review the studies examining the impact of a physician-pharmacist collaboration on the medication adherence of diabetic patients with renal impairment.La polypharmacie concerne de nombreux patients avec une maladie chronique. Elle est appropriée lorsque chaque médicament a été prescrit dans un but thérapeutique spécifique discuté avec un patient motivé et capable de gérer ses médicaments. Elle peut cependant être inappropriée lorsque le traitement devient trop complexe pour une personne fragile. Le risque est une non-adhésion au traitement, dont découle souvent une intensification de la thérapie en raison d’objectifs thérapeutiques non atteints. La collaboration médecin-pharmacien est donc primordiale pour l’accompagnement éducatif du patient complexe dans la gestion de ses médicaments. Dans cet article, nous revoyons les études examinant l’adhésion thérapeutique chez le patient diabétique avec une atteinte rénale lors d’une collaboration médecin-pharmacien.

In our aging population, kidney disease management needs to take into account the frailty of the elderly. Standardized geriatric assessments can be proposed to help clinicians apprehend this dimension in their daily practice. These tools allow to better identify frail patients and offer them more personalized and harmless treatments. This article aims to focus on the kidney diseases commonly observed in elderly patients and analyze their specific nephrogeriatric care modalities. It should be noticed that all known kidney diseases can be also observed in the elderly, most often with a quite similar clinical presentation. This review is thus focused on the diseases most frequently and most specifically observed in elderly patients (except for monoclonal gammopathy associated nephropathies, out of the scope of this work), as well as the peculiarities of old age nephrological care.

Diabetic nephropathy is a leading cause of chronic kidney disease and dialysis. We know that a good diabetes control slows the progression of kidney disease, but the risk of hypoglycemia is greater in patients with chronic kidney disease and contributes to their mortality. Chronic kidney disease and diabetes are major cardiovascular risk factors with additive effects. Decreasing cardiovascular mortality is a major aim in chronic kidney disease. The ideal antidiabetic molecule in these patients should reduce the risk of dialysis, reduce cardiovascular mortality and carry no risk of hypoglycaemia. This article aims to summarize for the general practician the nephrological implications of new antidiabetic drugs and their use in chronic kidney disease patients.La néphropathie diabétique est une cause majeure d’insuffisance rénale chronique et de mise en dialyse. Un bon contrôle du diabète permet un ralentissement de la progression de la maladie rénale, mais le risque d’hypoglycémie est plus important chez les patients en insuffisance rénale chronique et contribue à leur mortalité. L’insuffisance rénale chronique et le diabète sont des facteurs de risque cardiovasculaires additifs, et la diminution de la mortalité cardiovasculaire est un objectif majeur en insuffisance rénale chronique. La molécule antidiabétique idéale devrait diminuer le risque de mise en dialyse, réduire la mortalité cardiovasculaire et ne pas engendrer d’hypoglycémie. Cet article vise à résumer les implications néphrologiques des nouveaux antidiabétiques et leur possibilité d’utilisation chez l’insuffisant rénal chronique.

National audience; Diabetic nephropathy is usually a presumptive diagnosis based on clinical and biological evidence. Renal biopsies are performed in diabetic patients with atypical findings evoking non-diabetic renal disease who could benefit from specific therapies. French speaking nephrologists were asked which criteria they retain to indicate renal biopsy in patients with type 2 diabetes and albuminuria>0.5g/day or equivalent through an online anonymous questionnaire. Among the suggested criteria were absence of diabetic retinopathy, hematuria, rapid decrease in GFR, short diabetes duration or rapid raise of proteinuria. 188 people answered the poll among whom interns (12%), fellows (13%), university hospital practitioners (26%), general hospital practitioners (24%), practitioners in a non-profit organization (13%), practitioners on private activity (10%), multi-modal practitioners (3%) and people without clinical activity (2%). Increasing proteinuria was retained as an indication criterion for renal biopsy by 51% of respondents, nephrotic syndrome by 56% of respondents, absence of diabetic retinopathy by 57% of respondents, short diabetes duration by 65% of respondents, rapid GFR decline by 75% of respondents and hematuria by 78% of respondents. These data highlight the high diversity of opinions on this topic and their discrepancies with guidelines and current literature regarding the association between non-diabetic renal disease and clinical and biological features. The lack of adhesion of nephrologists to guidelines was especially noteworthy regarding the absence of diabetic retinopathy. These results emphasize the need for studies focusing on biopsy indication criteria in patients with type 2 diabetes.; Le diagnostic de néphropathie diabétique est généralement clinique. Une biopsie rénale peut être réalisée en cas d’atypie afin d’éliminer une maladie rénale non diabétique. Nous avons évalué l’opinion des néphrologues francophones par un questionnaire anonyme portant sur les critères cliniques et biologiques — en particulier l’absence de rétinopathie diabétique, la présence d’une hématurie, la diminution du débit de filtration glomérulaire ou l’élévation de la protéinurie — les amenant à retenir l’indication de biopsie rénale chez des patients diabétiques de type 2 avec albuminurie>0,5g/jour ou équivalent. Cent quatre-vingt-huit personnes ont répondu au questionnaire, réparties entre internes (12 %), assistants (13 %), praticiens en hôpital universitaire (26 %), en hôpital général (24 %), en secteur associatif (10 %), en secteur privé (10 %), en exercice mixte (3 %) ou sans pratique clinique (2 %). L’élévation de la protéinurie était un critère d’indication de biopsie rénale pour 51 % des participants, le syndrome néphrotique pour 56 % des participants, l’absence de rétinopathie diabétique pour 57 % des participants, la courte durée du diabète pour 65 % des participants, la progression rapide de l’insuffisance rénale chronique pour 75 % des participants et l’hématurie pour 78 % des participants. Notre enquête révèle donc une incertitude de la communauté néphrologique quant aux critères d’indication de biopsie rénale chez les patients diabétiques de type 2 ayant une protéinurie et la discordance des opinions vis-à-vis des recommandations et de la littérature, en particulier au regard de l’absence de rétinopathie diabétique. Ces résultats soulignent la nécessité d’une étude analysant les résultats de ces biopsies au regard de leurs indications.

The strategy for the management of hyperglycaemia in type 2 diabetes was updated in October 2018 by a group of experts of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). They are triggered by the results of cardiovascular outcome trials published since 2015, which demonstrated a cardiovascular (and renal) protection with two classes of medications, SGLT2 inhibitors (gliflozins) and some GLP-1 receptor agonists (mainly liraglutide) in patients with established cardiovascular disease. Thus, after failure of lifestyle and metformin, the addition of one of these agents is recommended in presence of atherosclerotic cardiovascular disease. In case of heart failure or renal disease, the preference is given to a SGLT2 inhibitor, provided that estimated glomerular filtration rate is adequate (superior to 45-60 ml/min/1.73 m²). In all other patients, the choice is guided by the main objective, in concertation with the patient : to reduce the risk of hypoglycaemia (gliptin, gliflozin, pioglitazone or GLP1 receptor agonist), body weight excess (SGLT2 inhibitor or GLP-1 receptor) or medication cost (sulphonylurea, pioglitazone). If oral treatment is insufficient, the preference is now given to a GLP-1 receptor agonist rather than basal insulin. Thus, instead of a glucocentric and metabolic viewpoint predominant in the previous position statement, a paradigm change is proposed, focusing on cardiovascular and renal protection, within a patient-centred approach.Les recommandations pour le traitement de l’hyperglycémie du diabète de type 2 viennent d’être mises à jour en octobre 2018 par un groupe d’experts au nom de l’American Diabetes Association (ADA) et l’European Association for the Study of Diabetes (EASD). Elles tiennent compte des résultats des essais cliniques publiés depuis 2015, démontrant une protection cardiovasculaire (et rénale) avec deux classes de médicaments, les inhibiteurs des SGLT2 (gliflozines) et certains agonistes des récepteurs du GLP-1 (notamment le liraglutide) chez des patients avec maladie cardiovasculaire athéromateuse. Dès lors, en cas de contrôle insuffisant par metformine, l’ajout d’un de ces médicaments est privilégié en présence d’une maladie athéromateuse. S’il existe une insuffisance cardiaque ou une maladie rénale, la préférence est donnée à un inhibiteur des SGLT2, à condition que le débit de filtration glomérulaire soit suffisant (sup�rieur a 45-60 ml/min/1,73 m²). Chez tous les autres patients, le choix doit être guidé par l’objectif principal, fixé de commun accord avec le patient: réduire le risque hypoglycémique (gliptine, gliflozine, pioglitazone ou agoniste des récepteurs du GLP-1), favoriser une perte pondérale (inhibiteur des SGLT2 ou agoniste des récepteurs du GLP-1) ou limiter le coût (sulfamide, pioglitazone). En cas d’échec du traitement oral, la préférence pour le passage à un traitement injectable est désormais donnée à un agoniste des récepteurs du GLP-1 plutôt qu’à une insuline basale. Ainsi, d’une vue glucocentrique et métabolique prédominant dans les recommandations précédentes, un changement de paradigme est proposé, centré sur la prévention des maladies cardiovasculaires et de l’insuffisance rénale, dans une approche personnalisée du patient.

Type 2 diabetes has an increasing prevalence. Life expectancy is dominated by cardiovascular risk, which is the leading cause of death in these patients. Up to one third of diabetic patients will develop diabetic nephropathy related to micro-angiopathy. Renal impairment further increases cardiovascular risk. Reducing cardiovascular morbidity and mortality is a major public health issue, as well as early preventing and managing chronic kidney disease (CKD). Good glycemic control prevents the micro-vascular complications of the disease (retinopathy, nephropathy, etc.) and, more recently recognized through prolonged monitoring of the VADT cohort, prevents cardiovascular complications. Control of blood pressure and dyslipidemia are essential in primary or secondary cardiovascular prevention. In addition, the blockers of the renin-angiotensin system slow down the progression of the MRC. Elderly patients with chronic kidney disease (CKD) form another growing group of the nephrologist daily patient pool. Especially for very elderly patients with comorbidities, the question of favoring conservative treatment rather than starting or pursuing dialysis may arise. Survival and quality of life are indeed not necessarily better in elderly patients undergoing dialysis, complications can occur eventually leading to discontinuation, and are occasionally associated with a feeling of stubbornness. Creation of prognostic score is a useful tool to help the decision-making process. However, dialogue with the patient and his/her family, as well as multidisciplinary collaboration remain fundamentals to determine the most suitable care.

Beta cell replacement by pancreas or Langerhans islets transplantation is the only way to restore glucose homeostasis in type 1 diabetic patients. The counterpart is the need for long-term immunosuppression. These transplantations are therefore mainly indicated for patients candidates for kidney transplantation and for patients with poor quality of life due to unstable diabetes with life-threatening hypoglycemic events. Both beta cell replacement techniques have different benefits and risks and should be adapted to each type 1 diabetic patient. The transplant strategy must be personalized according to parameters assessed in the pre-transplant period, validated by a multidisciplinary team and reassessed regularly until transplantation.

The field of diabetes is constantly evolving, with numerous new molecules reaching the market in the treatment of type 2 diabetes. Paradoxically, this drug jungle is difficult for the primary care physician and can lead to therapeutic inertia. After the beneficial effect of empagliflozin on cardiovascular outcomes in the EMPA REG Outcome trial in 2015, liraglutide also shows cardiovascular benefits in high risk patients with type 2 diabetes. Therefore, these two studies, led to new recommendations by the Swiss Society for Endocrinology and Diabetes, by notably favouring the prescription of these molecules to type 2 diabetic patients in secondary prevention, after metformin.La diabétologie est une discipline en pleine évolution, notamment suite à l’apparition sur le marché de nombreuses nouvelles molécules qui enrichissent la panoplie des traitements possibles dans le diabète de type 2. Ceci s’accompagne paradoxalement d’une plus grande difficulté pour le médecin traitant à se retrouver dans cette jungle thérapeutique, ce qui peut mener à une certaine inertie thérapeutique. Après l’étude EMPA REG Outcome en 2015, qui a montré un bénéfice cardiovasculaire chez les patients diabétiques de type 2 à haut risque cardiovasculaire pour l’empagliflozine, une autre molécule, le liraglutide, a elle aussi montré un bénéfice cardiovasculaire chez les patients diabétiques de type 2 à haut risque. Ainsi, ces deux études ont mené à de nouvelles recommandations sur le plan suisse.

Chronic kidney disease remains a major challenge for public health systems and corresponds to the replacement of renal functional tissue by extracellular matrix proteins such as collagens and fibronectin. There is no efficient treatment to date for chronic kidney disease except nephroprotective strategies. The cannabinoid system and more specifically the cannabinoid receptors 1 (CB1) and 2 (CB2) may represent a new therapeutic target in chronic kidney disease. Experimental data obtained in models of diabetes and obesity suggested that CB1 blockade and CB2 stimulation may slow the development of diabetic nephropathy. In human kidneys, CB1 expression is increased in various chronic nephropathies and correlates with renal function. Moreover, endogenous CB1 and CB2 ligands are greatly increased during renal fibrogenesis. A microarray analysis performed in an experimental model of renal fibrosis found that the gene encoding for the CB1 receptor was among the most upregulated genes. We also demonstrated that renal fibrogenesis could be reduced by CB1 inhibition and CB2 stimulation in an experimental model through a direct mechanism involving CB1 on myofibroblasts, which are the major effector cells during renal fibrosis. Therefore, CB1 blockers may represent a novel therapeutic target in chronic kidney disease and diabetes.

The 9th World Kidney Day, on 13 March 2014, was devoted to the topic of renal aging. The proportion of older people in the general population is increasing steadily worldwide, with the most rapid growth in developing countries. This demographic upheaval is a consequence of socioeconomic development and increasing life expectancy. Chronic kidney disease is an important public health problem characterized by poor health outcomes and very high healthcare costs. Chronic kidney disease is a major risk multiplier in patients with diabetes, hypertension, heart disease and stroke, all of which are key causes of death and disability among older people. The prevalence of chronic kidney disease is higher in the elderly, in whom it contributes to the effects of aging. The decrease in renal function with age also compounds the effects of renal disease, whether primary or secondary to systemic or urinary tract disorders. This physiological reduction in functional capacity affects the glomerular filtration rate and renal tubular functions, including water and salt regulation and also the elimination of many drugs. The aging kidney is much more sensitive to toxic insults, especially those due to nonsteroidal antiinflammatory drugs and iodinated contrast agents. Prevention of renal deterioration in the elderly is based on monitoring renal function, adapting medications, and maintaining a regular supply of water and salt.

The diabetic kidney disease is the most frequent cause of end stage renal disease in Western countries. Its detection is obtained by simultaneously measuring urinary albumin excretion and estimating glomerular filtration rate through serum creatinine dosage. Many type 1 and type 2 diabetic patients can present decreased glomerular filtration rate before the occurrence of increased urinary albumin. While waiting for promising new pharmacological approaches currently evaluated in clinical trials, the best approach to stop the epidemic of diabetic nephropathy remains an early and individual multifactorial approach controlling the glucose level (without inducing hypoglycaemia), blood pressure (using a renin-angiotensin blocker), dyslipidaemia and over-weight.

Advanced-stage diabetic nephropathy requires multidisciplinary treatment for the patient. He/she must be informed, when necessary, of the possible dialysis methods and the assessment of the transplant options. Haemodialysis and peritoneal dialysis offer comparable survival rates. The enlightened choice of the patient is guided by the nephrology team. Survival on dialysis unfortunately remains uncertain due to numerous comorbidities, in particular cardiovascular conditions.

Acute oxalate nephropathy is a severe cause of acute kidney injury characterized by tubule-interstitial oxalate deposits with an inflammatory infiltrate. Three cases of AKI occuring in diabetic patients, and whose renal biopsy gave a diagnosis of acute oxalate nephropathy are reported. This cristal deposit AKI is due to either primary hyperoxaluria or secondary to enteric hyperabsorption. Its prognosis is dismal and rapid recognition by renal biopsy and determination of the cause of hyperoxaluria is mandatory in order to avoid end-stage kidney disease. This diagnosis should be suspected in cases of non resolving AKI, especially in diabetic patients who may have undetected pancreatic exocrine insufficiency.

Malakoplakia (MP) is a rare granulomatous disease, usually occurring in immunocompromised patients, linked to Escherichia coli infection. The lesions are usually located in the genitourinary tract, but there is a great variability in the topography and the clinical presentation.A 70-year-old diabetic kidney transplant patient under immunosuppressive treatment presented with a voluminous submandibular chronic lesion, involving the skin, associated with a burgeoning lesion of the oral mucosa. Histological examination of biopsies concluded to MP and bacteriological samples were positive for E. coli. Antibiotic treatment allowed for the regression of the lesion before surgical removal. Histological examination of resected material confirmed the diagnosis of invasive MP of the submandibular gland.The diagnosis of MP relies on histological examination, showing the presence of von Hansemann's cells and Michaelis- Gutmann bodies. The treatment is based on active antibiotics targeted against intracellular bacteria, possibly associated with surgery. We report the first case of MP involving the submandibular gland.

We conducted an exhaustive cross-sectional descriptive study, in 2009, on type 1 diabetics residing in the wilaya of Constantine. Our objective was to assess the frequency and risk factors associated with diabetic macular edema (DME) by mydriatic non-stereoscopic fundus photographs of nine retinal fields. The frequency of DME was 8.7%. There was no gender influence on the frequency of macular edema. There were as many men (46.4%) as women (53.6%) with ME (P = 0.8). On bivariate analysis, the duration of diabetes (P = 0.001), age (P = 0.0001), hypertension (P = 0.00001), renal involvement (P = 0.00001) and hypercholesterolemia (P = 0.01) were risk factors for DME.

To assess the prevalence of diabetic retinopathy (DR) in a young population with type I diabetes in Lebanon, to compare it to its prevalence worldwide according to the literature, and to analyze its potential risk factors.Screening for DR by fundus examination was performed in patients10 years and diabetic for over 8 years attending the Chronic Care Center (CCC) in Lebanon. Data regarding patients' age, duration of their diabetes, body mass index, systolic and diastolic blood pressure, smoking habits, dyslipidemia, microalbuminuria, mean HbA1c over the past five years, number of insulin injections, parents' educational level and geographical origin, were collected.220 teenagers and young adults (103 males and 117 females) aged between 12 and 46 years (mean age 24.2 y) were included in the study. The prevalence of DR was 14.6%, comparable to recent studies of similar populations. A non-proliferative DR was found in 25 children (11.4%) and a proliferative DR in 7 patients (3.2%). The mean duration of diabetes was 153 +/- 6.0 y and mean HbA1c 8.0 +/- 1.1%. The prevalenc of DR was not significantly influenced by genders (p = 0.52), smoking habits (p = 0.125), monitoring of blood glucose (p = 0.812), dyslipidemia (p = 0.435), and obesity. However, patients with DR were significantly older than those without DR (p0.001), had a longer duration of diabetes (p0.001), and higher systolic and diastolic pressures (p0.001 and p = 0.01 respectively). The presence of nephropathy was directly correlated with DR (p0.001). Finally, the parents' region of origin and educational level were significant risk factors for the presence of DR (p = 0.05 and p0.001 respectively).The prevalence of DR in young type I diabetic patients followed in the CCC in Lebanon is relatively low and comparable to that published worldwide, with a decrease during the last 25 years, due to a multidisciplinary approach and a centralized control of risk factors.

Diabetic nephropathy is a leading cause of end-stage renal disease worldwide. The mainstay of treatment has been management of hyperglycaemia, blood pressure and proteinuria using hypoglycemic agents, ACE inhibitors, and angiotensin receptor blockers. Since 2000, new therapeutic strategies began to emerge targeting the biochemical activity of glucose molecules on the renal tissue. Various substances have been studied with varying degrees of success, ranging from vitamin B to camel's milk. Silymarin reduces urinary excretion of albumin, tumor necrosis factor (TNF)-α, and malondialdehyde in patients with diabetic nephropathy and may be considered as a novel addition to the anti-diabetic nephropathy armamentarium. Although some results are promising, studies on a larger scale are needed to validate the utility of these molecules in the treatment of the DN.

Numerous patients with type 2 diabetes have renal impairment, especially in the elderly population. Metformin, the first choice oral glucose-lowering agent, is classically contraindicated in case of chronic kidney disease of stages 3-5 (creatinine clearance60 ml/min/1.73 m2), because of a risk of accumulation of the biguanide that may lead to lactic acidosis. Hence numerous patients with some degree of renal impairment are being treated with metformin in clinical practice, apparently without any harm. In contrast, several observational studies have shown that they may clinically benefit from this therapy, including with a significant reduction of all-cause mortality when compared to patients not receiving metformin. Thus, an increasing number of physicians plea for revisiting the official criteria of contraindication to the use of metformin in case of renal insufficiency. The present paper discusses this controversy and insists upon the mandatory cautions to be taken when using metformin in a diabetic patient with moderate (stage 3) chronic kidney disease (metformin being contraindicated in case of severe renal impairment - stages 4-5).

In an effort to slow the deterioration of renal function, several authors have recommended in the diabetic stage renal disease with moderate renal impairment decreased protein intake to 0.7 or 0.3 g / kg / day associated with energy intake of at least 30 to 35 kcal / kg / day. However, in clinical practice this proved difficult to achieve without exposing patients to the risk of under nutrition.To evaluate the effects of a protein restricted diet on the development of diabetic nephropathy and the nutritional status of diabetic patients with renal impairment at the stage of moderate renal impairment compared with those of a group of diabetics with the same characteristics put under basal diabetic diet.Prospective study of 57 diabetic patients in moderate stage renal disease of middle age (32 ± 0.6 years) followed at the National Institute of Nutrition of Tunis in 2010. Our patients were separated into two groups (group A comprising 30 patients, put on diabetic diet basal and group B comprising 27 patients used in protein-deficient diet: 0.6 to 0.7 g / kg /d). We followed the evolution of certain parameters: glomerular filtration rate (GFR), serum albumin, albuminuria, nutritional risk index (NRI) and we analyzed dietary intake at D0, D90 and D180.Renal function in patients in group B improved as demonstrated by the trend towards higher GFR. It increased from day 0 to day 90 and at day 180. In parallel, there was a beneficial effect on albuminuria which was reduced from 380 ± 56 mg/24h on day 0, to 322 ± 50mg/24h at day J90 and 302 ± 16 mg/24h at day 180. In group A, the opposite phenomena occurred. The patients in Group B have also reduced their overall caloric intake to less than 1800 kcal / day making sure that the balance of their diet quality could no longer be assured the result has a tendency to under nutrition noted more frequently in the latter group (NRI0 = 97.90%, NRI 90= 90.10% , NRI180=90,0%). In the literature these results were found by several studies.The protein-deficient diet (0.6 to 0.7 g/ kg /d) must be integrated into the overall care of diabetic renal insufficiency with moderate renal impairment but requires rigorous repeated dietary interviews and customized to avoid malnutrition can result.

People with type 2 diabetes are at increased risk of many complications, which are mainly due to complex and interconnected mechanisms such as hyperglycemia, insulino-resistance, low-grade inflammation and accelerated atherogenesis. Cardi-cerebrovascular disease are frequently associated to type 2 diabetes and may become life threatening, particularly coronaropathy, stroke and heart failure. Their clinical picture are sometimes atypical and silencious for a long time. Type 2 diabetes must be considered as an independent cardiovascular risk factor. Nephropathy is frequent in type 2 diabetes but has a mixed origin. Now it is the highest cause of end-stage renal disease. Better metabolic and blood pressure control and an improved management of microalbuminuria are able to slowdown the course of the disease. Retinopathy which is paradoxically slightly progressive must however be screened and treated in these rather old patients which are globally at high ophthalmologic risk. Diabetic foot is a severe complication secondary to microangiopathy, microangiopathy and neuropathy. It may be considered as a super-complication of several complications. Its screening must be done on a routine basis. Some cancer may be considered as an emerging complication of type 2 diabetes as well as cognitive decline, sleep apnea syndrome, mood disorders and bone metabolism impairments. Most of the type 2 diabetes complications may be prevented by a strategy combining a systematic screening and multi-interventional therapies.

De plus en plus de patients diabétiques sont pris en charge en HDC. Les conséquences sont multiples, notamment les problèmes de pied diabétique qui demeurent mal connus du patient diabétique et des soignants ce qui retentit considérablement sur la qualité de prise en charge. Nous avons réalisé une Etude transversale en Novembre 2011 au centre d'hémodialyse de l'hôpital Al Farabi d'Oujda, incluant tous nos patients diabétiques HDC. Nous avons relevé les données démographiques, clinico-biologiques et dialytiques. Nous avons receuilli les éléments suivants: la présence ou non de douleur évalué par l’échelle visuelle analogique (EVA), le périmétre de marche, le recours ou non aux soins de pédicurie, le chaussage adapté, les antécédents de chirurgie vasculaire, l'existence ou non de troubles statiques et trophiques des pieds et la recherche d'une neuropathie par un test utilisant un brin de coton. L'analyse statistique est réalisée à l'aide du logiciel 11,5. Dans notre série, 12,9% des patients HDC sont diabétiques et présentent des troubles podologiques, aucun de nos patients n'a bénéficié de pontages ni angioplastie du membre inférieur alors que 8% ont subi des amputations. Le périmètre de marche est limité chez 75% des patients. 16,6% < 50 m, 16,6% < 100 m, 25% < 250 m, 16,6% ne marchent pas. Parmi, 58,3% présentent des troubles de la statique. 16,6% présentent des troubles trophiques. Quarante-cinq pour cent ont une neuropathie dépistée au test au brin de coton. Huit pour cent des patients portent des chaussures adaptées. Vingt-cinq pour cent des patients ont des plaies diverses. Les diabétiques en HDC représentent une population de patients fragiles qui nécessitent une prise en charge multidisciplinaire visant d'abord la prévention, le diagnostic précoce des ulcérations du pied diabétique, le traitement adapté aussi bien de l'infection que de l’équilibre glycémique, de nombreuses amputations chez ces patients peuvent être évitées grâce à un suivi et un programme d’éducation thérapeutique adapté.

Résumé Le diabète constitue une cause fréquente d'insuffisance rénale chronique terminale (IRCT) dans le monde. Ce travail présente une étude clinique rétrospective dont le but est de décrire le profil clinico-biologique des patients diabétiques en IRCT, de le comparer aux patients non-diabétiques au stade d'IRCT, et de suivre l’évolution de leurs abords vasculaires, afin d'en déduire des conclusions sur une prise en charge particulière des patients diabétiques. Les paramètres cliniques et biologiques concernant les patients mis en hémodialyse dans notre formation entre le 01 janvier 2006 et le 31 décembre 2011, ont été recueilli et analysés. Nous avons procédé à l’étude comparative des patients en fonction de l'existence ou non d'une néphropathie diabétique, et nous nous sommes intéressés à l’évolution de leurs abords vasculaires. Il s'agit de 207 patients insuffisants rénaux chroniques, dont 86 diabétiques. Le groupe des patients diabétiques était moins suivi avant la mise en hémodialyse (3,66 mois vs. 6,32 mois), avec une prise beaucoup plus importante d'antihypertenseurs (1,87 vs. 1,14, p

The distinction between diabetic nephropathy lesions and non-diabetic renal lesions is not always obvious and is often based on renal biopsy. This study evaluated the prevalence and predictors of nondiabetic renal disease in people with type 2 diabetes. The study was conducted between January 2008 and October 2010 in the nephrology department of the military hospital in Rabat. The study included 16 patients with type 2 diabetes in whom renal biopsy was indicated. Non-diabetic renal disease was found in 6 of the patients (37.5%); IgA nephropathy was the most frequent non-diabetic renal disease (half of non-diabetic renal diseases). Hypertension was significantly less frequent in the non-diabetic renal disease group than the diabetic nephropathy group (16.7% versus 80.0%, P = 0024), duration of diabetes was a shorter (4.5 versus 15.5 years, P = 0.022) and diabetic retinopathy was absent (100% versus 40%, P = 0.026). There were no statistically significant differences between the 2 groups in relation to age, sex, creatinine level, 24-hour proteinuria, nephrotic syndrome and microscopic haematuria.

In France, 2.8 millions of patients have type 2 diabetes, which is a well-established risk factor for cardiovascular disease. In about 15 years, several large clinical trials tried to study the relationship between a tight glycaemic control and the occurrence of micro- and macroangiopathy. Meta-analyses of targeting intensive versus conventional glycaemic control focused on divergent results. In type 1 diabetes, a tight glycaemic control reduced the occurrence of microangiopathy whereas more time, at least 5 years is needed to reduce macroangiopathy. Conclusions drawn from studies are less clear for type 2 diabetes and depend on the caracteristics of the population studied, particularly for retinopathy. When microalbuminuria is the judgement criteria, its progression is lower in the intensive group than in the conventional one and it takes more than about 5 years to emerge; the impact on glomerular filtration rate is less clear. Worries about the excess of mortality observed in the ACCORD study in the intensive treatment group were not described in other studies. The decrease of mortality was not associated with an intensive glyceamic control. Intensified multifactorial intervention is finally needed to improve microangiopathy.

Between 2001 and 2007, treatments for type 2 diabetes have increased and therapeutic choices have improved. However glycemic control remains insufficient. Cardiovascular risk control has widely increased. Statins, hypertensive and antithrombotic treatments are more often prescribed. Blood pressure and LDL cholesterol levels have decreased whatever age. However, progress remains possible, especially regarding blood pressure control. Obesity has increased between 2001 and 2007 to reach 41% whereas the frequency of dietetic visits has decreased. Insulin therapy (more than obesity) determines the frequency of dietetic visits: dietetic care happens too late. Important improvements of the quality of follow-up are observed. However, fundus exams and more specifically albuminuria measurement remain insufficiently performed and their progression is too slow, as well as the podiatric examination. Only 10% of people with type 2 diabetes have an endocrinology visit, which has been stable between 2001 and 2007. Information expectations of people with type 2 diabetes are strong, especially for diet. Education demand is lower but more important for people who have already benefited. This improvement of medical care leads to an increase in the cost of reimbursements. The consequences of diabetes, more than the disease itself, alter the quality of life.

Diabetic foot problems remain, even today, a major world public health issue. The identification of patients at risk, diagnosis, prevention, assessment and treatments are all aspects of the approach to this pathology.

Screening for diabetic nephropathy is usually done by albuminuria/24h and the use of creatinine clearance. The objective of this study was to evaluate the renal function in Type 2 diabetes by using different formulas of creatinine clearance and to assess the contribution of cystatin C; 83 adults with type 2 diabetes (23 men and 60 women) and 83 adult controls (40 men and 43 women) were studied. Biochemical parameters were determinated on Coba 6000™ (Roche diagnostics). Diabetics showed a significant increase in blood glucose, cholesterol, triglycerides, LDLc, the ApoB, Lp(a), urea, uric acid, creatinine and cystatin C and lower HDLc. Cystatin was increased in patients with degenerative complications and in hypertensive patients. We found strong correlations of cystatin C with creatinine (r = 0.9454), urea (r = 0.8999) and uric acid (r = 0.8325). We found a significant exponentially increase of creatinine and cystatin C from one stage to another. Cystatin C has a strong association with MDRD (r = 0.8086) and CG (r = 0.7915) and a low one with creatinine clearance (r = 0.1044). In conclusion, the use of cystatin C for screening and early treatment of incipient diabetic nephropathy appears to be adequate. CG and MDRD formulas still hold their place, in regards to the classical determination of creatinine clearance, to monitor patients.