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International audience; In patients with diabetes hospitalized for COVID-19 in CORONADO study, 2.8% had a newly discovered.2.8% had a newly discovered diabetes (NDD): mean age 60.2 +/- 12.5 years and HbA(1C) 9.0 +/- 2.5%. When compared with center, age and sex-matched patients with established type 2 diabetes, NDD was not significantly associated with a more severe COVID-19 prognosis.

International audience; AIMS: Metformin exerts anti-inflammatory and immunosuppressive effects. We addressed the impact of prior metformin use on prognosis in patients with type 2 diabetes hospitalised for COVID-19. METHODS: CORONADO is a nationwide observational study that included patients with diabetes hospitalised for COVID-19 between March 10 and April 10, 2020 in 68 French centres. The primary outcome combined tracheal intubation and/or death within 7 days of admission. A Kaplan-Meier survival curve was reported for death up to day 28. The association between metformin use and outcomes was then estimated in a logistic regression analysis after applying a propensity score inverse probability of treatment weighting approach. RESULTS: Among the 2449 patients included, 1496 were metformin users and 953 were not. Compared with non-users, metformin users were younger with a lower prevalence of diabetic complications, but had more severe features of COVID-19 on admission. The primary endpoint occurred in 28.0% of metformin users (vs 29.0% in non-users, P = 0.6134) on day 7 and in 32.6% (vs 38.7%, P = 0.0023) on day 28. The mortality rate was lower in metformin users on day 7 (8.2 vs 16.1%, P \textless 0.0001) and on day 28 (16.0 vs 28.6%, P \textless 0.0001). After propensity score weighting was applied, the odds ratios for primary outcome and death (OR [95%CI], metformin users vs non-users) were 0.838 [0.649-1.082] and 0.688 [0.470-1.007] on day 7, then 0.783 [0.615-0.996] and 0.710 [0.537-0.938] on day 28, respectively. CONCLUSION: Metformin use appeared to be associated with a lower risk of death in patients with diabetes hospitalised for COVID-19.

Perturbation of pain sensation is considered one of the major initiating risk factors for diabetic foot ulcer. Sweat dysfunction leading to abnormal skin conditions, including dryness and fissures, can increase foot ulcer risk. The aim of this study was to evaluate Sudoscan™, a new, quick, non-invasive and quantitative method of measuring sudomotor dysfunction as a co-indicator of the severity of diabetic polyneuropathy (DPN).A total of 142 diabetic patients (age 62±18 years, diabetes duration 13±14 years, HbA(1c) 8.9±2.5%) were measured for vibration perception threshold (VPT), using a biothesiometer, and for sudomotor dysfunction, using electrochemical sweat conductance (ESC) based on the electrochemical reaction between sweat chloride and electrodes in contact with the hands and feet. Retinopathy status was also assessed, as well as reproducibility between two ESC measurements and the effect of glycaemia levels.ESC measurements in the feet of patients showed a descending trend from 66±17 μS to 43±39 μS, corresponding to an ascending trend in VPT threshold from15 V to25 V (P=0.001). Correlation between VPT and ESC was -0.45 (P0.0001). Foot ESC was lower in patients with fissures, while VPT was comparable. Both VPT and foot ESC correlated with retinopathy status. Bland-Altman plots indicated good reproducibility between two measurements, and between low and high glycaemia levels.Sudoscan™ is a reproducible technique with results that are not influenced by blood glucose levels. Sweating status may be a quantitative indicator of the severity of polyneuropathy that may be useful for the early prevention of foot skin lesions.

Objective: To examine associations between metabolic syndrome (MetS) and its individual components with risk of cognitive decline on specific cognitive functions. Methods: Participants were 4,323 women and 2,764 men aged 65 and over enrolled in the longitudinal Three-City Study. Cognitive decline, defined as being in the worst quintile of the distribution of the difference between baseline score and either 2- or 4-year follow-up, was assessed by the Mini-Mental State Examination (MMSE, global cognitive function), the Isaacs Set Test (IST, verbal fluency), and the Benton Visual Retention Test (BVRT, visual working memory). MetS was defined by National Cholesterol Education Program–Adult Treatment Panel III criteria (at least 3 of 5 cardio-metabolic abnormalities: hypertension, high waist circumference, hypertriglyceridemia, low high-density lipoprotein [HDL] cholesterol, hyperglycemia). Proportional hazards models were adjusted for age, gender, educational level, center, baseline cognitive score, APOE4 genotype, and other potential confounders. Results: MetS at baseline was associated with an increased risk of cognitive decline on MMSE (hazard ratio [HR] = 1.22 [1.08–1.37]; p = 0.001) and BVRT (HR = 1.13 [1.01–1.26]; p = 0.03) but not on IST (HR = 1.11 [0.95–1.29]; p = 0.18). Among MetS components, hypertriglyceridemia and low HDL cholesterol were significantly associated with higher decline on MMSE; diabetes, but not elevated fasting glycemia, was significantly associated with higher decline on BVRT and IST. Conclusions: MetS as a whole and several of its components had a negative impact on global cognitive decline and specific cognitive functions in older persons.

OBJECTIVE—Associations between metabolic syndrome and its individual components with risk of incident dementia and its different subtypes are inconsistent. RESEARCH DESIGN AND METHODS—The 7,087 community-dwelling subjects aged ≥65 years were recruited from the French Three-City (3C) cohort. Hazard ratios (over 4 years) of incident dementia and its subtypes (vascular dementia and Alzheimer's disease) and association with metabolic syndrome (defined according to the National Cholesterol Education Program Adult Treatment Panel III criteria) and its individual components (hypertension, large waist circumference, high triglycerides, low HDL cholesterol, and elevated fasting glycemia) were estimated in separate Cox proportional hazard models. RESULTS—Metabolic syndrome was present in 15.8% of the study participants. The presence of metabolic syndrome increased the risk of incident vascular dementia but not Alzheimer's disease over 4 years, independent of sociodemographic characteristics and the apolipoprotein (apo) Eε4 allele. High triglyceride level was the only component of metabolic syndrome that was significantly associated with the incidence of all-cause (hazard ratio 1.45 [95% CI 1.05–2.00]; P = 0.02) and vascular (2.27 [1.16–4.42]; P = 0.02) dementia, even after adjustment of the apoE genotype. Diabetes, but not impaired fasting glycemia, was significantly associated with all-cause (1.58 [1.05–2.38]; P = 0.03) and vascular (2.53 [1.15–5.66]; P = 0.03) dementia. CONCLUSIONS—The observed relation between high triglycerides, diabetes, and vascular dementia emphasizes the need for detection and treatment of vascular risk factors in older individuals in order to prevent the likelihood of clinical dementia.

The Cockcroft and Gault (CG) and Modification of Diet in Renal Disease (MDRD) equations underestimate the glomerular filtration rate (GFR) decline in diabetes. Do this decline and the albumin excretion rate (AER) influence their validity? In 161 diabetic patients, isotopically determined GFR (i-GFR) (51Cr-EDTA) was compared with estimated GFR (e-GFR) by the CG, MDRD, and the new Mayo Clinic Quadratic (MCQ) equations. We searched for a relation between the error in e-GFR and the AER. An influence of the AER outcome on the e-GFR decline was evaluated in 63 subjects followed up over 3 years. The MDRD and the MCQ were more precise and accurate than the CG, but they were biased. The error increased with AER for the CG (r = 0.25, P = .001) and the MDRD (r = 0.20, P = .009), but not for the MCQ. For the 63 patients followed up, the e-GFR declines by the 3 estimations were related to the initial AER, whereas no relation with arterial blood pressure, hemoglobin A(1C), hemoglobin, and blood lipids emerged. The MCQ declines were more pronounced: -10.5% +/- 8.9% in the macroalbuminuric group (P.05 vs both microalbuminuric [-2.6% +/- 10.1%] and normoalbuminuric [-0.1% +/- 6.6%] groups), and were related to the outcome of the AER (r = 0.33, P.05). As chronic kidney disease progresses in diabetes, the declining GFR and rising AER influence the estimation of GFR by the CG and MDRD equations, underestimating the GFR decline and the benefit of reducing the AER. The less affected MCQ evidences a slower e-GFR decline with AER control.

OBJECTIVE—About 20% of diabetic patients with chronic kidney disease (CKD) detected from the new American Diabetes Association recommendations (albumin excretion rate >30 mg/24 h or estimated glomerular filtration rate [GFR] RESEARCH DESIGN AND METHODS—A total of 89 patients with diabetes and a modification of diet in renal disease (MDRD) estimated GFR (e-GFR) RESULTS—The mean MDRD e-GFR (41.3 ± 13.1 ml/min per 1.73 m2) did not significantly differ from the i-GFR (45.6 ± 29.7). Of the subjects, 15 (17%) were normoalbuminuric. Their i-GFR did not differ from the albuminuric rate and from their MDRD e-GFR, although their serum creatinine was lower (122 ± 27 vs. 160 ± 71 μmol/l, P < 0.05): 71% would not have been detected by measuring serum creatinine (sCr) alone. They were less affected by diabetic retinopathy, and their HDL cholesterol and hemoglobin were higher (P < 0.05 vs. albuminuric). None of the CKD normoalbuminuric subjects started dialysis (microalbuminuric: 2/36, macroalbuminuric: 10/38) or died (microalbuminuric: 3/36, macroalbuminuric: 7/38) during the follow-up period (log-rank test: P < 0.005 for death or dialysis), and their albumin excretion rate and sCr values were stable after 38 months, whereas the AER increased in the microalbuminuric patients (P < 0.05), and the sCr increased in the macroalbuminuric patients (P < 0.01). CONCLUSIONS—Although their sCr is usually normal, most of the normoalbuminuric diabetic subjects with CKD according to an MDRD e-GFR below 60 ml/min per 1.73 m2 do really have a GFR below 60 ml/min per 1.73 m2. However, as expected, because of normoalbuminuria and other favorable characteristics, their risk for CKD progression or death is lower.

The National Kidney Foundation recommends stratification of renal failure into moderate (Glomerular Filtration Rate: GFR = 30-60 mL/min/1.73 m2), severe (15-30) or terminal (15) using the Cockcroft-Gault (CG) or the Modification of Diet in Renal Disease (MDRD) equations. We studied the biases in these methods in an attempt to improve the standard CG (MCG) and devise a strategy for stratification.GFR was measured by 51Cr-EDTA clearance in 200 diabetic patients: 100 (Group 1: study of concordance) before 2003 and 100 thereafter (Group 2: validation of MCG). The CG was modified by replacing body weight by its mean value: 76.In group 1, the recommended equations only correctly stratified 50 patients. The CG, not the MDRD, underestimated GFR if BMI was normal, and overestimated it in obese patients. In group 2, the MCG was well correlated with GFR and not biased by weight. Over the whole population, the MCG and MDRD were more accurate for the diagnosis of moderate and severe renal failure. The MDRD showed the lowest differences with GFR, except if GFR60, where the MCG performed better. All formulae overestimated low GFR, the MDRD also underestimated high GFR. The best stratification (147/200) was obtained using the MCG if creatininemia120 micromol/l and the MDRD if creatininemiaor =120 micromol/l.The CG is biased by weight, the MCG corrects this. The more accurate MDRD cannot be used in all patients as it underestimates high GFR. The best stratification was obtained using the MCG at low and the MDRD at high creatininemia.

OBJECTIVE—The Cockcroft-Gault formula is recommended for the evaluation of renal function in diabetic patients. The more recent Modification of Diet in Renal Disease (MDRD) study equation seems more accurate, but it has not been validated in diabetic patients. This study compares the two methods. RESEARCH DESIGN AND METHODS—In 160 diabetic patients, we compared the Cockcroft-Gault formula and MDRD equation estimations to glomerular filtration rates (GFRs) measured by an isotopic method (51Cr-EDTA) by correlation studies and a Bland-Altman procedure. Their accuracy for the diagnosis of moderately (GFR RESULTS—Both the Cockcroft-Gault formula (r = 0.74; P < 0.0001) and MDRD equation (r = 0.81; P < 0.0001) were well correlated with isotopic GFR. The Bland-Altman procedure revealed a bias for the MDRD equation, which was not the case for the Cockcroft-Gault formula. Analysis of ROC curves showed that the MDRD equation had a better maximal accuracy for the diagnosis of moderate (areas under the curve [AUCs] 0.868 for the Cockcroft-Gault formula and 0.927 for the MDRD equation; P = 0.012) and severe renal failure (AUC 0.883 for the Cockcroft-Gault formula and 0.962 for the MDRD equation; P = 0.0001). In the 87 patients with renal insufficiency, the MDRD equation estimation was better correlated with isotopic GFR (Cockcroft-Gault formula r = 0.57; the MDRD equation r = 0.78; P < 0.01), and it was not biased as evaluated by the Bland-Altman procedure. CONCLUSIONS—Although both equations have imperfections, the MDRD equation is more accurate for the diagnosis and stratification of renal failure in diabetic patients.

Background/Aims: Lean body mass (LBM) is reduced in uremia, but this has not been reported in diabetic nephropathy. Subjects and Methods: We compared predicted % LBM to DEXA measurements in 10 non-diabetic uremic, 10 non-uremic diabetic and 10 uremic diabetic subjects matched for age, gender and BMI. We also measured % LBM by anthropometry, bio-impedance analysis (BIA) and compared them with DEXA in 49 diabetic subjects with a wide range of renal failure. The results were compared and a Bland & Altman procedure was performed. Associations between glomerular filtration rate (GFR) and % LBM were tested. Results: In matched groups, predicted % LBM values were overestimated in non-diabetic uremic subjects, and underestimated in non-uremic diabetic subjects. In uremic diabetic subjects, the error was intermediary. As compared to DEXA (% LBM: 69.0 ± 7.1%), measurement of % LBM by anthropometry (71.4 ± 8.0%, p < 0.05) and BIA (67.2 ± 7.6%, p < 0.05) were biased in the 49 diabetic subjects. The mean of anthropometric and BIA (Ant+BIA) were similar to DEXA results (69.3 ± 6.8%, p = 0.64), with best correlation coefficients and Bland & Altman plots. GFR was correlated to % LBM assessed by DEXA, BIA and Ant+BIA. Conclusion: In diabetic subjects with chronic kidney disease, LBM should be measured, rather than predicted. A good evaluation is possible, even without DEXA.

OBJECTIVE We investigated whether loss of bone is detectable during follow-up of diabetic patients with chronic kidney disease (CKD). RESEARCH DESIGN AND METHODS In 40 initially non-dialysed diabetic patients with CKD (isotopic glomerular filtration rate 30 mg/24 h), body composition (DEXA scan) and glomerular filtration rate (GFR determined from (51)Cr-EDTA clearance) were measured at a 2-year interval, and compared by paired t-tests. RESULTS The 40 patients, mainly with Type 2 diabetes (n = 28), were men (n = 28), aged 65 +/- 11 years, with diabetes duration 18 +/- 11 years. GFR was initially 38.0 (range 8-89) ml/min/1.73 m(2). CKD progressed during follow-up: eight started haemodialysis and GFR declined in the 32 others (P < 0.05 vs. initial). T-scores for total body (initial -0.61 +/- 1.11, final -1.11 +/- 1.40; P < 0.001) and femoral neck (initial -1.88 +/- 0.15, final -2.07 +/- 0.15; P < 0.05) declined. Ten patients were osteopaenic at baseline (no osteoporosis), whereas most were osteopaenic (n = 21, P < 0.05) and five were osteoporotic at final assessment. The 16 patients who became osteopaenic or osteoporotic during follow-up did not differ from the others for the type of diabetes, age, GFR, albumin excretion rate, HbA(1c), GFR reduction and the requirement for dialysis during follow-up. They were all men (P < 0.01 by chi-squared test), with reduced initial total body T-score (-1.20 +/- 0.82, others -0.32 +/- 1.13; P < 0.05) and a lower body mass index (24.6 +/- 4.3; others 27.7 +/- 4.3; P < 0.05). CONCLUSION Bone loss, especially in the femoral neck, is progressive in diabetic patients with CKD.

Objectives To investigate the respective associations and clinical usefulness of the metabolic syndrome (MetS) and its individual components to predict the risk of first coronary heart disease (CHD) events in elderly. Design The Three-City is a French prospective multisite community-based cohort. Setting Three large French cities: Bordeaux, Dijon and Montpellier. Participants 7612 subjects aged 65 and over who were free of CHD at baseline. Main outcome measures The MetS was defined by the 2005 National Cholesterol Education Program Adult Treatment Panel III criteria. Results During a median follow-up of 5.2 years, 275 first CHD events were adjudicated. The MetS was associated with increased risks of total (adjusted HR: 1.78; 95% CI 1.39 to 2.28), fatal (HR: 2.40; 95% CI 1.41 to 4.09) and non-fatal (HR: 1.64; 95% CI 1.24 to 2.17) CHD events. The association with total CHD was significant in women (HR: 2.56; 95% CI 1.75 to 3.75) but not in men (HR: 1.39; 95% CI 0.99 to 1.94; p for interaction=0.012). When in the same multivariable model, hyperglycemia and abdominal adiposity in women, hyperglycemia, lower HDL cholesterol and abdominal adiposity (inverse association) in men were the components significantly associated with CHD. The components of the MetS but not the MetS itself improved risk prediction beyond traditional risk factors (NRI= 9.35%, p Conclusion The MetS is a risk marker for CHD in community-dwelling elderly subjects but may not be useful for CHD risk prediction purposes compared to its individual components.

Diabetes is the leading cause of chronic kidney disease (CKD), which makes estimation of renal function crucial. Serum creatinine is not an ideal marker of glomerular filtration rate (GFR), which also depends on digestive absorption, and the production of creatinine in muscle and its tubular secretion. Formulas have been devised to estimate GFR from serum creatinine but, given the wide range of GFR, proteinuria, body mass index and specific influence of glycaemia on GFR, the uncertainty of these estimations is a particular concern for patients with diabetes. The most popular recommended formulas are the simple Cockcroft-Gault equation, which is inaccurate and biased, as it calculates clearance of creatinine in proportion to body weight, and the MDRD equation, which is more accurate, but systematically underestimates normal and high GFR, being established by a statistical analysis of results from renal-insufficient patients. This underestimation explains why the MDRD equation is repeatedly found to give a poor estimation of GFR in patients with recently diagnosed diabetes and is a poor tool for reflecting GFR decline when started from normal, as well as the source of unexpected results when applied to epidemiological studies with a 60mL/min/1.73m(2) threshold as the definition of CKD. The more recent creatinine-based formula, the Mayo Clinic Quadratic (MCQ) equation, and the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) improve such underestimation, as both were derived from populations that included subjects with normal renal function. Determination of cystatin C is also promising, but needs standardisation.

The dietary advice is a part of the global care for type 2 diabetes. First, overweight implies a caloric restriction. When poor glucose control is associated with weight gain, important errors are obvious (excess fat and sugar), providing more pills or insulin without correcting them is poorly effective, but promotes further weight gain. Normal body weight, or poor glucose control despite loss of weight, needs to reappraise the diagnosis: diabetes type, intercurrent disease. The cofactors of the "metabolic syndrom" are usually present, so saturated fat has to be reduced, while maintaining fish, fruits, vegetables and whole grain cereals. Blood pressure and dyslipidemia may need further counselling about dietary sodium, carbohydrates, cholesterol. When insulin, sulfonylurea or glinids are indicated, the dietary intake of carbohydrates has to be regular to avoid hypoglycemia.

Background Renal hypertrophy occurs early in diabetic nephropathy, its later value is unknown. Do large kidneys still predict poor outcome in patients with diabetes and Chronic Kidney Disease (CKD)? Methods Seventy-five patients with diabetes and CKD according to a Glomerular Filtration Rate (GFR, by 51Cr-EDTA clearance) below 60 mL/min/1.73 m2 or an Albumin Excretion Rate above 30 mg/24 H, had an ultrasound imaging of the kidneys and were cooperatively followed during five years by the Diabetology and Nephrology departments of the Centre Hospitalier Universitaire de Bordeaux. Results The patients were mainly men (44/75), aged 62 ± 13 yrs, with long-standing diabetes (duration:17 ± 9 yrs, 55/75 type 2), and CKD: initial GFR: 56.5 (8.5-209) mL/min/1.73 m2, AER: 196 (20-2358) mg/24 H. Their mean kidney lenght (108 ± 13 mm, 67-147) was correlated to the GFR (r = 0.23, p < 0.05). During the follow-up, 9/11 of the patients who had to start dialysis came from the half with the largest kidneys (LogRank: p < 0.05), despite a 40% higher initial isotopic GFR. Serum creatinine were initially lower (Small kidneys: 125 (79-320) μmol/L, Large: 103 (50-371), p < 0.05), but significantly increased in the "large kidneys" group at the end of the follow-up (Small kidneys: 129 (69-283) μmol/L, Large: 140 (50-952), p < 0.005 vs initial). The difference persisted in the patients with severe renal failure (KDOQI stages 4,5). Conclusions Large kidneys still predict progression in advanced CKD complicating diabetes. In these patients, ultrasound imaging not only excludes obstructive renal disease, but also provides information on the progression of the renal disease.

International audience; BACKGROUND: Dietary fatty acids and antioxidants may contribute to decrease dementia risk, but epidemiologic data remain controversial. The aim of our study was to analyze the relationship between dietary patterns and risk of dementia or Alzheimer disease (AD), adjusting for sociodemographic and vascular risk factors, and taking into account the ApoE genotype. METHODS: A total of 8,085 nondemented participants aged 65 and over were included in the Three-City cohort study in Bordeaux, Dijon, and Montpellier (France) in 1999-2000 and had at least one re-examination over 4 years (rate of follow-up 89.1%). An independent committee of neurologists validated 281 incident cases of dementia (including 183 AD). RESULTS: Daily consumption of fruits and vegetables was associated with a decreased risk of all cause dementia (hazard ratio [HR] 0.72, 95% CI 0.53 to 0.97) in fully adjusted models. Weekly consumption of fish was associated with a reduced risk of AD (HR 0.65, 95% CI 0.43 to 0.994) and all cause dementia but only among ApoE epsilon4 noncarriers (HR 0.60, 95% CI 0.40 to 0.90). Regular use of omega-3 rich oils was associated with a decreased risk of borderline significance for all cause dementia (HR 0.46, 95% CI 0.19 to 1.11). Regular consumption of omega-6 rich oils not compensated by consumption of omega-3 rich oils or fish was associated with an increased risk of dementia (HR 2.12, 95% CI 1.30 to 3.46) among ApoE epsilon4 noncarriers. CONCLUSION: Frequent consumption of fruits and vegetables, fish, and omega-3 rich oils may decrease the risk of dementia and Alzheimer disease, especially among ApoE epsilon4 noncarriers. GLOSSARY: AD = Alzheimer disease; BMI = body mass index; CCPPRB = Consultative Committee for the Protection of Persons participating in Biomedical Research; DHA = docosahexaenoic acid; EI = energy intake; HR = hazard ratio; PUFA = polyunsaturated fatty acids.

OBJECTIVE—The Cockcroft-Gault and Modification of Diet in Renal Disease (MDRD) equations poorly predict glomerular filtration rate (GFR) decline in diabetic patients. We sought to discover whether new equations based on serum creatinine (the Mayo Clinic Quadratic [MCQ] or reexpressed MDRD equations) or four cystatin C–based equations (glomerular filtration rate estimated via cystatin formula [Cys-eGFR]) were less biased and better predicted GFR changes. RESEARCH DESIGN AND METHODS—In 124 diabetic patients with a large range of isotopic GFR (iGFR) (56.1 ± 35.3 ml/min per 1.73 m2 [range 5–164]), we compared the performances of the equations before and after categorization in GFR tertiles. A total of 20 patients had a second determination 2 years later. RESULTS—The Cockcroft-Gault equation was the least precise. The MDRD equation was the most precise but the most biased according to the Bland-Altman procedure. By contrast with the MDRD and, to a lesser extent, the MCQ, three of the four Cys-eGFRs were not biased. All equations overestimated the low GFRs, whereas only the MDRD and Rule's Cys-eGFR equations underestimated the high GFRs. For the subjects studied twice, iGFR changed by −8.5 ± 17.9 ml/min per 1.73 m2. GFR changes estimated by the Cockcroft-Gault (−4.5 ± 6.8) and MDRD (−5.7 ± 6.2) equations did not correlate with the isotopic changes, whereas new equation-predicted changes did: MCQ: −8.7 ± 9.4 (r = 0.44, P < 0.05) and all four Cys-eGFRs: −6.2 ± 7.4 to −7.3 ± 8.4 (r = 0.60 to 0.62, all P < 0.005), such as 100/cystatin-C (r = 0.61, P < 0.005). CONCLUSIONS—The new predictive equations better estimate GFR than the Cockcroft-Gault equation. Although the MDRD equation remains the most accurate, it poorly predicts GFR decline, as it overestimates low and underestimates high GFRs. This bias is lesser with the MCQ and Cys-eGFR equations, so they better predict GFR changes.

About 20% of diabetic patients with chronic kidney disease (CKD) detected from the new American Diabetes Association recommendations (albumin excretion rate30 mg/24 h or estimated glomerular filtration rate [GFR]60 ml/min per 1.73 m2) may be normoalbuminuric. Do the characteristics and outcome differ for subjects with and without albuminuria?A total of 89 patients with diabetes and a modification of diet in renal disease (MDRD) estimated GFR (e-GFR)60 ml/min per 1.73 m2 underwent a 51Cr-EDTA B-isotopic GFR determination and were followed up for 38 +/- 11 months.The mean MDRD e-GFR (41.3 +/- 13.1 ml/min per 1.73 m2) did not significantly differ from the i-GFR (45.6 +/- 29.7). Of the subjects, 15 (17%) were normoalbuminuric. Their i-GFR did not differ from the albuminuric rate and from their MDRD e-GFR, although their serum creatinine was lower (122 +/- 27 vs. 160 +/- 71 micromol/l, P0.05): 71% would not have been detected by measuring serum creatinine (sCr) alone. They were less affected by diabetic retinopathy, and their HDL cholesterol and hemoglobin were higher (P0.05 vs. albuminuric). None of the CKD normoalbuminuric subjects started dialysis (microalbuminuric: 2/36, macroalbuminuric: 10/38) or died (microalbuminuric: 3/36, macroalbuminuric: 7/38) during the follow-up period (log-rank test: P0.005 for death or dialysis), and their albumin excretion rate and sCr values were stable after 38 months, whereas the AER increased in the microalbuminuric patients (P0.05), and the sCr increased in the macroalbuminuric patients (P0.01).Although their sCr is usually normal, most of the normoalbuminuric diabetic subjects with CKD according to an MDRD e-GFR below 60 ml/min per 1.73 m2 do really have a GFR below 60 ml/min per 1.73 m2. However, as expected, because of normoalbuminuria and other favorable characteristics, their risk for CKD progression or death is lower.

Glycaemic control is a key element in the management of patients with chronic renal insufficiency, associated of course with treatment of all the other associated factors. Dietary management should not merely be wishful thinking but a reality, involving the control of body weight, the maintenance of lean body mass, the observance of a sufficient carbohydrate intake and the control of protein intake, which, always tends to be excessive in diabetics. Drug treatment with oral antidiabetics may be given without risk of iatrogenic effects: glitazone has no effect on renal metabolism but may increase water retention; glinides are insulin secretagogues without renal metabolism so there is no risk of hypoglycaemia in the event of impaired renal function; if not insulin remains an excellent alternative with, however, a change in its half-life with the elevated creatinine clearance. In all cases, the goal remains the control of glycosylated haemoglobin without iatrogenic effects.

Diabetologists and nephrologists must cooperate to improve uraemic diabetic patient's outcome, with a special attention to their nutritional status. We describe the management of these patients at the CHU of Bordeaux since 2001, and its first results. Renal function is assessed by the glomerular filtration rate, predicted by the Cockcroft-Gault formula according to clinical guidelines. We compared its results to reference isotopic measurements (51Cr-EDTA) in one hundred and twenty two patients. This comparaison showed clearly a bias because the GFR calculated by the formula is proportionnal to body weight: the prediction is overestimated by 55% in obese (BMI30) and 15% in overweighted (25BMI30) patients, who represent the majority of type 2 diabetic patients; the MDRD equation is not affected by this bias. Nutritional follow-up is based on body composition assessment by DEXA, but more simple methods (Skinfold thickness, bio-impedancemetry) have given similar results in our first forty nine patients. After 2 years of follow-up, no patient have lost fat or fat-free mass, except seven patients who have lost 6 kg fat-free mass during the 6 months after starting hemodialysis. The kind of this fat-free mass loss (muscular loss, or correction of hyperhydratation) remains a matter of discussion.

Background : A poor nutritional status reduces the life expectancy of diabetes patients undergoing hemodialysis. Objective : The study objective was to specify the nutritional outcome in patients with chronic kidney disease (CKD) and well-controlled diabetes. Design : Forty-five diabetes patients with CKD were enrolled in a cooperative-care program designed to control glucose, blood pressure, LDL cholesterol, and the albumin excretion rate (AER). Their glomerular filtration rate (GFR), body composition, serum albumin (SA), and resting energy expenditure were assessed and compared at baseline and 2 y later. Results : Thirty-five patients did not start dialysis. Their glycated hemoglobin, blood pressure, LDL cholesterol, and AER improved; their GFR declined slowly (-3.3 mL·min -1 .1.73 m -2 .y -1 ) .Their body mass index (BMI), lean body mass, and SA increased. The GFR decline was correlated negatively with the initial BMI (r = -0.37, P < 0.05) and positively with the initial GFR (r = 0.34, P < 0.05). Ten patients started hemodialysis : except for higher total body water (P < 0.05) and extracellular volume (P < 0.01), their initial nutritional status did not differ significantly from that of 10 patients with comparable baseline severe CKD but without dialysis. At the second evaluation, patients on hemodialysis lost lean body mass, and their SA was lower than that of the patients with severe CKD (P = 0.05); lean body mass was unchanged and SA was higher (P = 0.01) in the patients with severe CKD. No significant difference was detected for resting energy expenditure. Conclusions : Nutritional status improved in CKD patients with well-controlled diabetes without dialysis, and it deteriorated in patients who started dialysis. A high initial BMI was associated with a slower decline in GFR.

Background. Although recommended, both theCockcroft and Gault formula (CG) and the modifica-tion of diet in renal disease (MDRD) equation arenot ideally predictive of glomerular filtration rate(GFR) in diabetic subjects; we tested whether the newMayo Clinic Quadratic (MCQ) equation performedbetter.Methods. In 200 diabetic subjects with a wide range ofrenal function, GFR was measured by 51Cr-EDTAclearance, and compared with the results of the threepredictive equations by regression analysis and Blandand Altman procedures. The correlations with bodymass index, age and albumin excretion rates weretested. The precisions (absolute difference as percent-age), diagnostic accuracies [receiver operating char-acteristic (ROC) curves for the diagnosis of moderateand severe chronic kidney disease (CKD)], and theresults of stratification according to the KDOQclassification were compared.Results. The CG and MCQ overestimated mean GFR,whereas the MDRD underestimated it. CorrelationcoefficientsandareasundertheROCcurveswerebetterfortheMDRDandtheMCQascomparedwiththeCG,which was biased by body weight (þ30% overestima-tioninobesediabeticsubjects).Theabsolutedifferenceswith true GFR were slightly lower for the MDRDthan the MCQ, and both better than the CG. Boththe MDRD and MCQ correctly stratified 65% of thesubjects (CG: 55%, P

OBJECTIVE—Hyperglycemia increases glomerular filtration rate (GFR), but the influence of HbA1c (A1C) on GFR and GFR’s prediction by recommended equations remains to be determined. RESEARCH DESIGN AND METHODS—In 193 diabetic patients, we searched for an association between A1C and isotopically measured GFR (51Cr-EDTA) and their predictions by the Cockcroft and Gault formula (CG) and the modification of diet in renal disease (MDRD) equation. Their accuracy for the diagnosis of moderate (GFR RESULTS—The mean GFR was 57.0 ± 34.8 ml/min per 1.73 m2 and was well correlated with both estimations (CG r = 0.75, MDRD r = 0.83; P < 0.05). The areas under the ROC curves were higher with the MDRD (P < 0.05). A1C was correlated (P < 0.001) with the GFR (r = 0.29), MDRD (r = 0.38), CG (r = 0.26), and the absolute differences between the GFR and their CG but not MDRD estimations (r = 0.17, P < 0.05). Each +1% A1C was associated with +6.0 ml/min per 1.73 m2 GFR (CG +5.6, MDRD +5.3). After separating well-controlled (n = 88, A1C 7.0 ± 0.7%) and poorly controlled (n = 105, 9.6 ± 1.3%) patients, the diagnostic accuracies were better (P < 0.05) for the MDRD, except for the diagnosis of moderate renal failure in well-controlled patients (NS). CONCLUSIONS—GFR and its estimations correlate with A1C. Although the relations between GFR and its estimations were not affected by the degree of glucose control, the precision and diagnostic accuracy of the CG formula were diminished for A1C >8%. The MDRD equation was more accurate and robust in diabetic patients with impaired renal function.

The Cockcroft-Gault (CG) formula and the modification of diet in renal disease (MDRD) equation are commonly used to estimate glomerular filtration rate (GFR), but their validity at extreme body weight is questionable. This may be significant for diabetic patients. In 122 diabetic patients with renal damage, we compared both estimates to isotopically determined GFR by correlation studies and a Bland and Altman procedure before and after categorizing the patients according to body mass index (BMI). Over the whole population, the CG overestimated GFR (CG, 51.4 +/- 23.1 mL/[min . 1.73 m2]; isotopic GFR, 44.6 +/- 21.1 mL/[min . 1.73 m2], P < .0001). The MDRD (45.2 +/- 17.9; NS vs isotopic GFR) did not overestimate GFR, but it underestimated high GFR as revealed by the Bland and Altman procedure (r = -0.26, P < .005). The CG underestimated GFR in patients with normal BMI (-14%, P < .01) and overestimated it in overweight (15%, P < .005) and obese patients (55%, P < .0001); the result and the error of the estimation were correlated with BMI. This bias did not affect the MDRD. The use of ideal instead of measured body weight improved the CG prediction, but underestimated GFR. As the BMI of the 87 type 2 diabetic subjects was higher, the CG overestimated their mean GFR by 18% (P < .001), whereas the MDRD did not. There were 25% fewer patients with delayed referral using the MDRD than with the CG. Because the estimate of GFR by the CG is proportional to body weight, it is not suited for obese diabetic patients. Although it is less easy to calculate, the MDRD is not affected by weight, and its use would avoid delay in referral to nephrologists.

Introduction La perte de sensibilite est consideree comme le facteur de risque majeur « du pied diabetique ». La perturbation de la fonction sudorale favorisant la survenue d’anomalies cutanees (secheresse de la peau, fissures et petites ulcerations) peut egalement augmenter le risque. Le but de l’etude est d’evaluer une nouvelle methode non-invasive, rapide et quantitative (SUDOSCAN™) destinee a mesurer la fonction sudorale comme co-indicateur de la severite d’une neuropathie peripherique et du risque de pied diabetique. Patients et methodes 142 patients diabetiques (âge 62 ± 18 ans, anciennete du diabete 13 ± 14 ans, HbA1c 8.9 ± 2.5 %) ont beneficie d’une mesure du seuil de perception vibratoire avec un biothesometre et de la fonction sudorale par mesure au niveau des pieds de la conductance electrochimique resultant de la reaction entre les chlorures de la sueur et des electrodes en nickel. L’atteinte retinienne a ete egalement determinee. La reproductibilite entre 2 mesures et l’effet du niveau glycemique sur les mesures ont egalement ete evaluees. Resultats Les coefficients de variation des conductances electrochimique des pieds entre 2 mesures et entre des mesures a un niveau haut ou normal de la glycemie sont respectivement de 10 et 11 %. La conductance des pieds passe de 66 ± 17 μs a 43 ± 39 μS quand le seuil de perception vibratoire passe de 25v (p = 0.001) avec une correlation de -0.45 (p Conclusion 1) La mesure de la fonction sudorale par SUDOSCAN™ est une methode reproductible, 2) les resultats ne sont pas influences par le niveau glycemique, 3) le seuil de perception vibratoire et la conductance electrochimique sont bien correlees, 4) la conductance parait associee aux fissures 5) elle l’est egalement aux lesions retiniennes. Cette methode peut constituer un co- indicateur de la severite d’une polyneuropathie et ameliorer la prevention du pied diabetique par un meilleur depistage et un meilleur suivi.

Objectif L’objectif de cette etude etait d’analyser les relations entre le syndrome metabolique (Smet) – et ses composantes (anomalies metaboliques et facteurs de risque cardio-vasculaire agreges les uns aux autres) : hypertension, tour de taille augmente, hypertriglyceridemie, HDL-cholesterol bas, glycemie elevee (en s’interessant aux differences entre hyperglycemie a jeun et diabete) – et le risque de demence incidente – avec ses principaux sous-types : maladie d’Alzheimer (MA), demence vasculaire (Demvasc). Patients et methodes Il s’agit des donnees de l’etude des 3 Cites (7 087 sujets non dements prevalents, de 65 ans et plus, recrutes dans les villes de Bordeaux, Dijon et Montpellier). Le risque de survenue d’une demence a partir de l’inclusion, en fonction de la presence d’un Smet (criteres NCEP-ATP III) a ete analyse par modeles de Cox a entree retardee, avec prise en compte des facteurs de confusion et interactions potentiels (genotype de l’apolipoproteine E - facteur de risque genetique de demence - et facteurs sociodemographiques). Resultats La presence d’un Smet (15.8 %) augmentait le risque de Demvasc incidente a 4 ans, mais pas de MA. L’hypertriglyceridemie etait la seule composante du Smet significativement associee a l’incidence de la demence toute cause (RR = 1.45 [1,05-2,00] ; p = 0,02) et de la Demvasc (RR = 2,27 [1,16-4,42] ; p = 0,02). Par ailleurs le diabete mais pas l’hyperglycemie a jeun etait associe a un risque augmente de Demvasc. Conclusion Les relations observees entre l’hypertriglyceridemie, le diabete et la Demvasc souligne la necessite d’une detection et d’un traitement des facteurs de risque cardio-vasculaire chez les sujets âges afin de prevenir la survenue de la demence.

Pucci et al. (1) recently reported their study of the use of cystatin C (cysC) to detect decreases in renal function in patients with diabetes. CysC had an advantage over other methods only for detecting very early impairment of renal function [glomerular filtration rate (GFR) < 90 and 75 mL · min−1 · (1.73 m2)−1], whereas detection of the 70 patients with GFR

To the Editor: In their paper published in Diabetologia [1], Bruno et al. assessed whether a reduction in estimated glomerular filtration rate (eGFR), calculated using the abbreviated Modification of Diet in Renal Disease (MDRD) study equation [2], predicted mortality in type 2 diabetes. Although an eGFR of

Objectif Dans le contexte de l’epidemie d’obesite, les caracteristiques des patients adultes hospitalises pour diabete inaugural ont-elles change entre 1996 et 2008 ? Patients et methodes Nous avons identifie les patients hospitalises pour « Diabete inaugural » sur le registre des admissions de notre unite de nutrition-diabetologie adulte, en 1996–1997 et en 2008–2009, et compare entre ces deux periodes leurs caracteristiques cliniques (sexe, âge, poids, signes de diabete et notamment consommation de boissons sucrees pour compenser la polyurie), biologiques (glycemie, HbA1C, cetonurie, C-peptide) et leurs devenirs pendant l’hospitalisation (glycemie, besoins insuliniques) et 4 mois plus tard (poids, HbA1C). Les resultats (exprimes en moy ± ET) ont ete compares par ANOVA et Chi-2, avant puis apres categorisation selon la presence d’anticorps antiGAD. Resultats 153 patients (106 hommes, 51 antiGAD +) ont ete identifies : 61 en 1996-1997 et 92 en 2008–2009, avec des presentations cliniques similaires : perte de −6,7 ± 5,8 kg, hyperglycemie a 20 ± 16 mmol/L, HbA1C a 11,9 ± 2,5%. La representation des patients antiGAD + etait similaire dans les deux periodes (n = 18 en 1996–1997, 33 en 2008–2009, NS). Les patients de 2008–2009 etaient plus jeunes (41 ± 16 ans vs 1996–1997 : 47 ± 18, p Conclusion Les patients adultes hospitalises pour diabete inaugural dans notre unite sont plus nombreux qu’il y a 12 ans, plus jeunes du fait de patients antiGAD + plus jeunes comme rapporte en pediatrie, ils tendent a consommer plus souvent des boissons sucrees, et ils ont besoin de plus d’insuline. Deux tiers des patients sont antiGAD-, ils pesent 12 kg de plus qu’il y a 12 ans. Nos patients ne sont pas representatifs de la population generale, et une part des changements observes peut etre liee a des modifications de pratique medicale (mise en route a domicile de l’insulinotherapie chez des patients âges), mais la presentation hospitaliere du diabete inaugural parait bien affectee par l’epidemie d’obesite.

Introduction Les NASH seraient moins frequentes voire moins agressives chez les femmes. Repondent-elles mieux aux conseils dietetiques ? Patients et methodes Chez 86 patients non diabetiques connus porteurs de NASH (55 diagnostics sur PBH, 31 presomptions) adresses a notre equipe entre 2004 et 2009, nous avons realise une enquete alimentaire, une mesure de Depense Energetique au Repos (DER), une analyse de composition corporelle, un bilan lipidique et une HGPO. Les patients ont recu des conseils : alimentation hypocalorique, reduction des graisses saturees, puis ont ete suivis a la consultation. Les comparaisons entre sexes ont ete effectuees par ANOVA et Chi2. Resultats Les 86 patients (42 femmes) etaient âges de 49 ± 11 annees, leur IMC etait de 30,0 ± 4,4 kg/m2, % de graisse corporelle 38,0 ± 8,4, leurs ALAT 83 ± 66U et GammaGT 128 ± 116U. Le pourcentage de steatose etait de 50 ± 27 % (5-90), correle a l’apport energetique quotidien (r = 0,41, p Conclusion L’effet des conseils dietetiques, modeste, concerne surtout les femmes porteuses de NASH. Pour les hommes, l’intervention doit probablement davantage porter sur l’activite physique.

Introduction En utilisant les proprietes lumineuses des AGEs, l’auto fluorescence cutanee (AF) evalue l’accumulation des produits de glycation avancee (AGE) impliquee dans le developpement de complications du diabete. La mesure d’AF a l’avant bras peut-elle etre un marqueur de l’equilibre glycemique au long cours ? Est-elle associee a la frequence et a la gravite des complications micro et macroangiopathiques ? Materiels et methodes Nous avons mesure l’AF avec un appareil AGE-Reader chez 248 sujets diabetiques de type 1 de janvier a decembre 2009 âges de 50 ± 16 ans, diabetiques depuis 22 ± 13 ans, au niveau de l’avant bras (site recommande de mesure). Les relations entre l’AF, la derniere HbA1c et les moyennes des cinq et dix dernieres HbA1c (suivi en consultation tous les 6 mois) mais aussi les complications de retinopathie, nephropathie diabetique et macroangiopathie, ont ete analysees : comparaisons par ANOVA et regressions lineaires. Resultats La mesure d’AF etait de 2,12 ± 0,57, correlee a l’âge et a la duree de diabete (r = 0,40 p L’AF ajustee a l’âge etait correlee a la moyenne des 5 dernieres HbA1c (r = 0,21, p L’AF augmentait avec la gravite de la retinopathie (background n = 88, AF = 2,23 ± 0,58, p Correlee a l’excretion urinaire d’albumine et a la creatininemie, elle augmentait aussi avec la severite de la nephropathie (macroalbuminurie n = 10 AF = 3,19 ± 0,73, p Conclusion Mesurable de facon simple, rapide, non agressive, l’AF cutanee est correlee a l’equilibre glycemique des 5 dernieres annees, et associee aux complications de retinopathie, nephropathie et macroangiopathie chez les patients diabetiques de type 1. La prochaine etape sera de chercher si la valeur de l’AF est predictive de complications nouvelles ou de leur aggravation.

Introduction L’autofluorescence (AF) cutanee est une mesure non invasive du niveau de depot des produits de glycation avancee (AGE), appelee a se developper en diabetologie. Les AGE sont aussi impliques dans d’autres phenomenes : vieillissement, insuffisance renale, mais aussi cirrhose hepatique (Ahmed et al, 2005). Nous n’avons pas connaissance de donnees publiees concernant l’AF cutanee en cas de cirrhose. Patients et Methodes Nous avons mesure l’AF cutanee avec le lecteur AGE-reader chez 14 patients hospitalises pour cirrhose (diagnostic porte par ponction-biopsie hepatique), dont 8 ayant un ictere clinique, et chez 7 sujets controles normaux. Les resultats sont exprimes en moyennes ± ecarts types, compares par analyse de variance avec correction de Bonferroni. Resultats L’AF etait superieure chez les patients cirrhotiques non icteriques (CnonIct) par rapport aux temoins (T) (CnonIct = 3,0 ± 0,8, T = 1,9 ± 0,2, p Conclusion Ces resultats preliminaires suggerent d’importantes perturbations de l’AF cutanee au cours des hepatopathies : augmentation en cas de cirrhose, diminution en cas d’ictere, probablement liee aux proprietes optiques de la bilirubine. A la difference de l’âge et de l’insuffisance renale, la cirrhose hepatique est une cause moins facilement identifiable, potentiellement occulte, d’elevation de l’AF cutanee.

Introduction L'hypertrophie renale est precoce au cours de la nephropathie diabetique ; sa valeur pronostique ulterieure n'est pas connue. Patients et methodes Nous avons suivi, pendant 5 ans, 75 patients diabetiques (âge 62±13 ans, duree de diabete 17±9 ans, 44 hommes, 20 DT1) presentant une atteinte renale definie par un debit de filtration glomerulaire (DFG, par 51Cr-EDTA) 2 (moyenne : 60,4±39,7) ou une excretion urinaire d'albumine > 30mg/24h (moyenne : 477±605mg/24H). Leurs 2 reins ont ete mesures lors d'une echographie renale initiale. Resultats Les tailles des reins droit (108±13mm) et gauche (108±16mm) etaient similaires, et bien correlees (r=0,71, p 108mm ; moy : 118±10mm), et compares aux «petits reins» (moy : 98±8mm). Aucune de leurs autres caracteristiques (sexe, âge, duree de diabete, pression arterielle, HbA1C, BMI, albuminurie) n'etait differente, sauf le DFG initial plus eleve en cas de «gros reins» (70±46mL/min/1,73m 2 versus 50±29 si «petits reins», p log-rank : p=0,024). L'analyse de survie multivariee (Cox) a montre que le DFG initial (ExpB=0,94, p=0,005) et la taille des reins (ExpB=1,05, p=0,02) etaient predicteurs de la mise en dialyse. Apres stratification des sujets selon leur niveau de fonction renale (KDOQI), le mauvais pronostic associe aux «gros reins » restait significatif chez les 19 patients les plus avances, en insuffisance renale severe, meme si leurs reins etaient de plus petite taille (mediane : 104mm si insuffisance renale severe, 107 mm si insuffisance renale moderee, 112mm si microalbuminurie sans insuffisance renale). Conclusion Meme si avec l'evolution les reins deviennent plus petits, leur grande taille reste un predicteur de progression de la nephropathie, jusqu'a l'entree en dialyse.

Introduction Il faut reduire l’albuminurie des patients diabetiques nephropathes pour ralentir le declin de leur fonction renale. Ce declin est sous-evalue par les estimations conventionnelles du debit de filtration glomerulaire (DFG) : Cockcroft & Gault (CG) et MDRD. L’albuminurie influence-t-elle leurs performances ? Patients et methodes Chez 161 patients diabetiques, nous avons mesure le DFG (DFGi, par methode isotopique : 51Cr-EDTA), nous l’avons estime (DFGe) par CG, MDRD, et l’equation plus recente « Mayo Clinic Quadratic » (MCQ) afin de rechercher un lien entre l’erreur d’estimation et l’albuminurie. Soixante-trois des patients ont ete suivis pendant 3 ans pour tester si l’albuminurie et son evolution etaient liees au declin du DFGe. Resultats Les 3 estimations etaient bien correlees (CG : r = 0,74, MDRD : 0,81, MCQ : 0,83) au DFGi (60 ± 35 mL/min/1,73 m 2 ), avec une moins bonne precision pour CG (Differences absolues avec DFGi : CG 43 ± 55 %, MDRD 30 ± 36 %, MCQ 32 ± 46 %). L’erreur relative « (DFGe-DFGi) /DFGi » etait correlee a l’albuminurie pour l’estimation par CG (r = 0,25 ; p = 0,001 ; effet persistant apres ajustement pour le DFG) et MDRD (r = 0,20 ; p = 0,009), mais pas MCQ (r = 0,03, NS). Il en resultait une surestimation marquee du DFG en cas de macroproteinurie (CG : + 44 %, vs + 9 % si normoalbuminurie ; MDRD + 16 %, vs + 3 % si normoalbuminurie). Chez les 63 patients suivis, l’atteinte renale a progresse, la creatininemie passant de 146 ± 7 μmol/L a 186 ± 15 (p = 0,001), et l’albuminurie de 401 ± 520 mg/24 h, a 647 ± 1 041 (p = 0,08). Le declin a 3 ans du DFGe (CG : − 3,9 ± 9,3 %, MDRD : − 2,1 ± 12,8 %, MCQ : − 5,2 ± 10,0 %) etait correle a l’albuminurie initiale, et pas aux autres facteurs connus de progression (TA, HbA1C, lipides, hemoglobine). Seul le suivi par MCQ permettait de degager une influence significative de l’evolution de l’albuminurie sur ce declin. Conclusion Avec la progression de l’atteinte renale, la reduction du DFG et l’accentuation de l’albuminurie font donc sous-evaluer le declin du DFG estime par CG ou MDRD, mais aussi le benefice du traitement anti-proteinurique. La modification de secretion tubulaire de creatinine en cas de proteinurie rend probablement compte de ce biais, moins marque avec l’equation MCQ.

Introduction Il est recommande d’estimer le debit de filtration glomerulaire (DFG), pour diagnostiquer et stratifier (en 5 stades) l’atteinte renale chez les patients diabetiques. Peut-on ameliorer cette estimation en dosant la cystatine C (cysC) ? Patients et methodes Chez 124 patients diabetiques presentant un large eventail de DFG (8-164 mL/min/1.73m2) mesure par methode isotopique (51Cr-EDTA), nous avons estime ce DFG par : 1) les equations recommandees : Cockcroft & Gault (CG) et MDRD, 2) l’equation « Mayo Clinic Quadratic » (MCQ), 3) une estimation « Composite » recemment publiee et calculee a partir des taux seriques de creatinine et de cysC, 4) une approche simplifiee en divisant MDRD par cysC lorsque celle-ci etait Resultats Les meilleures performances pour le diagnostic d’insuffisance renale moderee (DFG Conclusion Donc les estimations recommandees du DFG a partir de la creatininemie ont des defauts. Mesurer la cystatine C et l’inclure dans les formules ameliore l’estimation, sans forcement beaucoup en augmenter la complexite.