Ulcère gastrique et dégénérescence maligne : surveillance endoscopique

Les auteurs rapportent leur expérience dans le domaine de la relation entre ulcère gastrique bénin et malin. Le problème diagnostique soulevé comporte 3 aspects différents : a) discrimination entre ulcéro-cancer invasif et ulcère gastrique bénin ; b) objectivation d'un « cancer gastrique superficiel » suspecté ou réel, associé à une lésion gastrique bénigne; c) l'identification des lésions précancéreuses survenant au voisinage d'ulcères chroniques ou de cicatrices d'ulcères. La méthode endoscopique adoptée repose sur un lavage gastrique mucolitique préalable, une observation à la gastrocaméra avec documentation et l'emploi subséquent de fibroscopes à optiques grossissantes, exploration complétée par des colorations vitales de muqueuses et des biopsies multiples; si nécessaire une seconde exploration endoscopique est effectuée après un délai de 2 semaines dans environ 2/3 des cas. Dans notre matériel clinique comportant 687 ulcères gastriques, 279 cancers gastriques invasifs et 48 « cancers gastriques superficiels », ces méthodes combinées ont permis d'obtenir une sensibilité de 87,4 et 100 %, une spécificité de 77,3 et 82,5 %, avec un indice de risque de 2,8 et 0,0 %, respectivement dans les deux catégories a et b; un diagnostic final endoscopique exact a été obtenu respectivement chez 92 et 100 % des patients. Au cours des ulcères gastriques chroniques bénins, l'exploration endoscopique exhaustive identifie une population à haut risque représentant 10 % des cas; le risque de malignité sur lésions gastriques bénignes peut être évalué à 1,77 % des cas

Chronic kidney disease in type 2 diabetes: lessons from the Renal Insufficiency And Cardiovascular Events (RIACE) Italian Multicentre Study.

The Renal Insufficiency And Cardiovascular Events (RIACE) Italian Multicentre Study is an ongoing observational survey that examines the role of estimated glomerular filtration rate (eGFR) as an independent predictor of cardiovascular and renal outcomes in 15,773 Italian subjects with type 2 diabetes. The analysis of data collected at the enrollment visit provided a picture of chronic kidney disease (CKD) and its association with other complications, risk factors for cardiovascular disease (CVD) and treatments in a large contemporary cohort. Main results of this analysis were that (a) non-albuminuric renal impairment is the predominant clinical phenotype in patients, particularly women, with reduced eGFR; (b) concordance between CKD and diabetic retinopathy is low, with only a minority of patients with renal dysfunction presenting with any or advanced retinal lesions; (c) the non-albuminuric form is associated with a significant prevalence of CVD, especially at the level of the coronary vascular bed; (d) CKD is associated with hemoglobin (Hb) A(1c) variability more than with average HbA(1c), whereas retinopathy and CVD are not; (e) in elderly individuals with moderate-to-severe eGFR reduction, use of agents which are not recommended, such as sulphonylureas and metformin, is still frequent; and (f) though complications are generally more prevalent in men (except non-albuminuric renal impairment) women show a less favorable CVD risk profile and achieve therapeutic targets to a lesser extent than men, despite the fact that treatment intensity is not lower. These data update existing information on the natural history of CKD in patients with type 2 diabetes

Clinical significance of nonalbuminuric renal impairment in type 2 diabetes

Objective: In type 2 diabetes, prevalence of nonalbuminuric renal impairment is increasing worldwide, though its clinical significance remains unclear. This large-cohort study aimed at evaluating the association of this phenotype with cardiovascular risk factors and other complications. Methods: Type 2 diabetic patients from the Renal Insufficiency And Cardiovascular Events (RIACE) Italian Multicenter Study (n=15773), visiting consecutively 19 hospital-based Diabetes Clinics in years 2007-2008, were examined. Serum creatinine was assessed by the Jaffe method; albuminuria was measured by immunonephelometry or immunoturbidimetry. Results: Of patients with renal impairment, as identified by an estimated glomerular filtration rate (eGFR) less than 60ml/min per 1.73m, 56.6% were normoalbuminuric, 30.8% were microalbuminuric, and 12.6% were macroalbuminuric. Percentages were similar when GFR was estimated using the more accurate Chronic Kidney Disease Epidemiology Collaboration equation instead of the simplified Modification of Diet in Renal Disease formula, and were independent of age, thus indicating that the increasing prevalence of this phenotype does not reflects misclassification of elderly patients. Nonalbuminuric renal impairment was not associated with HbA1c and correlated less strongly with retinopathy and hypertension than albuminuria, either alone or associated with reduced eGFR. It was associated with a higher prevalence of cardiovascular disease (CVD) than albuminuria alone, but lower than albuminuric renal impairment. Female sex correlated with nonalbuminuric renal impairment and male sex with the albuminuric forms. Conclusion:S: These data show that type 2 diabetic patients with nonalbuminuric renal impairment exhibit distinct clinical features, suggesting predominance of macroangiopathy as underlying renal pathology, and that this phenotype is associated with significant CVD burden. © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

HbA1c variability as an independent correlate of nephropathy, but not retinopathy, in patients with type 2 diabetes: The renal insufficiency and cardiovascular events (RIACE) Italian Multicenter Study

OBJECTIVE-To examine the association of hemoglobin (Hb) A1c variability with microvascular complications in the large cohort of subjects with type 2 diabetes from the Renal Insufficiency And Cardiovascular Events (RIACE) Italian Multicenter Study. RESEARCH DESIGNANDMETHODS-Serial (3-5) HbA1c values collected in a 2-year period before enrollment were available from 8,260 subjects from 9 centers (of 15,773 patients from 19 centers). HbA1c variability was measured as the intraindividual SD of 4.52 ± 0.76 values. Diabetic retinopathy (DR) was assessed by dilated funduscopy. Chronic kidney disease (CKD) was defined based on albuminuria, as measured by immunonephelometry or immunoturbidimetry, and estimated glomerular filtration rate (eGFR) was calculated from serum creatinine. RESULTS-Median and interquartile range of average HbA1c (HbA1c-MEAN) and HbA1c-SD were 7.57% (6.86-8.38) and 0.46% (0.29-0.74), respectively. The highest prevalence of microalbuminuria, macroalbuminuria, reduced eGFR, albuminuric CKD phenotypes, and advanced DR was observed when bothHbA 1c parameters were above themedian and the lowest when bothwere below the median. Logistic regression analyses showed that HbA1c-SD adds toHbA1c-MEAN as an independent correlate of microalbuminuria and stages 1-2 CKD and is an independent predictor of macroalbuminuria, reduced eGFR, and stages 3-5 albuminuric CKD, whereas HbA1c-MEAN is not. The opposite was found for DR, whereas neither HbA1c-MEAN nor HbA 1c-SD affected nonalbuminuric CKD. CONCLUSIONS-In patients with type 2 diabetes, HbA1c variability affects (albuminuric) CKD more than average HbA1c, whereas only the latter parameter affects DR, thus suggesting a variable effect of these measures on microvascular complications. © 2013 by the American Diabetes Association