H. Gin

Serum fatty acid profiles in type I and type II diabetes: Metabolic alterations of fatty acids of the main serum lipids

Fatty acid profiles of various lipid fractions were determined in carefully selected insulin-dependent and non-insulin-dependent diabetics to assess relationships between serum fatty acid composition and type of diabetes. Clear-cut hypertriglyceridemia with slight hypercholesterolemia was found in both diabetic types. The decrease of lignoceric acid in sphingomyelin is the only alteration found in both types of diabetes. In the insulin-dependent diabetics, there were increases in levels of oleic acid and of alpha-linolenic acid in esterified cholesterol, and in levels of alpha-linolenic acid in the triglyceride fraction. In the non-insulin-dependent diabetics, there were increases in levels of oleic acid and total monounsaturated fatty acids in the triglyceride fraction and there was an increase in levels of saturated fatty acids and a decrease in levels of polyunsaturated acids in phosphatidylcholine; in sphingomyelin, dihomogamma-linoleic acid levels were enhanced. Arachidonic acid levels were normal in our patient population.

Cystatin C improves the diagnosis and stratification of chronic kidney disease, and the estimation of glomerular filtration rate in diabetes.

AIMSnEstimation of glomerular filtration rate (GFR) is recommended to diagnose and stratify chronic kidney disease (CKD). Can cystatin-C (cysC) assay improve the results in diabetic patients?nnnMETHODSnIn 124 diabetic patients with a wide range of GFR, as determined by 51Cr-EDTA clearance (i-GFR), we estimated e-GFR by: the recommended Cockcroft-Gault (CG) formula and Modification of Diet in Renal Disease (MDRD) study equation; the new Mayo Clinic quadratic (MCQ) equation; the recently proposed composite estimation including both serum creatinine and cysC; and a simplified approach dividing the MDRD by cysC if less than 1.10mg/L.nnnRESULTSnThe highest diagnostic accuracy (receiver operating characteristic [ROC] curves) and the highest proportions of well-stratified patients were obtained by cysC and the MDRD which, however, underestimated i-GFR for patients without CKD (-17%, P<0.001). The CG overestimated GFR in KDOQI stages 1 and 2, ignored stage 5 and was the least accurate. The MCQ equation overrepresented stage 2, overestimating GFR at this stage (+23%, P<0.005). The composite estimation (54.7+/-27.0mL per minute 1.73m(2)) correlated best with i-GFR (56.1+/-35.3; r=0.90, P<0.001), and did not significantly differ from it across the entire population and within each Kidney Disease Outcome Quality Initiative (KDOQI) stage but was also biased (Bland-Altman procedure). Simply dividing the MDRD by cysC ifless than1.10mg/L produced a comparable performance and eliminated the bias.nnnCONCLUSIONnThe recommended creatinine-based estimations of GFR need to be improved. CysC assay helps in the diagnosis and stratification of CKD and leads to better estimates of GFR in diabetic patients without any substantial increase in complexity.

Expert consensus on management of diabetic patients with impairment of renal function

Service dendocrinologie-diabétologie, Hôpital Sud, 16, boulevard de Bulgarie, 35200 Rennes Hôpital Privé de l’Est parisien, 11, avenue de la République, 93600 Aulnay-sous-Bois Service de diabétologie, Université Bordeaux II, 146, rue Léo Saignat, 33000 Bordeaux Service d’endocrinologie et diabétologie, CHU Poitiers, 2, rue de la Milétrie, BP 577, 86021 Poitiers cedex Service de néphrologie-immunologie clinique, Hôpital Bretonneau, CHU Tours, 2, boulevard Tonnellé, 37044 Tours cedex Service de néphrologie, Hôpitaux Universitaires de Strasbourg, BP 426, Strasbourg cedex 67091; et Faculté de Médecine, Université de Strasbourg, 1, rue Kirschleger, 67000 Strasbourg Service dendocrinologie et maladies métaboliques, Groupe Hospitalier Saint-Louis-Lariboisière, AP-HP, 2, rue Claude Vellefeaux, 75475 Paris cedex 10 Service d’endocrinologie-diabétologie-nutrition, Groupe Hospitalier Bichat-Claude Bernard, APHP, 46, rue Henri Huchard, 75722 Paris cedex 18 ; et Unité INSERM U695, Faculté de Médecine Paris 7 Clinique de nephrologie, CHU Grenoble, boulevard de la Chantourne, 38043 Grenoble cedex

A simplified Cockcroft-Gault formula to improve the prediction of the glomerular filtration rate in diabetic patients

AIMnThe 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.nnnMETHODSnGFR 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.nnnRESULTSnIn 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 GFR > 60, 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 creatininemia < 120 micromol/l and the MDRD if creatininemia > or =120 micromol/l.nnnCONCLUSIONnThe 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.

Microalbuminurie et excrétion urinaire d'albumine: recommandations pour la pratique clinique

Measurement of urinary albumin excretion (UAE) may be done on a morning urinary sample or on a 24 hours-urine sample. Values defining microalbuminuria are: 24 hour-urine sample: 30–300 mg/24 hours; morning urine sample: 20–200 mg/ml or 30–300 mg/g creatinine or 2.5–25 mg/mmol creatinine (men) or 3.5–35 mg/mol (women). Timed urine sample: 20–200 μg/min. The optimal use of semi-quantitative urine test-strip is not clearly defined. It is generally believed that microalbuminuria reflects a generalized impairment of the endothelium; however, no definite proof has been shown in humans.

Early decrease in resting energy expenditure with bedtime insulin therapy

AIMSnIn type 2 diabetes (T2D), insulin-induced weight gain may stem from a reduction in resting energy expenditure (REE). We sought to determine the early effects of insulin introduction on REE in 20 poorly controlled T2D patients.nnnMETHODSnAfter improving the glycaemia, REE was measured on Day 0 and Day 4 during two treatment regimens: bedtime insulin (n=10, group 1); and one off (3-day) intravenous insulin infusion (n=10, group 2).nnnRESULTSnBoth groups were similar in age, gender, BMI, C-peptide, HbA(1c) and initial REE. By Day 4, fasting glycaemia had similarly improved in both groups: group 1: -5.3+/-2.7mmol/L vs group 2: -5.8+/-4.2 mmol/L. In group 2, the second REE was measured 12h after stopping the intravenous insulin infusion, whereas subcutaneous insulin was maintained in group 1. REE did not change in group 2 (-1.3+/-6.5%), whereas it decreased significantly in group 1 (-8.0+/-7.0%; P<0.05).nnnCONCLUSIONnBedtime insulin led to an early and specific reduction in REE.

RecommandationMicroalbuminurie et excrétion urinaire d'albumine : recommandations pour la pratique cliniqueMicroalbuminuria and urinary albumin excretion: clinical practice guidelines

Measurement of urinary albumin excretion (UAE) may be done on a morning urinary sample or on a 24 hours-urine sample. Values defining microalbuminuria are: 24 hour-urine sample: 30–300 mg/24 hours; morning urine sample: 20–200 mg/ml or 30–300 mg/g creatinine or 2.5–25 mg/mmol creatinine (men) or 3.5–35 mg/mol (women). Timed urine sample: 20–200 μg/min. The optimal use of semi-quantitative urine test-strip is not clearly defined. It is generally believed that microalbuminuria reflects a generalized impairment of the endothelium; however, no definite proof has been shown in humans.

P348 Essai de différents types de chaussage sur la démarche et les pressions plantaires

Objectif Il est souvent propose au patient diabetique neuropathe presentant un mal perforant, de porter une chaussure therapeutique. Letude propose danalyser chez le sujet temoin linfluence dune chaussure therapeutique avec ou sans semelle sur la marche et les pressions plantaires. Patients et methodes Vingt et un temoins (13 femmes, 8 hommes), âge moyen 23 ans, sans surcharge ponderale, sans anomalie podologique, portent sur un pied une chaussure therapeutique avec ou sans semelle pre ou thermoformee et une meme basket sur lautre pied. Les pressions plantaires ainsi que la marche sont enregistrees a laide de capteurs mis dans la chaussure au cours dune marche de 20 m. Resultats La chaussure therapeutique (Tera-Diab NEUT-Podiartis) naltere pas la marche, diminue les pressions anterieures du pied ( p p p p Conclusion Letude chez le sujet temoin montre quil existe des differences reelles entre les differentes propositions dappareillage qui peuvent etre proposees. Ces resultats obtenus chez le sujet temoin ne presument pas de ce qui peut etre observe chez le patient neuropathe, mais demontrent quen cas de pied neuropathe ou meme de mal perforant, le choix therapeutique ne doit pas etre un choix standardise mais un choix reflechi: la mesure de la repartition des pressions a linterieur de la chaussure therapeutique est un element devant contribuer a la qualite de la prescription. Declaration d’interet Les auteurs declarent avoir un interet avec un organisme prive, industriel ou commercial en relation avec le sujet presente. Sidas-Podiathec.

P178 Existe-t-il une relation entre la sévérité de la neuropathie diabétique et les pressions plantaires ?

Introduction La polyneuropathie sensitivomotrice diabetique expose aux deformations et aux ulcerations du pied. L’augmentation des pressions plantaires est aussi un facteur de risque d’ulcerations. Cependant le lien eventuel entre severite de la neuropathie et pressions plantaires a ete peu etudie. L’hypothese d’un contact traumatisant du pied avec le sol, lie a l’atteinte proprioceptive, nous a conduit a rechercher s’il existait une correlation entre la severite de la neuropathie diabetique sensitive profonde et l’augmentation des pressions plantaires. Patients et methodes Soixante-six patients diabetiques beneficierent d’une evaluation quantitative du seuil de sensibilite profonde a l’aide d’un neuro-esthesiometre. Cinq groupes de patients furent constitues en fonction du seuil de neuro-esthesiometrie exprime en volts, apres exclusion des autres causes de neuropathie peripheriques : groupe 1 (n = 6 ; seuil normal inferieur a 5), groupe 2 (n = 9 ; seuil entre 6 et 10), groupe 3 (n = 25 ; seuil entre 11 et 25), groupe 4 (n = 11 ; seuil entre 26 et 40), groupe 5 (n = 15 ; seuil superieur a 40). Les pressions plantaires statiques puis dynamiques lors de la marche etaient mesurees a l’aide d’une plate forme podobarometrique. Le logiciel permit de calculer un pas moyen et d’analyser les pressions moyennes et maximales sur differentes zones d’interet du pied. Resultats Les valeurs de pressions plantaires statiques et dynamiques ne differaient pas entre les differents groupes de patients, aussi bien pour les valeurs moyennes que pour les pics de pression. CES resultats etaient observes pour toutes les zones des pieds (hallux, metatarsiens, talons, avant et arriere pieds) excepte pour l’avant pied droit ou les pressions augmentaient significativement avec la severite de la neuropathie (coefficient de correlation de 0,36 ; pxa0=xa00,003). Discussion Ces resultats suggerent qu’au-dela de la severite de l’atteinte proprioceptive, la presence d’hyperkeratose, d’amputations ou de deformations podologiques jouent un role determinant dans la survenue d’hyperpressions plantaires. Conclusion Ce travail n’a pas montre de correlation entre la severite de l’atteinte neuropathique sensitive profonde mesuree a l’aide du neuroesthesiometre et l’augmentation des pressions plantaires chez les patients diabetiques.

O8 La cystatine C améliore l’estimation de la fonction rénale chez les patients diabétiques

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.