RESUMEN
Importance: Early-stage chronic kidney disease (CKD) characterized by microalbuminuria is associated with future cardiovascular events, progression toward end-stage renal disease, and early mortality in patients with type 2 diabetes. Objective: To compare the albuminuria-lowering effects of Roux-en-Y gastric bypass (RYGB) surgery vs best medical treatment in patients with early-stage CKD, type 2 diabetes, and obesity. Design, Setting, and Participants: For this randomized clinical trial, patients with established type 2 diabetes and microalbuminuria were recruited from a single center from April 1, 2013, through March 31, 2016, with a 5-year follow-up, including prespecified intermediate analysis at 24-month follow-up. Intervention: A total of 100 patients with type 2 diabetes, obesity (body mass indexes of 30 to 35 [calculated as weight in kilograms divided by height in meters squared]), and stage G1 to G3 and A2 to A3 CKD (urinary albumin-creatinine ratio [uACR] >30 mg/g and estimated glomerular filtration rate >30 mL/min) were randomized 1:1 to receive best medical treatment (n = 49) or RYGB (n = 51). Main Outcomes and Measures: The primary outcome was remission of albuminuria (uACR <30 mg/g). Secondary outcomes were CKD remission rate, absolute change in uACR, metabolic control, other microvascular complications, quality of life, and safety. Results: A total of 100 patients (mean [SD] age, 51.4 [7.6] years; 55 [55%] male) were randomized: 51 to RYGB and 49 to best medical care. Remission of albuminuria occurred in 55% of patients (95% CI, 39%-70%) after best medical treatment and 82% of patients (95% CI, 72%-93%) after RYGB (P = .006), resulting in CKD remission rates of 48% (95% CI, 32%-64%) after best medical treatment and 82% (95% CI, 72%-92%) after RYGB (P = .002). The geometric mean uACRs were 55% lower after RYGB (10.7 mg/g of creatinine) than after best medical treatment (23.6 mg/g of creatinine) (P < .001). No difference in the rate of serious adverse events was observed. Conclusions and Relevance: After 24 months, RYGB was more effective than best medical treatment for achieving remission of albuminuria and stage G1 to G3 and A2 to A3 CKD in patients with type 2 diabetes and obesity. Trial Registration: ClinicalTrials.gov Identifier: NCT01821508.
Asunto(s)
Complicaciones de la Diabetes/complicaciones , Diabetes Mellitus Tipo 2/complicaciones , Derivación Gástrica , Obesidad/complicaciones , Obesidad/cirugía , Insuficiencia Renal Crónica/complicaciones , Insuficiencia Renal Crónica/terapia , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
BACKGROUND/AIMS: The aim of this study is to evaluate the risk factors for mortality, morbidity, and long-term survival in elderly patients with colorectal cancer when compared to younger patients. METHODOLOGY: Patients operated on with colorectal cancer were divided into 2 groups according to age: Group 1 (75 years old or older, n=90) and group 2 (<75 years, n=430). RESULTS: Preoperative hemoglobin levels were lower in group 1 (p = 0.008). Poorer clinical status defined by ASA score (p = 0.008) results and blood transfusions (p = 0.003) were more frequent in group 1 when compared to group 2. Group 1 had a significantly higher operative mortality rate than group 2 (p = 0.01). Regarding cancer-related survival after 1, 2, and 4 years, there was no significant difference between the 2 groups. CONCLUSIONS: Poorer clinical conditions with special regard to anemia are more frequent among patients of 75 years and older and this finding may lead to an increase in operative mortality when compared to younger patients. Even though, senior patients with colorectal cancer should not be denied surgical and adjuvant therapy on account of age alone since cancer-related survival remains comparable to younger patients' results.