Respiratory and haemodynamic effects of acute postoperative pain management: evidence from published data

Background. This study examines the evidence from publisheddata concerning the adverse respiratory and haemodynamic effectsof three analgesic techniques after major surgery; i.m. analgesia,patient-controlled analgesia (PCA), and epidural analgesia. Methods. A MEDLINE search of the literature was conducted forpublications concerned with the management of postoperativepain. Information relating to variables indicative of respiratorydepression and of hypotension was extracted from these studies.Over 800 original papers and reviews were identified. Of thesepapers, 212 fulfilled the inclusion criteria but only 165 providedusable data on adverse effects. Pooled data obtained from thesestudies, which represent the experience of a total of nearly20 000 patients, form the basis of this study. Results. There was considerable variability between studiesin the criteria used for defining respiratory depression andhypotension. The overall mean (95% CI) incidence of respiratorydepression of the three analgesic techniques was: 0.3 (0.1–1.3)%using requirement for naloxone as an indicator; 1.1 (0.7–1.7)%using hypoventilation as an indicator; 3.3 (1.4–7.6)%using hypercarbia as an indicator; and 17.0 (10.2–26.9)%using oxygen desaturation as an indicator. For i.m. analgesia,the mean (95% CI) reported incidence of respiratory depressionvaried between 0.8 (0.2–2.5) and 37.0 (22.6–45.9)%using hypoventilation and oxygen desaturation, respectively,as indicators. For PCA, the mean (95% CI) reported incidenceof respiratory depression varied between 1.2 (0.7–1.9)and 11.5 (5.6–22.0)%, using hypoventilation and oxygendesaturation, respectively, as indicators. For epidural analgesia,the mean (95% CI) reported incidence of respiratory depressionvaried between 1.1 (0.6–1.9) and 15.1 (5.6–34.8)%,using hypoventilation and oxygen desaturation, respectively,as indicators. The mean (95% CI) reported incidence of hypotensionfor i.m. analgesia was 3.8 (1.9–7.5)%, for PCA 0.4 (0.1–1.9)%,and for epidural analgesia 5.6 (3.0–10.2)%. Whereas theincidence of respiratory depression decreased over the period1980–99, the incidence of hypotension did not. Conclusions. Assuming a mixture of analgesic techniques, AcutePain Services should expect an incidence of respiratory depression,as defined by a low ventilatory frequency, of less than 1%,and an incidence of hypotension related to analgesic techniqueof less than 5%.     

Comparative Effects of Haemodialysis and Haemofiltration on Plasma Atrial Natriuretic Peptide

The effects of 4 h haemodialysis (15 patients) or 4 h haemofiltration(five patients) on plasma concentrations of atrial natriureticpeptide (ANP) were compared by means of a sensitive radioreceptorbinding assay, and related to accompanying changes in body weight,blood pressure and plasma renin activity. Before dialysis, plasmaANP concentrations were considerably elevated: haemodialysisgroup 10–484 pmol/l (mean 156 pmol/l); haemofiltrationgroup 72–320 pmol/l (mean 170 pmol/l). Although plasmaconcentrations of ANP fell markedly with treatment in both groups:post-haemodialysis 2–187 pmol/l (mean 67 pmol/l); post-haemofiltration47–135 pmol/l (mean 79 pmol/l), after treatment it remainedabove the normal range in 14 of the 20 patients. Pretreatmentplasma ANP was related to systolic blood pressure (r=0.459;P<0.05) but bore no relationship to mean or diastolic bloodpressure, or plasma renin activity. The fall in plasma ANP concentrationduring treatment correlated with the postural blood pressuredrop after dialysis (r=0.505; P<0.05), but was unrelatedto changes in weight or plasma renin activity with haemodialysisor haemofiltration. Plasma ANP concentrations rose rapidly againin the 60 min after dialysis treatment, without change in bodyweight. These results show that high levels of biologically active ANPcirculate in end-stage renal disease. The fact that these arenot reduced to normal by haemodialysis or haemofiltration, despiterestoration to normovolaemic or hypovolaemic state, suggeststhat the increased levels of ANP in end-stage renal failureare due to both hypervolaemia and other factors, which may includeoccult cardiac dysfunction and loss of renal clearance.     

Evaluation of diagnostic criteria for analgesic nephropathy in patients with end-stage renal failure: results of the ANNE study

It was found that in Belgium, renal imaging techniques, demonstratinga decreased renal mass of both kidneys combined with eitherbumpy contours or papillary calcifications, were the only methodsto reliably diagnose analgesic nephropathy (AN) in patientswith end-stage renal failure. However, these criteria were selectedin an area with a high prevalence of this disease (15.6% ofthe dialysis population at December 1990). To evaluate the criteriaselected to diagnose AN in populations with lower or unknownprevalences of AN, the Analgesic Nephropathy Network of Europe(ANNE) was formed, consisting of 23 dialysis units from 14 Europeancountries and Brazil. During 1991–1992, 598 new patientswith equivocal diagnosis of renal disease (excluding biopsy-provenglomerulonephritis, polycystic disease, diabetic nephropathyand other systemic diseases) and who began renal replacementtherapy in the ANNE centres were evaluated by a short questionnaireand two renal imaging techniques: sonography and either tomographyor computed tomography (CT) scan. A comparison of 82 abusers(daily use of analgesic mixtures for at least 5 years) and 495controls corroborated the excellent diagnostic performance ofthe renal imaging techniques for AN. We recommend the use ofthese renal imaging criteria in all patients without a clearrenal diagnosis in order to obtain a more reliable insight intothe magnitude of the AN problem in different countries.     

Effectiveness of acute postoperative pain management: I. Evidence from published data

Background. This review examines the evidence from publisheddata concerning the incidence of moderate-severe and of severepain after major surgery, with three analgesic techniques; intramuscular(i.m.) analgesia, patient controlled analgesia (PCA), and epiduralanalgesia. Methods. A MEDLINE search of the literature was conducted forpublications concerned with the management of postoperativepain. Over 800 original papers and reviews were identified.Of these 212 papers fulfilled the inclusion criteria but only165 provided usable data on pain intensity and pain relief.Pooled data on pain scores obtained from these studies, whichrepresent the experience of a total of nearly 20 000 patients,form the basis of this review. Results. Different pain measurement tools provided comparabledata. When considering a mixture of three analgesic techniques,the overall mean (95% CI) incidence of moderate-severe painand of severe pain was 29.7 (26.4–33.0)% and 10.9 (8.4–13.4)%,respectively. The overall mean (95% CI) incidence of poor painrelief and of fair-to-poor pain relief was 3.5 (2.4–4.6)%and 19.4 (16.4–22.3)%, respectively. For i.m. analgesiathe incidence of moderate-severe pain was 67.2 (58.1–76.2)%and that of severe pain was 29.1 (18.8–39.4)%. For PCA,the incidence of moderate-severe pain was 35.8 (31.4–40.2)%and that of severe pain was 10.4 (8.0–12.8)%. For epiduralanalgesia the incidence of moderate-severe pain was 20.9 (17.8–24.0)%and that of severe pain was 7.8 (6.1–9.5)%. The incidenceof premature catheter dislodgement was 5.7 (4.0–7.4)%.Over the period 1973–1999 there has been a highly significant(P<0.0001) reduction in the incidence of moderate-severepain of 1.9 (1.1–2.7)% per year. Conclusions. These results suggest that the UK Audit Commission(1997) proposed standards of care might be unachievable usingcurrent analgesic techniques. The data may be useful in settingstandards of care for Acute Pain Services. Br J Anaesth 2002; 89: 409–23     

Urinary and plasma endothelin 1 in essential hypertension and in hypertension secondary to renoparenchymal disease

An alteration in renal metabolism of endothelin may contributeto hypertension in the SHR and it has been shown that the excretionrate of endothelin is reduced in patients with essential hypertension. We measured plasma and urinary endothelin 1 (ET-1) in 20 untreatedessential hypertensives with normal renal function, in eightnormotensive healthy subjects, and in 13 hypertensive patientswith primary renoparenchymal disease. Plasma ET-1 was higher (P</italic><0.01) in essentialhypertensives (median 1.69, interquartile range 1.2–3.3pg/ml) than in normal subjects (0.84, 0.37–1.10 pg/ml)but significantly less (P</italic><0.01) than in hypertensiveswith renoparenchymal disease (3.57, 1.45–9.52 pg/ml).ET-1 levels slightly correlated with diastolic pressure in essentialhypertensives (r=0.43, P<0.05) and tended to be correlatedwith systolic pressure in hypertensives with renal disease (r=0.47,P=0.08). ET-1 excretion in essential hypertensives (137, 99–154ng/24 h) and in normal subjects (120, 62–150 ng/24 h)was significantly lower than in renal hypertensives (191, 123–241ng/24 h). The ET clearance/GFR ratio (C1ET/GFR) was markedlyreduced (30%, 21–67%) in essential hypertensives and substantiallyraised in renal hypertensives (164%, 86–314%) in comparisonwith normal subjects (83%, 35–94%). Since the Cl_ET/GFR ratio should be 100% if all filtered ET-1is excreted, the data indicate that ET-1 is synthesized at areduced rate and/or broken down at an enhanced rate by the kidneyin essential hypertension and confirm that there is a high ET-1generation rate in remnant nephrons in hypertension secondaryto renal disease.     

Upper gastrointestinal lesions in children on chronic haemodialysis.

Sir, Peptic ulcer and its complications may easily develop afterrenal transplantation in the setting of already damaged gastroduodenalmucosa and/or in the presence of Helicobacter pylori infection[1,2]. We report upper gastrointestinal endoscopy (UGE) findingsand the incidence of H.pylori infection in children on intermittenthaemodialysis (HD) treatment. Twenty-five children with end-stage renal disease (ESRD) aged4–18 years (12.3 ± 3.9) and on intermittent HDfor 0.3–8 years (2.7 ± 2.1) were investigated.None of the patients received antibiotics,     

Comparison of ketamine and morphine for analgesia after tonsillectomy in children

In a double blind study we compared the effects of i.m. ketaminewith morphine on postoperative analgesia in children undergoingtonsillectomy. Eighty children (aged 6–15 yr) were randomizedto receive either i.m. morphine 0.1–0.15 mg kg^–1or ketamine 0.5–0.6 mg kg^–1, after induction ofa standard general anaesthetic. Pain scores 30 min after extubationwere higher (P<0.05) in the ketamine group, but were similarthereafter to the morphine group. Mean () times to recovery from anaesthesia were 20.1 ( 6.5) min in the ketamine group compared to 14.2 (5.6) min inthe morphine group (P<0.01). There were no differences insupplemental analgesia requirements, or the incidence of vomitingor dreaming between the groups. We conclude that ketamine 0.5mg kg^–1 i.m. may be an alternative analgesic for childrenundergoing tonsillectomy.     

Monoclonal gammopathy after intense induction immunosuppression in renal transplant patients

OBJECTIVES.: Incidence and risk factors of post-transplant monoclonal gammopathywere studied in renal transplant patients who received theirgrafts between 1982 and 1992 (n=390 grafts). Immunoelectrophoresiswas performed at annual intervals after transplantation. RESULTS.: Forty-six cases of clonal gammopathy were detected: 35 monoclonal,11 bi- or triclonal, with a predominance of IgG and K light-chainsubtypes (IgG, 39; IgA, 3; IgM, 4; K, 35; , 19). Gammopathywas transient in 17 patients (37%). The 5-year cumulative incidenceof gammopathy was 10.7%, much higher than expected for a groupof similar age from the general population. Thirty of the 46gammopathies appeared within the first 2 years of transplantation.Gammopathy never progressed to multiple myeloma during follow-up(median 1 year; (range 0–10)); one patient subsequentlydeveloped Kaposi sarcoma. The 2-year incidence of gammopathywas much higher in patients transplanted in 1989–1991(23/142) than in 1982–1988 (7/248) (P<0.0001). Thiscoincided with the use of quadruple induction immunosuppression(cyclosporin A+azathioprine+prednisone plus either ATG-Fresenius(ATG-F) or OKT3) since 1989. The risk for acquiring gammopathywithin 2 years of transplantation was 14.7% (95% CI 9.2, 20.3%)in patients receiving quadruple induction therapy, but only3.0% (CI 1.2, 6.1%) without such therapy (P<0.0001). Therisk for patients receiving quadruple immunosuppression withOKT3 was 24.5%, significantly greater than with ATG-F (11.8%,P<0.05). Discriminant analysis revealed that the type ofimmunosuppression, but not age or year of transplantation, wereindependent risk factors for gammopathy. CONCLUSIONS.: Monoclonal gammopathy frequently occurs after renal transplantation.Risks are higher for patients receiving quadruple inductionimmunosuppression, particularly if it includes OKT3. Follow-upof these patients is warranted for the early detection of malignanttransformation.     

PATIENT-CONTROLLED ANALGESIA WITH LOW DOSE BACKGROUND INFUSIONS AFTER LOWER ABDOMINAL SURGERY IN CHILDREN

Forty-five children (aged 6–12 yr) undergoing appendicectomyreceived one of three analgesic regimens using patient-controlledanalgesia (PCA) with morphine: no background infusion (BO);background infusion 4 µg kg^–1 h^–1 (B4); backgroundinfusion 10 µh^–1 h^–1 (B10). Total consumptionof morphine was greater in group B10 compared with groups BO(P<0.01) and B4 (P<0.05). There was no significant differencein morphine consumption in groups BO and B4. All three groupsself-administered similar amounts of morphine and there wereno significant differences in pain scores or incidence of excessivesedation. Group B4 suffered less hypoxaemia compared with groupsBO (P<0.01) and B10 (P<0.001). Group B10 suffered morenausea and vomiting than groups BO (P<0.001) and B4 (P<0.001),but there was no significant difference in the incidence ofnausea and vomiting between groups BO and B4. Groups B4 andB10 spent more time at night asleep than group BO (P<0.05).There were no significant differences between the groups inthe amount of time spent asleep during the day. Inclusion ofa background infusion of morphine 4 µg kg^–1 h^–1in a PCA regimen for children did not increase the incidenceof side effects and was associated with less hypoxaemia anda better sleep pattern than no background infusion. (Br. J.Anaesth. 1993; 71: 818–822)     

Analgesic nephropathy

Many questions about analgesic nephropathy (AN) lack clear-cut answers. We present available evidence for and against proposed answers to many of these questions. These include: (1) Is acetaminophen (AC) nephrotoxic when taken as the sole analgesic? (2) Is the combination of acetylsalicylic acid (ASA) and AC more nephrotoxic than AC taken alone, and if so, why? (3) What are the minimum doses and durations of ingestion required to produce analgesic nephrotoxicity? (4) Is the combination of ASA and AC (a major metabolite of phenacetin) less nephrotoxic than that of phenacetin and ASA combined? (5) Does caffeine in combination with analgesics contribute to nephrotoxicity? (6) What is the incidence of end-stage renal disease (ESRD) due to AN? (7) What uniform diagnostic criteria should be established for AN? (8) What are the earliest anatomic and biochemical abnormalities? (9) What are the mechanisms of renal injury? (10) Does AC cause uroepithelial neoplasia? (11) What research might be most beneficial? Based mainly on associations, some strong, we suggest that AN still exists as a cause of ESRD in the United States, where AC/ASA combinations are available over the counter, and in Canada, where they are not. We also suggest that the evidence needed to recommend that the AC/ASA combination be excluded from over-the-counter analgesic preparations still has limitations. A prospective multicenter study comparing incidence related to AC/ASA in the United States and to AC in Canada and the United States may be needed to answer this question. For such a study to be worthwhile, an adequate incidence in both countries is required.     

The pulsatility index and the resistive index in renal arteries in patients with hypertension and chronic renal failure

BACKGROUND.: The pulsatility index (PI) and the resistive index (RI) areused as pulsed-wave Doppler measurement of downstream renalartery resistance. Little information is available on theirvalue in chronic renal failure and their correlation to parametersof renal function and haemodynamics. The aim was to comparePI and RI of renal arteries in healthy volunteers and in patientswith hypertension and chronic renal failure, and furthermoreto study the correlation of these indices to measurements ofrenal haemodynamics and function by standard methods in patientswith renal failure and hypertension. METHODS.: Twenty-five hypertensive patients (10 females, 15 males, meanage 52 years (24–74) with a glomerular filtration rate(GFR) less than 50 ml/min and an arterial blood pressure above140 mmHg systolic and 95 mmHg diastolic were included in thestudy. Ten healthy, normotensive volunteers (4 females and 6males, mean age 43 years (30–62)) served as controls inthe Doppler examinations. Doppler examinations were performedin segmental arteries by an Acuson 128. The PI and the RI wascalculated from the blood flow velocities. RESULTS.: Both the PI and the RI were significantly higher in the patientgroup (P) than in the control group (C) (PI, P 1.65 (1.31–1.86),C 1.19 (0.93–1.25), P=0.003; RI, P 0.76 (0.69–0.81),C 0.67 (0.64–0.70), P=0.003). Both PI and RI correlated significantly with effective renalplasma flow (PI: r= –0.5, P=0.02; RI: r=–0.5, P=0.006),renal vascular resistance (PI: r=0.4, P= 0.05; RI: r=0.5, P=0.02),filtration fraction (PI: r=0.6, P=0.005; RI: r=0.5, P=0.01)and clearance of creatinine (PI: r=–0.6, P=0.008; RI:r=–;0.6, P= 0.006). Only RI correlated significantly toGFR (r=–0.5, P=0.02). The indices did not correlate toserum creatinine, or mean arterial blood pressure. CONCLUSION.: PI and RI seems to be closely related to parameters of renalhaemodynamics and clearance of creatinine in patients with chronicrenal failure and hypertension.     

Are prediction equations for glomerular filtration rate useful for the long-term monitoring of type 2 diabetic patients?

Background. The aim of this study was to compare the accuracyof prediction equations [modification of diet in renal disease(MDRD), simplified MDRD, Cockcroft–Gault (CG), reciprocalof creatinine and creatinine clearance] in a cohort of patientswith type 2 diabetes. Methods. A total of 525 glomerular filtration rates (GFRs) using¹²⁵I-iothalamate were carried out over 10 years in 87 type 2diabetic patients. Accuracy was evaluated at three levels ofrenal function according to the baseline values obtained withthe isotopic method: hyperfiltration (GFR: >140 ml/min/1.73m²; 140 isotopic determinations in 27 patients), normal renalfunction (GFR: 140–90 ml/min/1.73 m²; 294 isotopic determinationsin 47 patients) and chronic kidney disease (CKD) stages 2–3(GFR: 30–89 ml/min/1.73 m²; 87 isotopic determinationsin 13 patients). The annual slope for GFR (change in GFR expressedas ml/min/year) was considered to ascertain the variabilityin the equations compared with the isotopic method during follow-up.Student's t-test was used to determine the existence of significantdifferences between prediction equations and the isotopic method(P < 0.05 with Bonferroni adjusted for five contrast tests). Results. In the subgroup of patients with hyperfiltration, aGFR slope calculated with ¹²⁵I-iothalamate –4.8 ±4.7 ml/min/year was obtained. GFR slope in patients with normalrenal function was –3.0 ± 2.3 ml/min/year. In bothsituations, all equations presented a significant underestimationcompared with the isotopic GFR (P < 0.01; P < 0.05). Inthe subgroup of CKD stages 2–3, the slope for GFR with¹²⁵I-iothalamate was –1.4 ± 1.8 ml/min/year. Thebest prediction equation compared with the isotopic method provedto be MDRD with a slope for GFR of –1.4 ± 1.3 ml/min/year(P: NS) compared with the CG formula –1.0 ± 0.9ml/min/year (P: NS). Creatinine clearance presented the greatestvariability in estimation (P < 0.001). Conclusions. In the normal renal function and hyperfiltrationgroups, none of the prediction equations demonstrated acceptableaccuracy owing to excessive underestimation of renal function.In CKD stages 2–3, with mean serum creatinine 133 µmol/l(1.5 mg/dl), the MDRD equation can be used to estimate GFR duringthe monitoring and follow-up of patients with type 2 diabetesreceiving insulin, anti-diabetic drugs or both.     

Comparison of intravenous and oral ketoprofen for postoperative pain after adenoidectomy in children

One hundred children, aged 1–9 yr, undergoing adenoidectomywere randomized to receive ketoprofen 1 mg kg^–1either i.v. with an oral placebo (n=40) or ketoprofen 1 mg kg^–1orally with an i.v. placebo (n=40), or both oral and i.v. placebo(n=20). The study design was prospective and double blind withparallel groups. The pain was assessed at rest and during swallowingusing the Maunuksela pain scale (0=no pain, 10=worst possiblepain) after surgery for 3 h. Fentanyl 0.5 µg kg^–1i.v. was given for rescue analgesia. Children in the i.v. groupneeded significantly less doses (1, 1–3; median and 10th/90thpercentiles) of rescue analgesic compared with the oral group(2, 1–3; P=0.024). Of those who needed rescue analgesic,three out of 30 children in the i.v. group required three ormore doses of fentanyl compared with 10 out of 28 children inthe oral group. There were no differences between the groupswith respect to pain scores, operation times, perioperativebleeding or frequency of adverse events. Br J Anaesth 2000; 85: 224–7 ^* Corresponding author     

Primary renal vasculitis in Norfolk--increasing incidence or increasing recognition?

BACKGROUND: The incidence of renal vasculitis has previously been estimated using histological definitions or only a single clinical diagnosis, e.g. Wegener's Granulomatosis (WG). Our hospital is the single referral centre for the former Norwich Health Authority (NHA) which encompasses a stable, homogeneous, well-defined and studied population. We estimated the overall incidence of primary renal vasculitis and the incidence within individual clinical disease classifications. METHODS: All cases of primary renal vasculitis diagnosed within the NHA over 66 months (1992-1997) were identified by review of renal biopsies, the Norfolk Vasculitis Register, hospital discharge summaries and plasmapheresis records. Patients were classified using the 1990 American College of Rheumatology criteria for Polyarteritis Nodosa (PAN), Churg Strauss Syndrome (CSS) and Henoch-Schonlein Purpura; the Chapel Hill Consensus Conference Definitions for Microscopic Polyangiitis (mPA) and the Lanham criteria for CSS. Incidence figures were calculated using the NHA adult population of 413747 (1994). Ninety-five per cent confidence intervals (C.I.) were calculated using the poisson distribution. RESULTS: The overall annual incidence for primary renal vasculitis was 18/million (C.I. 12.9-24.4). The annual incidence of renal involvement of individual diseases was as follows: WG 7.9/million (95% C.I. 4.7-12.5); mPA 7.5/million (95% C. I. 4.4-12.0); PAN 7.0/million (95% C.I. 4.0-11.4); HSP 3.1/million (95% C.I. 1.2-6.3); CSS 1.3/million (95% C.I. 0.3-3.9). CONCLUSIONS: The annual incidence for primary renal vasculitis overall and the individual subtypes in Norfolk is much higher than previous European estimates. This may reflect an increasing incidence in primary renal vasculitis with time or underestimation in previous studies. However the incidence of renal vasculitis in our population is markedly lower than reported in Kuwait. There may therefore be true variation in incidence between populations which could have implications for the aetiology of primary vasculitis.     

Analgesic efficacy of tramadol 2 mg kg(-1) for paediatric day-case adenoidectomy

We studied the analgesic efficacy of tramadol 2 mg kg^–1for post-operative analgesia after day-case adenoidectomy inchildren aged 1–3 yr. Eighty children were allocatedrandomly to receive tramadol 2 mg kg^–1 i.v.or placebo immediately after induction of anaesthesia. Anaesthesiawas induced with alfentanil 10 µg kg^–1and propofol 4 mg kg^–1 followed by mivacurium0.2 mg kg^–1 for tracheal intubation. Anaesthesiawas continued with sevoflurane in nitrous oxide and oxygen.All children were given ibuprofen rectally at approximately10 mg kg^–1 before the start of surgery. Post-operativepain and recovery assessments were performed by a nurse blindedto the analgesic treatment using the Aldrete recovery score,the pain/discomfort scale and measurement of recovery times.Rescue medication (pethidine in increments of 5 mg i.v.)was administered according to the pain scores. A post-operativequestionnaire was used to evaluate the need for analgesia athome up to 24 h after operation. Rescue analgesic at homewas rectal or oral ibuprofen 125 mg. Children in the tramadolgroup required fewer pethidine doses than those in the placebogroup (P=0.014). Forty-five per cent of children receiving tramadoldid not require post-operative analgesia at all compared with15% of children receiving placebo (P=0.003). Recovery timesand the incidence of adverse effects were similar in the twogroups in the recovery room and at home. The requirement forrectal ibuprofen at home did not differ between groups. Br J Anaesth 2001; 86: 572–5     

Prognosis of diabetic patients on dialysis: analysis of Lombardy Registry data

METHODS.: This 1993 Lombardy Registry Report refers to all of the dataregarding treated diabetics collected between 1 January 1983and 31 December 1992 by means of individual patient questionnairessent to all of Lombardy's 44 Renal Units (100% replies). RESULTS.: The acceptance rate of diabetics for dialysis increased from5.6 in 1983 to 10.4 patients per million population in 1992for a total of 731 patients (379 type I, 352 type II). The yearlypercentage of new diabetics increased from 9 to 11%, and theproportion of patients with two or more risk factors increasedfrom 14.7% in 1983–1987 to 22.0% in 1988–1992. Theuse of peritoneal dialysis declined over the 10-year periodfrom 50% in 1983–1984 to 30% in the last 2 years. Thedifference in age of the patients on peritoneal and haemodialysistended to decrease. The survival of all diabetic patients was82% at 1 year, 48% at 3 years, and 28% at 5 years. The relativedeath risk of the patients on peritoneal dialysis compared tothose on haemodialysis, after taking into account age and themain comorbid conditions (type of diabetes, severe vasculardisease, cirrhosis and the generic other risk factors), didnot differ significantly from one, as estimated by the Cox proportionalhazard regression model (344 events). The main causes of deathof these patients were cardiovascular diseases (about 50.0%),cachexia (from 17.2% in 1983/1984 to 22% in 1991/1992), andinfections (about 11%). The mean hospitalization rate was higherin diabetics than in patients with standard nephropathies (i.e.in 45–64-year-old patients: 32.8 versus 13.9 days/patient-year). CONCLUSION.: Multivariate analysis showed that age, type of diabetes, severevascular disease, cirrhosis, and the generic other risk factorswere significantly related to survival; but diabetic patientswithout any baseline risk factors also had a poor prognosisand morbidity was very high in absolute terms. Medical caretherefore needs to be improved in order to reverse prognosticrisk factors and prevent cardiovascular and non-cardiovascularevents.     

Rectal acetaminophen does not reduce morphine consumption after major surgery in young infants

BACKGROUND: The safety and value of acetaminophen (paracetamol) in additionto continuous morphine infusion has never been studied in newbornsand young infants. We investigated the addition of acetaminophento evaluate whether it decreased morphine consumption in thisage group after major thoracic (non-cardiac) or abdominal surgery. METHODS: A randomized controlled trial was performed in 71 patients giveneither acetaminophen 90–100 mg kg^–1 day^–1orplacebo rectally, in addition to a morphine loading dose of100 µg kg^–1 and 5–10 µg kg^–1h^–1 continuous infusion. Analgesic efficacy was assessedusing Visual Analogue Scale (VAS) and COMFORT scores. Extramorphine was administered if VAS was 4. RESULTS: We analysed data of 54 patients, of whom 29 received acetaminophenand 25 received placebo. Median (25–75th percentile) agewas 0 (0–2) months. Additional morphine bolus requirementsand increases in continuous morphine infusion were similar inboth groups (P = 0.366 and P = 0.06, respectively). There wasno significant difference in total morphine consumption, respectively,7.91 (6.59–14.02) and 7.19 (5.45–12.06) µg kg^–1 h^–1for the acetaminophen and placebo group (P = 0.60). COMFORT[median (25–75th percentile) acetaminophen 10 (9–12)and placebo 11 (9–13)] and VAS [median (25–75thpercentile) acetaminophen 0.0 (0.0–0.2) and placebo 0.0(0.0–0.3)] scores did not differ between acetaminophenand placebo group (P = 0.06 and P = 0.73, respectively). CONCLUSIONS: Acetaminophen, as an adjuvant to continuous morphine infusion,does not have an additional analgesic effect and should notbe considered as standard of care in young infants, 0–2months of age, after major thoracic (non-cardiac) or abdominalsurgery.     

Aluminium mobilization following renal allograft transplantation may have an immunomodulatory role by reducing the incidence of graft rejection

Urinary aluminium excretion was prospectively monitored duringthe first year following first cadaver renal allograft transplantationin 79 consecutive patients. Plasma and urinary aluminium concentrationssteadily declined with time. Thirty-five patients had 0–1episodes of acute graft rejection compared to 44 with two ormore rejections; more of the former group had been prescribedaluminium-containing phosphate binders (74% versus 56%, P<0.02),and following transplantation this group had a persistentlygreater urinary aluminium excretion, suggesting a greater aluminiumbody burden. There were no significant differences in termsof gender distribution, blood transfusion, or HLA matching betweenthe groups, thus suggesting that either the subsequent mobilizationof aluminium body stores following transplantation and/or theaccumulation of aluminium in the reticuloendothelial systemprior to transplantation may have had an immunomodulatory effectin reducing the incidence of renal allograft rejection.     

Reduced speed of sound in tibial bone of haemodialysed patients: association with serum PTH level

BACKGROUND: In end-stage renal disease, average bone mineral density hasbeen reported to be normal or only modestly reduced, more soin the cortical bone. The purpose of the present study was toexplore the potential use of quantitative ultrasound, a methodreflecting both quantitative and qualitative properties of bone,in assessing bone status in patients on maintenance haemodialysis. METHODS: We studied 71 patients (age 17–81 years, time on dialysis0–18 years). The speed of sound waves (tSOS; m/s) propagatingalong the cortical bone has been determined at the tibial shaft.tSOS results were expressed as Z scores, i.e. units of standarddeviations from age- and sex-matched normal mean values, andcorrelated with relevant clinical and biochemical variables. RESULTS: SOS Z score averaged –2.0 (range –6.8 to 0.6; P<0.001)and was negative in 93% of the patients. Significant inversecorrelations were found between SOS Z score and both time ondialysis (r=–0.52; P<0.0001) and serum PTH (r=–0.39;P=0.002). Markedly reduced SOS Z score, below –2, wasfound in 80% of the patients whose PTH levels exceeded 34 pmol/l(five times the upper normal limit), compared with 43% of thepatients whose PTH levels were below 34 pmol/l (P=0.04). Comparedto patients with out bone pain (n=51), subjects with bone pain(n=20) had somewhat lower SOS Z scores –2.5±2.0versus –1.8±1.4; n=0.08), but this could be accountedfor by longer time on dialysis. CONCLUSIONS: tSOS is substantially reduced in the majority of haemodialysedpatients and is related to time on dialysis and serum PTH level.The clinical value of this novel method needs further exploration.