Time to medical fitness for discharge following surgical evacuation of chronic subdural haematoma with general or regional anaesthesia: a prospective randomised trial

General or regional anaesthesia can be used for chronic subdural haematoma evacuation, but no study has compared these types of anaesthesia in terms of peri-operative outcomes. This single-centre, prospective, randomised study included adult patients (age ≥ 18 years) undergoing surgical chronic subdural haematoma evacuation. Patients were randomly allocated to general (target-controlled total intravenous anaesthesia with propofol and remifentanil) or regional anaesthesia (bilateral scalp block with remifentanil sedation if required). The primary outcome measure was duration of hospital stay, based on the day patients were judged by an investigator blinded from the allocation group to be medically fit for discharge. Secondary outcomes included: rate of regional anaesthesia failure; rate of intra-operative and postoperative adverse events at 24 hours; and pain scores at 24 hours. Data from 60 patients were analysed (30 general anaesthesia and 30 regional anaesthesia). Median (IQR [range]) time until patients were judged medically fit for discharge was 3 (3–3 [2–10]) days and 3 (2–5 [2–15]) days for general and regional anaesthesia, respectively (p = 0.700). Regional anaesthesia failed in two patients. There were more intra-operative adverse events in patients who received general anaesthesia (25 vs. 11, respectively; p = 0.001). The occurrence of postoperative adverse events was similar for general and regional anaesthesia (16 vs. 13 patients, respectively; p = 0.605). In patients requiring chronic subdural haematoma evacuation, general and regional anaesthesia are comparable in terms of duration of time until medically fit for discharge and occurrence of postoperative complications. The rate of intra-operative adverse events (mainly arterial hypotension) is greater with general anaesthesia.     

A renal allograft recipient with late recurrence of focal and segmental glomerulosclerosis after switching from cyclosporine to tacrolimus

BACKGROUND: Focal and segmental glomerulosclerosis (FSGS) is one of the most frequent and severe primary glomerulonephritis that recurs in transplanted kidneys. Although cyclosporine seems to have no effect on the frequency of FSGS recurrence, there is evidence that cyclosporine reduces proteinuria and prolongs graft survival in patients with recurrent glomerulonephritis after renal transplantation. The effect of tacrolimus on nephrotic syndrome after renal transplantation is controversial. METHODS: We describe the case of a 30-year-old man with steroid-resistant nephrotic syndrome due to FSGS who developed nephrotic syndrome 5 years after renal transplantation due to recurrent disease when he was switched from cyclosporine to tacrolimus. RESULTS: He was given pulses of methylprednisolone and returned to cyclosporine. His proteinuria decreased, but he rapidly developed chronic renal failure. CONCLUSIONS: This observation strongly suggests that tacrolimus should be given with considerable care in renal transplant recipients with FSGS.     

The effect of endothelin antagonists on renal ischaemia-reperfusion injury and the development of acute renal failure in the rat.

BACKGROUND:It is recognized that endothelins are released in response to hypoperfusion and anoxia of the kidney and may be responsible for the consequent deterioration in renal function. This study examined the ability of a non-selective (SB209670) and ET(A)-selective (UK-350,926) endothelin antagonist to attenuate ischaemia-induced renal failure in unilaterally nephrectomized rats. METHODS:The animals were anaesthetized, drug infusion commenced, and the renal artery occluded for 30 min. The endothelin antagonists were given for 30 min before, during, and 60 min after the ischaemic period, at 10, 30 and 100 micro g/kg/min or for 60 min after the start of reperfusion. RESULTS:On day 1, following 30 min renal artery occlusion, there was a 95% reduction in glomerular filtration rate, an 8-10-fold increase in plasma creatinine, and 10-15-fold increases in fractional excretions of sodium and potassium, which were partially resolved on day 3 and normalized on day 8. The lowest dose of SB209670 was without effect on the renal functional responses but they were blunted (all P<0.05) by the highest dose. At 30 and 100 micro g/kg/min UK-350,926, the decreases in renal function subsequent to the ischaemic challenge were attenuated. Administration of UK-350,926 at 100 micro g/kg/min for 1 h starting 60 min after the start of reperfusion, had no effect on the magnitude of the renal disturbances over the first 3 days. CONCLUSIONS:The data show that both the ET(A)/ET(B) and selective ET(A)-receptor antagonist ameliorated the ischaemia-reperfusion injury when given in the peri-ischaemic period but not when the ET(A)-receptor antagonist was given for 60 min at 100 micro g/kg/min after the ischaemic period.     

The influence of allopurinol on kidney haemodynamic and excretory responses to renal ischaemia in anaesthetized rats.

1. This study examined the impact of allopurinol on the renal functional responses to a 30 min period of ischaemia in anaesthetized rats. 2. Immediately on reperfusion, blood pressure rose transiently, while renal blood flow remained stable throughout at control values. Glomerular filtration rate was decreased by some 90% over the first and 80% over the sixth hour (P<0.001). 3. Allopurinol, 50 or 100 mg kg-1, had no effect on the blood pressure or renal blood flow responses over the 6 h reperfusion period but glomerular filtration decreased by 60% initially, and to less than 30% of basal at 6 h. 4. Urine flow and absolute sodium excretion increased 2 - 3 fold in the first 2 h but decreased thereafter. Fractional sodium excretion was 30 times higher for the first 2 h but decreased reaching some 10 fold higher at 6 h. In the presence of allopurinol, urine flow and absolute sodium excretion increased by 5 - 6 fold in the first 2 h, and fell by half by 6 h which was greater than in the vehicle group (P<0.01). Fractional sodium excretion increased 20 fold in the allopurinol animals in the first 2 h period, but fell at a faster rate (P<0.01) than in untreated rats. 5. Potassium excretion decreased (P<0.05) by one half for the 6 h reperfusion period but in the allopurinol animals it was minimally altered. 6. Allopurinol largely ameliorated the decrease in kidney haemodynamic and excretory function following an ischeamic period for the initial few hours of reperfusion.     

Risk factors for bacterial infections in chronic haemodialysis adult patients: a multicentre prospective survey

All adult patients from 13 dialysis centres were prospectivelyfollowed up for 6 months in an attempt to appraise the currentrisk factors for bacterial infections in stable chronicallyhaemodialysed patients. Parameters recorded as potential riskfactors for BI were age, gender, cause of renal failure, timeelapsed since the start of dialysis, history of transplantation,recent surgical procedure, previous bacterial infection, currentimmunosuppressive or erythropoietin therapy, type of angioaccessdevice, and serum ferritin level. Six hundred and seven patients(mean age 56.5 years, range 18–85) were enrolled in thestudy. Mean time elapsed since the start of dialysis was 4.7years. One hundred and eighteen patients had developed at leastone bacterial infection during the study period whereas 489had remained free of bacterial infection at the end of the follow-up.In multivariate analysis three parameters were found to be significantand independent risk factors for bacterial infection: previoushistory of bacterial infection (at least one versus no previousepisode), type of angioaccess device (catheter versus nativefistula), and elevated serum ferritin level (greater versuslower than 500 µg/l). These results support the evidencethat impaired host defences in chronic haemodialysis patientsmay be secondary to the dialysis procedure and suggest thatthe incidence of bacterial infection in these patients may befurther reduced by appropriate supportive therapy.     

Lymphoproliferative disorders after renal transplantation: role of medical imaging

Post-transplantation lymphoproliferative disorders (PTLD) are a complication of immunosuppressed transplant recipients, and their incidence is reported to be 20–120 times greater than the rate in the general population. After kidney transplantation, PTLD more likely arise within the renal transplant fossa. Radiological patterns of these forms are presented and discussed, according to a review of the literature, and illustrated by cases from our institution. Ultrasound plays an essential role in the early diagnosis of PTLD by detecting a urinary obstruction associated with adenopathy or an ill-defined mass not previously seen. However, in the case of an inconclusive US examination, CT or MRI should be performed to confirm the presence of a mass. Both techniques are useful in evaluating the extension of the process within the transplantation fossa; MRI seems more accurate and can be used for the follow-up, especially after reduction in immunosuppressive therapy without transplant removal. Received 8 October 1997; Revision received 17 March 1998; Accepted 23 March 1998