[Anesthesiological approach to patients with chronic kidney disease]. / Anestezioloski pristup bolesniku s kronicnom bubreznom bolesti.

Anesthesia in patients with chronic kidney disease (CKD) represents a challenge for anesthesiologists and other specialists in the perioperative team. There is a high incidence of CKD among patients preoperatively, especially in elderly population. For anesthesiologists, it is an imperative to understand the pathophysiology of CKD, prevention of further kidney damage and its complications. This requires experienced anesthesiologist, careful preoperative patient assessment, recognition and modification of the potential risk factors in order to improve patient outcome. Priorities for successful prevention of kidney damage are appropriate fluid distribution peri- and intraoperatively, maintenance of euvolemia, and avoiding hypotension.

Kidney transplantation from deceased donors with high terminal serum creatinine.

The increasing number of possible recipients for kidney transplantation and relatively unchanged number of organ donors has led to consideration of alternative strategies and expansion of deceased donor criteria in order to expand donor pool. Previously, kidneys from expanded criteria donors (ECD) were strongly underestimated because of the conventional opinion suggesting these kidneys to have a higher rate of preservation injury, delayed graft function, rejection and nonfunction. Reducing the difference between graft outcome in patients transplanted from ECD and standard criteria donor (SCD) is one of the goals of many respectable kidney transplantation centers. This assignment includes major concern about reduction of cold ischemia time, recipient selection, novel and adapted immunosuppressive regimens, increased nephron mass by dual kidney transplantation, and using histologic criteria for marginal donor graft selection. There are not many reports on the outcome of kidneys transplanted from donors with acute renal failure and high terminal creatinine. This review presents the exact definition of marginal donor, especially donor with acute renal failure. The management of such grafts during preimplantation and implantation period, outcomes and post-transplantation care are the main assignments for transplantation teams. Recipients of such grafts should be well informed about the possibilities and potential complications and sign their informed consent thereafter. Some respectable studies have shown that under certain, highly controlled conditions, these kidneys can be used safely, with excellent short- and long-term outcomes.

The effect of preemptive intravenous low-dose magnesium sulfate on early postoperative pain after laparoscopic cholecystectomy.

As an N-methyl-D-aspartate antagonist, magnesium sulfate has analgesic properties and reduces noxious input during surgery. The aim of the study was to determine the effect of preemptive intravenous low-dose magnesium sulfate on early postoperative pain after laparoscopic cholecystectomy. In this prospective, randomized study, 60 ASA I-II patients undergoing elective laparoscopic cholecystectomy were assigned to three groups (n = 20 each). After anesthesia induction, prior to surgical incision, patients received magnesium sulfate 5.0 mg/kg (group A), magnesium sulfate 7.5 mg/kg (group B) or saline intravenously (group C). General anesthesia was performed with the same drugs in all three groups. Postoperative pain intensities at rest, according to the visual analog scale (VAS 0-10), were evaluated at 1, 3, 6, 9 and 24 hours after surgery. According to the VAS scores, patients intravenously received metamizol 2.5 g (VAS 3-4), diclofenac 75 mg (VAS 5-7) or tramadol 1 mg/kg (VAS 8-10). VAS scores at 1 hour postoperatively were significantly lower in groups A (4.7 +/- 1.7; p < 0.05) and B (3.2 +/- 1.8; p < 0.01) than in group C (5.2 +/- 2.0). At 3 hours postoperatively, VAS score was significantly lower in group B (2.4 +/- 1.5) than in group A (3.7 +/- 1.8) or group C (3.8 +/- 2.3) (p < 0.05). After 6, 9 and 24 hours postoperatively, there were no differences in VAS scores among the groups. In conclusion, preemptive intravenous administration of both 5.0 mg/kg and 7.5 mg/kg of magnesium sulfate significantly reduced early postoperative pain after laparoscopic cholecystectomy, but 7.5 mg/kg was found to be more effective. There was no effect on pain reduction at 6, 9 and 24 hours after surgery and no adverse effects were recorded.

[Renal transplantation in the elderly: characteristics of donor and recipient]. / Transplantacija bubrega kod starijih osoba--vaznost obiljezja darivatelja i primatelja.

Aging is a natural process that occurs in all tissues and organs resulting in a decreasing functional capacity. Aging of the population results in an increased number of elderly patients who require replacement of renal function. Renal transplantation is the method of choice for this group of patients if they have no contraindications for immunosuppressive therapy. The lack of donors is the main obstacle for renal transplantation. However, the use of organs from elderly donors for transplantation in elderly recipients is an appropriate method of renal replacement therapy in this group of patients.

[Disorders of hemostasis in chronic renal failure and renal transplantation]. / Poremecaj hemostaze u bolesnika s kronicnim bubreznim zatajenjem i nakon transplantacije bubrega.

The presence of end-stage renal disease (ESRD) has been associated with profound clinical effects on hemostasis ranging from thrombosis to bleeding complications. The pathogenesis of uremic bleeding is multifactorial. It has been attributed to platelet dysfunction, the most important feature, particularly platelet-platelet and platelet-vessel wall interactions. Renal replacement therapy has helped reduce bleeding episodes, but the risk of morbidity and mortality due to hemorrhage persists. Abnormalities of blood coagulation and fibrinolysis predispose uremic patients to hypercoagulable state carrying the risk of atherosclerotic cardiovascular disease and thrombotic complications such as thrombosis of the vascular access wall. There are differences in the measurement of various hemostatic parameters in patients with ESRD concerning treatment with either hemodialysis (HD) or continuous ambulatory peritoneal dialysis (CAPD). Hemostatic disturbances are overlapped by changes in the coagulation/fibrinolytic system after renal transplantation (RT). Despite the etiology, renal transplant patients are at an increased risk of thromboembolic events as a consequence of prothrombotic clotting and fibrinolytic abnormalities. This hypercoagulable state is to a large extent associated with immunosuppressive drugs. This review will give a summary of views on hemostasis in patients with ESRD and after RT.