Towards safer use of opioids.

The main aim of our work was to improve the safety of opioid use in our institution, an acute generalhospital with 620 beds. Initially, all reported opioid errors from 2001 - 2006 were audited. The findings directed a range of multidisciplinary staff educational inputs to improve opioid prescribing and administration practice, and encourage drug error reporting. 448 drug errors were reported, of which 54 (12%) involved opioids; of these, 43 (79%) involved codeine, morphine or oxycodone. 31 of the errors (57%) were associated with administration, followed by 12 (22%) with dispensing and 11 (20%) with prescribing. There were 2 reports of definite patient harm. A subsequent audit examined a 17-month period following the introduction of the above teaching: 17 errors were noted, of which 14 (83%) involved codeine, morphine or oxycodone. Again, drug administration was most error-prone, comprising 11 (65%) of reports. However, just 2 (12%) of the reported errors now involved prescribing, which was a reduction.

Renal allograft failure after simultaneous pancreas-kidney transplantation: univariate and multivariate analyses of donor and recipient risk factors.

Although donor and recipient risk factors for renal allograft failure are well known after kidney transplantation, they are less well defined after simultaneous pancreas-kidney transplantation. The purpose of this study is to evaluate the impact of donor and recipient risk factors on the outcome of the renal allograft in simultaneous pancreas-kidney recipients. Simultaneous pancreas-kidney transplant performed between 4/88 and 6/94 were reviewed (n = 61) and univariate (Kaplan-Meier) and multivariate (Cox regression) analyses of factors which affect kidney graft survival were performed. Twelve donor and eleven pre- and post-transplant recipient risk factors were evaluated. Overall kidney allograft survival rates at 1, 2 and 5 yr were 81%, 76% and 66%. Donor age > and = 40 yr (RR = 2.3), donor female gender (RR = 3.5), donor admission to pronouncement of brain death > and = 48 h (RR = 3), the occurrence of surgical complications (RR = 2.1), and serum > and = 2 mg/dl on post-transplant day (RR = 1.9) were independently associated with an increased hazard of graft failure. With the exception of length of donor admission, all of these factors were also shown to predict the risk of renal graft failure by univariate analysis. In conclusion, we have identified donor and recipient risk factors which independently predict the risk of renal graft failure after simultaneous pancreas-kidney transplantation. Whether the differences between our center-specific risk factors and those obtained from renal transplant registry data are true differences or simply reflect sampling error is unclear.

Treatment of renal allograft acute rejection with methylprednisolone: effect of fixed dose versus dose per body mass index.

Considerable interpatient variability in steroid pharmacokinetics has been observed in renal transplant recipients. The purpose of this retrospective study is to evaluate the relationship between the dose of methylprednisolone (MP) used to treat acute rejection (AR) after renal transplantation and the response to treatment. 117 first AR episodes from 408 renal transplants were reviewed. The dose of MP used to treat AR was < 45 mg/kg/m2 in 60 patients and > and = 45 mg/kg/m2 in 57 patients. The correlation between fixed dose ( < 1.25 vs. > and = 1.25 g) and dose based on BMI was evaluated by simple linear regression analysis (r2 = 0.78, p < 0.0005). Response to treatment was as follows: MP successful (Group 1, n = 80); MP failed, OKT3 successful (Group 2, n = 17); MP and OKT3 failed (Group 3, n = 3) and MP failed, no further treatment (n = 17). No relationship was observed between the dose of MP, whether fixed or based on BMI, and (1) response to treatment of the first AR, (2) incidence of a second AR and (3) response to subsequent treatment with OKT3. Actuarial graft survival was higher in Group 1 compared to Group 2 (p < 0.0005), lower in Black recipients (p = 0.02) and higher when > and = 45 mg/kg/m2 of MP was used to treat AR (p = 0.06). In conclusion, no relationship between the dose of MP, whether fixed or based on BMI, and the response to treatment of AR was observed. MP dosage based on BMI may be a reasonable alternative to a fixed-dose regimen with the advantage of limiting steroid exposure and the consequent side-effects.

Renal retransplants: effect of primary allograft nephrectomy on early function, acute rejection and outcome.

Although risk factors for failure of renal retransplants have been well studied, the impact of allograft nephrectomy on subsequent renal transplantation in the cyclosporin era is not well defined. The purpose of this study is to define the effect of nephrectomy of the primary allograft on subsequent allograft survival, early allograft function, incidence of acute rejection and patient sensitization. The records of 127 renal retransplant recipients were reviewed. Of these 127 patients who underwent retransplantation, 40 (31%) underwent nephrectomy of the primary allograft prior to retransplantation whereas 40 (31%) did not. Nephrectomy of cadaveric primary allografts was performed more commonly (48% vs 30%, p = 0.003) and earlier (78% vs 54% < 1 month post-transplant, p = 0.0006) in the pre-CSA period compared to the CSA period. Biopsy-proven acute rejection episodes occurred more frequently in the nephrectomy group (73% vs 42%, p = 0.03). Although primary allograft nephrectomy was associated with higher preformed antibody levels, it had no effect on early graft function, frequency of acute rejection or allograft outcome after retransplantation, in the CSA group. In conclusion, in the cyclosporin era, nephrectomy of the primary allograft has no significant influence on retransplantation.

Renal allograft and patient outcome after transplantation: pancreas-kidney versus kidney-alone transplants in type 1 diabetic patients versus kidney-alone transplants in nondiabetic patients.

Despite recent advances and improved outcome, pancreas transplantation remains controversial. The purpose of this review was to study renal allograft outcome after simultaneous pancreas-kidney transplants (SPK, n = 61), kidney-alone transplants in type I diabetic patients (KA-D, n = 63), and kidney-alone transplants in nondiabetic patients (KA-ND, n = 80). Patients were matched for donor age, donor gender, donor race, interval from donor admission to procurement, DR mismatch, and recipient gender. The mean renal allograft cold ischemic time and recipient age were lower in the SPK group. Patient survival was highest in the KA-ND group (99% and 86% at 1 and 5 years, respectively), intermediate in the SPK group (90% and 78% at 1 and 5 years, respectively), and lowest in the KA-D group (89% and 66% at 1 and 5 years, respectively) (P = 0.004). similarly, renal allograft survival was higher in the KA-ND (89% and 63% at 1 and 5 years, respectively) and SPK (82% and 69% at 1 and 5 years, respectively) groups compared with the KA-D group (76% and 49% at 1 and 5 years, respectively) (P = 0.07). This difference disappeared when renal graft survival was censored for death, which probably reflects the selection bias. Actuarial pancreas graft survival was 76% and 62% at 1 and 5 years, respectively. Acute rejection (AR) was more frequent in the SPK group than in the KA-D and KA-ND groups (41% v 16% v 29%; P = 0.007). Delayed graft function (DGF), on the other hand, occurred more frequently in the KA-D group than in the KA-ND and SPK groups (66% v 55% v 38%; P = 0.08). Death as a result of a cardiovascular event occurred more frequently in the KA-D group. Cardiovascular death and renal graft failure occurred earlier in the SPK group. Cox regression analysis revealed a 1.6 and 1.8 times higher risk of renal graft failure in the SPK group when the donor was > or = 40 years old or female and a five times higher risk of graft failure in the KA-ND group in the presence of AR. Graft survival in patients with AR/DGF was lower than that in patients with no AR/no DGF in both the KA-D (71% and 63% v 100% and 100% at 1 and 5 years, respectively; P = 0.03) and KA-ND (90% and 56% v 100% and 100% at 1 and 5 years, respectively; P = 0.001) groups. Acute rejection did not affect graft survival in the SPK group. In the absence of AR, DGF had no effect on graft survival in any of the groups. Although the selection bias in favor of pancreas transplantation does not allow for definitive conclusions, our results show that outcome after SPK transplantation is acceptable and factors that influence the outcome after this procedure may be different from the ones affecting KA-D recipients.

A cost-effectiveness analysis of epoetin usage for patients with AIDS.

Epoetin (recombinant human erythropoietin) therapy for patients with AIDS may reduce the need for blood transfusion; however, it is expensive. We conducted a cost-effectiveness analysis of the use of epoetin for AIDS patients from a healthcare system perspective. We constructed a decision analysis model using probability, outcome and cost data from the literature and hospital sources. The incremental cost-effectiveness ratio was measured in dollars per unit of blood saved. In AIDS patients undergoing transfusion with serum epoetin concentrations less than or equal to 500 U/L treatment with epoetin cost $US1007 per unit of blood saved compared with treatment without epoetin. One-way sensitivity analysis revealed that the incremental cost-effectiveness ratio was sensitive to the efficacy and unit price of epoetin, but less sensitive to the current price cap determined by the distributor.

Removal of plasma porphyrins with high-flux hemodialysis in porphyria cutanea tarda associated with end-stage renal disease.

Plasma porphyrin levels are markedly increased in patients with porphyria cutanea tarda (PCT) associated with end-stage renal disease. Conventional hemodialysis (CHD) with lower blood flow rates (less than 250 mL/min) and cuprophan or cellulose acetate membranes is ineffective in removing significant amounts of porphyrins in this condition. Changes in plasma porphyrin levels and porphyrin clearances during hemodialysis with higher blood flow rates and more-permeable, high-efficiency cellulose acetate and high-flux polysulfone dialyzers were evaluated in a chronic hemodialysis patient with PCT and markedly elevated plasma porphyrins. The polysulfone membrane achieved significantly better fractional porphyrin removal (P = 0.02) and porphyrin clearances (P less than 0.01) than did the high-efficiency cellulose acetate membrane. After conversion from maintenance CHD with a standard cellulose acetate dialyzer to a 4-wk period of high-flux hemodialysis (HFHD) with a polysulfone dialyzer, predialysis plasma porphyrins fell by 37%. After returning to CHD, plasma porphyrins returned to the higher prestudy levels. These observations suggest that HFHD with more permeable membranes and higher blood flow rates removes porphyrins more effectively than does CHD. HFHD may be a useful adjunct to other measures used in treating dialysis patients with PCT.

Pasteurella multocida peritonitis in an HIV-positive patient on continuous cycling peritoneal dialysis.

Pasteurella multocida has been reported only once previously as a cause of peritonitis in a patient undergoing chronic peritoneal dialysis. The present report describes findings associated with a case of P. multocida peritonitis in a human immunodeficiency virus (HIV)-positive patient in which renal replacement therapy consisted of continuous cycling peritoneal dialysis. To our knowledge this is the first report of this unique infection in an HIV-positive end-stage renal disease patient. In addition, the recent literature on this unusual organism is reviewed in detail. These findings emphasize the potential for increased susceptibility to zoonoses in immunocompromised patients, particularly with indwelling intraperitoneal catheters which may serve as a portal of entry for unusual organisms.

The effects of intravenous theophylline infusion versus intravenous sodium bicarbonate infusion on lithium clearance in normal subjects.

Ten normal subjects ingested lithium carbonate (600 mg p.o. b.i.d.) for three 1-week intervals. At the end of each weekly interval, subjects' lithium clearances were randomly perturbed for 12 hours with the subject in a supine position by infusing either normal saline (308 mEq), sodium bicarbonate (350 mEq) in normal saline (308 mEq), or theophylline (mean = 14.0 micrograms/ml) in normal saline (308 mEq). Subjects were placed on a 200 mEq/day sodium diet during the lithium clearance perturbation stages of the study. When each patient's normal saline lithium clearance was used as a control, it was found that the theophylline produced a significantly greater % increase in lithium clearance than did the sodium bicarbonate. Theophylline infusions increased patients' individual lithium clearances by 51 +/- 52%, while sodium bicarbonate infusions increased lithium clearances by 0.6 +/- 33%. Theophylline infusions ought to be investigated as an alternative to hemodialysis in lithium intoxications requiring the immediate reduction of lithium concentrations.

Familial adult glomerulocystic kidney disease.

During an evaluation for nephrotic syndrome, a 20-year-old woman was found by ultrasonographic examination to have large kidneys with multiple renal cysts suggestive of polycystic kidney disease. A subsequent renal biopsy revealed membranous glomerulopathy due to systemic lupus erythematosus, as well as the unexpected finding of glomerulocystic kidney disease (GCKD), an uncommon disorder previously reported to occur primarily in infants and children. No evidence of renal dysplasia was present and no cysts were found in any abdominal or pelvic organs. Other than one bifid renal pelvis, no significant congenital anomalies or structural chromosomal abnormalities were present. Ultrasonographic evaluation of the patient's family revealed similar-appearing cortical cysts in several members, all of whom had no clinical evidence of renal dysfunction. The pattern of involvement was compatible with autosomal dominant inheritance. Follow-up ultrasonograms of the patient and affected family members 1 year after the initial study showed enlargement of the cysts with development of additional cysts in two individuals and no change in the other family members. Although renal failure was present and progressed in our patient, renal function remained normal in all affected family members 1 year after detection of the renal cysts. This patient and her family provide additional insight into the inheritance and natural history of GCKD and demonstrate that this condition should be considered in the evaluation of multicystic renal disease in adults. In contrast to several previously reported cases, it appears that GCKD may be associated with normal renal function for many years.

Arthroscopic partial medial meniscectomy in the older patient.

We reviewed the cases of sixty-three patients who were more than forty years old when they underwent arthroscopic partial medial meniscectomy. Thirty-five patients returned for clinical evaluation and another eight were evaluated by questionnaire and telephone interview. Over the thirty-five-month follow-up period, progressive varus deformity and medial joint-space narrowing were not observed. Of the twenty-seven knees in Group I (non-degenerative tears) that underwent arthroscopic partial meniscectomy, satisfactory results were found in 96 per cent. Of the seventeen knees in Group II (degenerative tears) over-all satisfactory results were found in only 65 per cent. A history of pre-existing degenerative arthritis in patients with degenerative tears seemed to correlate with a less favorable outcome.

Arthroscopic meniscectomy.

A technique is described for doing arthroscopic meniscectomies using short curved instruments passed through flexible, sealable Teflon sleeves. The goal, with few exceptions, was to achieve en bloc subtotal resection of the posterior two-thirds of the meniscus. The location and character of the lesions found in this series tend to support this pattern of excision. Immediate postoperative morbidity is astonishingly less than that seen with open meniscectomy. Economic losses, including medical costs and time off work, were significantly less, and short term results compare favorably with those of conventional meniscectomy in regard to relief of symptoms and restoration of function.