A Critical Reassessment of the Kidney Risk Caused by Tetrastarch Products in the Perioperative and Intensive Care Environments

Purpose: To reassess the results of former meta-analyses focusing on the relationship between novel HES preparations (130/0.4 and 130/0.42) and acute kidney injury. Previous meta-analyses are based on studies referring to partially or fully unpublished data or data from abstracts only. Methods: The studies included in the former meta-analyses were scrutinized by the authors independently. We completed a critical analysis of the literature, including the strengths, weaknesses and modifiers of the studies when assessing products, formulations and outcomes. Results: Both the published large studies and meta-analyses show significant bias in the context of the deleterious effect of 6% 130/0.4-0.42 HES. Without (1) detailed hemodynamic data, (2) the exclusion of other nephrotoxic events and (3) a properly performed evaluation of the dose-effect relationship, the AKI-inducing property of 6% HES 130/0.4 or 0.42 should not be considered as evidence. The administration of HES is safe and effective if the recommended dose is respected. Conclusions: Our review suggests that there is questionable evidence for the deteriorating renal effect of these products. Further well-designed, randomized and controlled trials are needed. Additionally, conclusions formulated for resource-rich environments should not be extended to more resource-scarce environments without proper qualifiers provided.

Reinterpreting Renal Hemodynamics: The Importance of Venous Congestion and Effective Organ Perfusion in Acute Kidney Injury

The significance of effective renal perfusion is relatively underemphasized in the current literature. From a renal standpoint, besides optimizing cardiac output, renal perfusion should be maximized as well. Among the several additional variables of the critically ill, such as intra-abdominal pressure, the presence of venous congestion and elevated central venous pressures, airway pressures generated by mechanical ventilation do affect net renal perfusion. These forces represent both a potential danger and an ongoing opportunity to improve renal outcomes in the critically ill and an opportunity to move beyond the simplified viewpoint of optimizing volume status. Therefore, to optimize nephron-protective therapies, nephrologists and intensive care physicians should be familiar with the concept of net renal perfusion pressure. This review appraises the background literature on renal perfusion pressure, including the initial animal data and historical human studies up to the most current developments in the field, exploring potential avenues to assess and improve renal blood supply.

The value of combined hemodynamic, respiratory and intra-abdominal pressure monitoring in predicting acute kidney injury after major intraabdominal surgeries

Background: The incidence of postoperative acute kidney injury (AKI) is predominantly determined by renal hemodynamics. Beside arterial blood pressure, the role of factors causing a deterioration of venous congestion (intraabdominal pressure, central venous pressure, mechanical ventilation) has emerged. The value of combined hemodynamic, respiratory and intra-abdominal pressure (IAP) monitoring in predicting postoperative acute kidney injury has received only limited exploration to date.

Methods: Data were collected for adult patients admitted after major abdominal surgery at nine Hungarian ICUs. Hemodynamic parameters were compared in AKI vs. no-AKI patients at the time of admission and 48 h thereafter. Regarding ventilatory support, we tested mean airway pressures (Pmean). Effective renal perfusion pressure (RPP) was calculated as MAP−(IAP + CVP + Pmean). The Mann–Whitney U and the chi-square tests were carried out for statistical analysis with forward stepwise logistic regression for AKI as a dependent outcome.

Results: A total of 84 patients (34 ventilated) were enrolled in our multicenter observational study. The median values of MAP were above 70 mmHg, IAP not higher than 12 mmHg and CVP not higher than 8 mmHg at all time-points. When we combined those parameters, even those belonging to the ‘normal’ range with Pmean, we found significant differences between no-AKI and AKI groups only at 12 h after ICU admission (median and IQR: 57 (42–64) vs. 40 (36–52); p < .05). Below it’s median (40.7 mmHg) on admission, AKI developed in all patients. If above 40.7 mmHg on admission, they were protected against AKI, but only if it did not decrease within the first 12 h.

Conclusions: Calculated effective RPP with the novel formula MAP−(IAP + CVP + Pmean) may predict the onset of AKI in the surgical ICU with a great sensitivity and specificity. Maintaining effective RPP appears important not only at ICU admission but during the next 12 h, as well. Additional, larger studies are needed to explore therapeutic interventions targeting this parameter.

Estimation of the severity of breathlessness in the emergency department: a dyspnea score

Background

Dyspnea is a frequent complaint in emergency departments (ED). It has a significant amount of subjective and affective components, therefore the dyspnea scores, based on the patients’ rating, can be ambiguous. Our purpose was to develop and validate a simple scoring system to evaluate the severity of dyspnea in emergency care, based on objectively measured parameters.

Methods

We performed a double center, prospective, observational study including 350 patients who were admitted in EDs with dyspnea. We evaluated the patients’ subjective feeling about dyspnea and applied our Dyspnea Severity Score (DSS), rating the dyspnea in 7 Dimensions from 0 to 3 points. The DSS was validated using the deterioration of pH, base-excess and lactate levels in the blood gas samples (Objective Classification Scale (OCS) 9 points and 13 points groups).

Results

All of the Dimensions correlated closely with the OCS values and with the subjective feeling of the dyspnea. Using multiple linear regression analysis we were able to decrease the numbers of Dimensions from seven to four without causing a significant change in the determination coefficient in any OCS groups. This reduced DSS values (exercise tolerance, cooperation, cyanosis, SpO2 value) showed high sensitivity and specificity to predict the values of OCS groups (the ranges: AUC 0.77–0.99, sensitivity 65–100%, specificity 64–99%). There was a close correlation between the subjective dyspnea scores and the OCS point values (p < 0.001), though the scatter was very large.

Conclusions

A new DSS was validated which score is suitable to compare the severity of dyspnea among different patients and different illnesses. The simplified version of the score (its value ≥7 points without correction factors) can be useful at the triage or in pre-hospital care.

Renal blood supply and fluid therapy

There are different underlying mechanisms of acute kidney injury (AKI) in various type of shock, but restoration of renal blood flow (RBF) is crucial in prevention of AKI. The first 24-48 hours of shock seem to be critical. Monitoring of global RBF and its intrarenal distribution is not possible in current clinical practice. The only way for optimization of renal blood supply is optimization of macrohemodynamics. In volume-responsive AKI, fluid therapy restores kidney function. Many clinical signs and parameters can be of use in determining the volume status. The accuracy of the assessment may be improved with the help of tools quantifying the clinical parameters (e.g. hypovolemic index – HVI). The basis of intravenous fluid therapy are crystalloids, and their effect is reported to be shorter than 120 min. Every form of hydroxyethyl starch has been shown to be harmful for patients at risk of impaired renal function. In sepsis, the boundary between volume-responsive and volume-unresponsive AKI is blurred. Fluid responsiveness can be lost in the course of AKI as early as on the first day of sepsis. According to the results of the ARDS Network study, the conservative approach in fluid therapy resulted in a shorter time of mechanical ventilation and did not affect the renal function, except for a slight increase of the serum creatinine level. Fluid overload is to be avoided, as renal venous and lymphatic congestion can limit the urine filtration rate, further worsening edema.

A sarcopenia prevalenciája, valamint az egészség- és életmódbeli tényezőkkel való kapcsolata a tartós ellátást nyújtó intézményekben élő idősek körében

Introduction: Earlier studies dealing with sarcopenia were conducted among community-living or hospitalized older adults; however, to date, study focusing on older adults living in institutions providing long-term care is lacking. Aim: The aim of this study was to describe the prevalence of sarcopenia and its associations with lifestyle and health factors among older people living in institutions providing long-term care. Method: Two hundred five individuals participated in the study. Sarcopenia was diagnosed based on muscle mass, muscle strength and functional performance. The independent variables were functional mobility, protein intake, smoking, current physical activity, and physical activity when middle-aged, multimorbidity, and falls in the previous year. Univariate models and a multivariate model were used to assess associations. Results: In total 73 participants had sarcopenia. Sarcopenia was associated with smoking, multimorbidity, physically active lifestyle when middle aged, and functional mobility. Conclusion: This study showed that lifestyle factors and health condition have important roles in the prevalence of sarcopenia. Orv. Hetil., 2016, 157(46), 1847–1853.

Short-term and long-term effects of nordic walking training on balance, functional mobility, muscle strength and aerobic endurance among Hungarian community-living older people: a feasibility study

AIM

The aim of this study was to investigate the short-term and long-term effects of a moderate intensity nordic walking program, and the feasibility of this exercise form among Hungarian community-living older adults.

METHODS

Forty one community-living older adults aged over 60 years (mean 67.5, SD 4.8 years) participated in a nordic walking program consisting of a 10-week supervised period and a 25-week unsupervised period. The age and gender matched control group did not receive any types of exercise programs. The balance, functional mobility, lower limb strength, and aerobic endurance were measured at baseline, after 10 weeks and after 25 weeks.

RESULTS

The balance, the functional mobility and the aerobic endurance significantly improved in the nordic walking group (P=0.001; P=0.04; P<0.0001, respectively), whereas there were significant deteriorations in the control group. In terms of lower limb muscle strenght (including iliopsoas, quadriceps, gluteus muscles, and hamstring muscles) we could not demonstrate improvement (P=0.274).

CONCLUSION

This study showed that nordic walking is a simple, well-tolerated and effective physical activity for older people in Hungary. Based on the findings of our studies, the nordic walking will play an important role in geriatric physiotherapy in order to improve or maintain the functional abilities of this growing population.

Effects of a multimodal exercise program on balance, functional mobility and fall risk in older adults with cognitive impairment: a randomized controlled single-blind study

BACKGROUND

Exercise programs have important role in prevention of falls, but to date, there are conflicting findings about the effects of exercise programs on balance, functional performance and fall risk among cognitively impaired older adults. AIM. To investigate the effects of a multimodal exercise program on static and dynamic balance, and risk of falls in older adults with mild or moderate cognitive impairment.

DESIGN

A randomized controlled study.

SETTING

A long-term care institute.

POPULATION

Cognitively impaired individuals aged over 60 years.

METHODS

Eighty-six participants were randomized to an exercise group providing multimodal exercise program for 12 months or a control group which did not participate in any exercise program. The Performance Oriented Mobility Assessment scale, Timed Up and Go test, and incidence of falls were measured at baseline, at 6 months and at 12 months.

RESULTS

There was a significant improvement in balance-related items of Performance Oriented Mobility Assessment scale in the exercise group both at 6 month and 12 month (P<0.0001, P=0.002; respectively). There was no statistically significant increase in gait-related items of Performance Oriented Mobility Assessment scale after the first 6-month treatment period (P=0.210), but in the second 6-month treatment period the POMA-G score improved significantly (P=0.001). There was no significant difference between groups regarding falls.

CONCLUSION

Our results confirmed that a 12-month multimodal exercise program can improve the balance in cognitively impaired older adults.

CLINICAL REHABILITATION IMPACT

Based on our results, the multimodal exercise program may be a promising fall prevention exercise program for older adults with mild or moderate cognitive impairment improving static balance but it is supposed that more emphasis should be put on walking component of exercise program and environmental fall risk assessment.

Adapted physical activity is beneficial on balance, functional mobility, quality of life and fall risk in community-dwelling older women: a randomized single-blinded controlled trial

BACKGROUND

Exercise programmes have important role in prevention of falls, but to date, we have little knowledge about the effects of Adapted Physical Activity programme on balance of older women.

AIM

The aim of this study was to investigate the effects of an Adapted Physical Activity programme on balance, risk of falls and quality of life in community-dwelling older women.

DESIGN

This was a randomized controlled study.

SETTING

Community, in a local sport centre.

POPULATION

Older women aged over 60 years.

METHODS

Seventy-six women were randomised to an exercise group providing Adapted Physical Activity programme for 25 weeks or a control group (in which they did not participate in any exercise programme). The one-leg stance test, Timed Up and Go test, incidence of fall and the quality of life (SF-36V2) were measured at baseline and after 25 weeks.

RESULTS

The one-leg stance test and the Timed Up and Go test in the exercise group was significantly better than in the control group after the intervention period (P=0.005; P=0.001, respectively). The Physical Functioning, Vitality and General Health subdomains of quality of life were also significantly better in the exercise group compared to the control group (P=0.004; P=0.005; P=0.038, respectively). Relative risk was 0.40 (90% CI 0.174 to 0.920) and the number needed to treat was 5 (95% CI 2.3 to 23.3).

CONCLUSION

This 25-week Adapted Physical Activity programme improves static balance, functional mobility, as well as Physical Functioning, Vitality and General Health subdomains of quality of life.

CLINICAL REHABILITATION IMPACT

Based on our results, the Adapted Physical Activity programme may be a promising fall prevention exercise programme improving static balance and functional mobility for community-dwelling older women.

The effect of functional movement ability on the quality of life after total hip replacement

AIMS AND OBJECTIVES

To analyse in detail the relationship between the movement and generic health-related quality of life (HRQoL) indicators and the subjective feeling of health of the patients, as well as the objective movement parameters measured by the surgeon and the patient's opinion about the success of the total hip replacement (THR).

BACKGROUND

We have only limited information about the effect of mobility function improvement on the HRQoL several years after THR. We have recently found that after THR postoperative health awareness is influenced mainly by cardiovascular diseases, but the effects of the movement parameters on the subsequent feelings of well-being were not examined.

DESIGN

Retrospective longitudinal study.

METHODS

This study involved 109 patients who had had THR. The patients' health status and objective and subjective mobility function at the time of operation and five years later were evaluated using questionnaires (including EQ-5D and WOMAC scores) and the hospital database.

RESULTS

All components of EQ-5D and WOMAC had significantly improved by Year 5 in patients who experienced a complete recovery after the operation, but not the mobility and pain components of EQ-5D for those patients who felt an improvement only in their subjective mobility function. The surgeon-assessed parameters and use of walking aids showed a similar distribution in patients who considered themselves to be healthy or only moderately sick five years after THR.

CONCLUSION

Successful THR significantly improves the feeling of well-being and the mobility function of patients even five years after the operation. In individual cases, however, other subjective and objective factors, but not the mobility function, have a major influence on the HRQoL.

RELEVANCE TO CLINICAL PRACTICE

Five years after successful THR, nursing care has to focus not only on the further improvement of the mobility but on strengthening the subjective feeling of the patient's well-being and health.

Epidemiology of postoperative acute kidney injury in Hungarian intensive care units: an exploratory analysis

BACKGROUND

The aim of this study was to evaluate the incidence and outcome of postoperative acute kidney injury (AKI) after major noncardiac surgery in Hungarian intensive care units (ICUs).

METHODS

We conducted an analysis of a multicenter survey on the epidemiology of AKI in Hungarian ICUs in respect of surgical interventions. The cohort study consisted of all patients (n = 295) over the age of 18 years who were admitted to ICUs after surgery between 1 October 2009 and 30 November 2009. AKI was defined and classified by the acute kidney injury network (AKIN) criteria.

RESULTS

Forty-eight (18.1%) patients had AKI during their ICU stay. By AKIN criteria, 27 (10.2%) patients were in stage 1, 11 (4.2%) patients in stage 2, and 10 (3.8%) patients in stage 3. The overall mortality rate of AKI was 39.6% (AKI 1: 25.9%, AKI 2: 40%, and AKI 3: 54.5%; p < 0.001) and the ICU mortality rate was 33.3% (AKI 1: 18.5%, AKI 2: 10%, and AKI 3: 54.5%; p < 0.001). According to logistic regression analysis, age (OR: 1.048; CI: 1.014-1.082; p = 0.005), vasopressor treatment (OR: 9.751; CI: 8.579-10.923; p < 0.001), sepsis (OR: 10.791; CI: 9.353-12.233; p = 0.001), serum-creatinine peak-concentration (OR: 1.035; CI: 1.021-1.047; p < 0.001), and intra-abdominal surgery (OR: 2.558; CI: 1.75-3.366; p = 0.020) were independent predictors for AKI.

CONCLUSIONS

The results of this study confirm that there is a high incidence of AKI following major noncardiac surgery, which is associated with higher ICU and in-hospital mortality.

Cardiovascular diseases and the health-related quality of life after total hip replacement

AIMS AND OBJECTIVES

To evaluate to what degree total hip replacement, or co-morbidities or their progression, influence the health-related quality of life of patients after the operation. We have looked for an objective method to reflect the severity of cardiovascular diseases and to better characterise the health-related quality of life of patients with total hip replacement.

BACKGROUND

The main weakness of the different health-related quality of life methods that are applied to the analysis is the lack of information regarding the contributory role of co-morbidities, especially cardiovascular diseases.

DESIGN

Retrospective longitudinal study.

METHODS

This study involved 109 patients who had had total hip replacement. The patients' health status - objective and subjective functional performance at the time of operation and five years later - was evaluated using questionnaires (including EQ-5D and Western Ontario and McMaster Universities' Ostoearthritis Index scores) and the hospital database. An Objective Cardiovascular Classification grouping was developed to evaluate the deterioration of cardiovascular diseases.

RESULTS

The subjective assessment of the patients' health status at Year 5 revealed highly significant differences between healthy and sick patients in respect of EQ-5D and Objective Cardiovascular Classification but not in the case of the Western Ontario and McMaster Universities' Ostoearthritis Index scores. Evaluating postoperative subjective health awareness, a higher sensitivity and specificity and a significantly better individual-discriminating role was demonstrated in Objective Cardiovascular Classification vs. EQ-5D.

CONCLUSION

After successful total hip replacement postoperative health awareness is influenced mainly by existing and developing cardiovascular diseases. It seems to be the case that for patients with significant hypertension, ischaemic heart disease or chronic heart failure, even successful surgery will not improve the patients' overall feeling of health.

RELEVANCE TO CLINICAL PRACTICE

Nursing care of patients with total hip replacement, in respect of cardiovascular diseases, can contribute a better health-related quality of life.

Epidemiology of acute kidney injury in Hungarian intensive care units: a multicenter, prospective, observational study

Background

Despite the substantial progress in the quality of critical care, the incidence and mortality of acute kidney injury (AKI) continues to rise during hospital admissions. We conducted a national, multicenter, prospective, epidemiological survey to evaluate the importance of AKI in intensive care units (ICUs) in Hungary. The objectives of this study were to determine the incidence of AKI in ICU patients; to characterize the differences in aetiology, illness severity and clinical practice; and to determine the influencing factors of the development of AKI and the patients' outcomes.

Methods

We analysed the demographic, morbidity, treatment modality and outcome data of patients (n = 459) admitted to ICUs between October 1^st, 2009 and November 30^th, 2009 using a prospectively filled in electronic survey form in 7 representative ICUs.

Results

The major reason for ICU admission was surgical in 64.3% of patients and medical in the remaining 35.7%. One-hundred-twelve patients (24.4%) had AKI. By AKIN criteria 11.5% had Stage 1, 5.4% had Stage 2 and 7.4% had Stage 3. In 44.0% of patients, AKI was associated with septic shock. Vasopressor treatment, SAPS II score, serum creatinine on ICU admission and sepsis were the independent risk factors for development of any stage of AKI. Among the Stage 3 patients (34) 50% received renal replacement therapy. The overall utilization of intermittent renal replacement therapy was high (64.8%). The overall in-hospital mortality rate of AKI was 49% (55/112). The ICU mortality rate was 39.3% (44/112). The independent risk factors for ICU mortality were age, mechanical ventilation, SOFA score and AKI Stage 3.

Conclusions

For the first time we have established the incidence of AKI using the AKIN criteria in Hungarian ICUs. Results of the present study confirm that AKI has a high incidence and is associated with high ICU and in-hospital mortality.

[Role of cardiovascular disorders in quality of life after total hip replacement]

This cohort, retrospective study, in the Jávorszky Ödön Hospital, Vác, Hungary, involved 109 patients after total hip replacement.

METHODS

The applied questionnaires included the EQ-5D health-related quality of life scores, the Western Ontario and McMaster Universities Ostoearthritis Index (WOMAC) scores, the preoperative and the postoperative 5th year health characteristics. The severity of co-morbidities was graded in respect of clinical signs and pharmacological treatment.

RESULTS

The WOMAC values significantly improved in the examination period. However - in spite of the changes in EQ-5D -, it had no influence on adherence of feeling sick after total hip replacement. Among the co-morbidities, the cardiovascular diseases had a distinguished role because their prevalence and deterioration showed a close relationship with the subjective health-feeling of the patients.

CONCLUSION

According to our study, we have to consider that in case of significant hypertension, ischemic heart diseases or chronic heart failure even the successful surgery will not improve the general sick-feeling of the patients.

[Principles of intensive care in severe acute pancreatitis in 2008]

Acute pancreatitis is a dynamic, often progressive disease; 14-20% require intensive care in its severe form due to multiorgan dysfunction and/or failure. This review was created using systematic literature review of articles published on this subject in the last 5 years. The outcome of severe acute pancreatitis is determined by the inflammatory response and multiorgan dysfunction - the prognostic scores (Acute Physiology and Chronic Health Evaluation, Glasgow Prognostic Index, Sepsis-related Organ Failure Assessment, Multi Organ Dysfunction Syndrome Scale, Ranson Scale) can be used to determine outcome. Clinical signs (age, coexisting diseases, confusion, obesity) and biochemistry values (serum amylase, lipase, C-reactive protein, procalcitonin, creatinine, urea, calcium) have important prognostic roles as well. Early organ failure increases the risk of late abdominal complications and mortality. Intensive care can provide appropriate multi-function patient monitoring which helps in early recognition of complications and appropriate target-controlled treatment. Treatment of severe acute pancreatitis aims at reducing systemic inflammatory response and multiorgan dysfunction and, on the other side, at increasing the anti-inflammatory response. Oral starvation for 24-48 hours is effective in reducing the exocrine activity of the pancreas; the efficacy of protease inhibitors is questionable. Early intravascular volume resuscitation and stable haemodynamics improve microcirculation. Early oxygen therapy and mechanical ventilation provide adequate oxygenation. Electrolyte and acid-base control can be as important as tight glucose control. Adequate pain relief can be achieved by thoracic epidural catheterization. Early enteral nutrition with immunonutrition should be used. There is evidence that affecting the coagulation cascade by activated protein C can play a role in reducing the inflammatory response. The complex therapy of acute pancreatitis includes appropriate antibiotics, thrombo-embolic prophylaxis and in certain cases plasmapheresis and/or haemofiltration. Reducing intraabdominal pressure may be necessary in the acute phase. Intensive care multidisciplinary teamwork can reduce the mortality of severe acute pancreatitis from 30% to 10%.

Intramucosal pH monitoring during liver transplantation

PURPOSE

To apply tonometry as a quick estimation of the early liver graft function.

PATIENTS AND METHODS

Forty-five liver-transplanted patients were examined. Data were collected prospectively and analysed retrospectively. According to the early graft function, patients were classified into two groups: in group 1 (n = 28) adequate graft function, in group 2 (n = 17) deteriorated graft function was detected in the early post-operative period. Complete conventional and volumetric haemodynamic monitoring and intramucosal pH (pHi), regional CO2 tension (PrCO2) measurements were performed during surgery and until the 36 hours post-operatively.

RESULTS

In group 2 the packed blood cell, fresh frozen plasma consumption intraoperatively, and the time of hepatectomy were significantly higher; ICU treatment days, respiration time was longer and mortality rate was higher. Almost the whole examination period pHi was mostly below 7.3 and PrCO2 above 50 mmHg in group 2. There were significant differences in pHi between the groups from the preparation phase until the 24th post-operative hour. In group 2, there were significantly lower values in cardiac output in the whole examination period and in the mean arterial pressure values in the revascularization phase. In group 1, the oxygen delivery values were significantly higher in the preparation phase and oxygen consumption values after revascularization phase. With regression analysis there were no significant correlations between pHi, PrCO2 and global haemodynamic parameters.

CONCLUSION

Regional parameters were completely different from global haemodynamic parameters, therefore pHi and PrCO2 can be a good indicator of the early liver graft dysfunction.

Analysis of systemic and regional procalcitonin serum levels during liver transplantation

Elevated procalcitonin (PCT) levels are observed early after orthotopic liver transplantation (OLTx). The aim of this study was to evaluate the changes in systemic and regional PCT serum levels from the time of organ harvesting until the early postoperative phase of OLTx ( n=28) and to investigate the prognostic suitability of postoperative changes in PCT level for the outcome of OLTx ( n=61). Only in seven of 28 donors were higher PCT levels found (0.84+/-0.43 ng/ml). During organ preservation, hepatectomy, and in the anhepatic phase, the PCT levels were in the normal range; in 11 of 28 cases hepatic vein PCT levels were higher during graft flush with own blood than the systemic or portal vein samples at the same time (1.27+/-0.43 ng/ml vs 0.16+/-0.26 ng/ml and 0.23+/-0.15 ng/ml, respectively, P<0.02). The elevation of PCT levels began immediately after graft reperfusion (1.04+/-0.77 ng/ml vs 0.27+/-0.22 ng/ml, P<0.001), and the levels at postoperative day 2 were significantly higher in the case of postoperative complications (30.6+/-19.6 ng/ml vs 4.8+/-3.6 ng/ml, P<0.001).

Effect of recipients' peri-operative parameters on the outcome of kidney transplantation

In this prospectively collected data base multifactorial study, the influence of the peri-operative recipients' parameters on the transplanted kidney function were examined. One hundred and twenty-one patients who underwent first cadaver kidney transplantation in our unit were involved and were followed up for another 2 yr. The recipients were divided into three groups. Group I, patients with non-functioning grafts, group II, with delayed graft function, and group III, with good graft function. All routinely measured parameters were involved in the examination. The pre-operative haematocrit level differed significantly among the three groups. Significant intra-operative differences were found among the three groups in mean arterial pressure, (group I: 81 +/- 31 mmHg, group II: 90 +/- 24 mmHg, vs. group III: 108 +/- 26 mmHg, p < 0.01) at 5 min before revascularisation. The patients who had better post-operative kidney function, had lower pre-operative haematocrit level, and higher blood pressure in the different phase of operation, than those who had post-operative kidney function problems. The second warm ischaemic time in Group III was significantly shorter than in group I. (Group I: 51.5 min vs. group II: 47 min, vs. group III: 46.3 min, p < 0.001). Rejection rate was higher during the first 5 post-operative days in patients with non-functioning grafts. (Group I: 53% and group II: 24% vs. group III: 12% p < 0.001). The other examined parameters had not differed significantly among the three groups. The kidney function differences observed in the early (first 5 d) post-operative period, remained similar at the end of the next 2 yr. According to our results the peri-operative fluid-balance is one of the most important factors which may influence the success of the kidney transplantation.

[Bronchoscopic evaluation of pulmonary complications following kidney transplantation]

The authors evaluated the efficiency of bronchoscopy in kidney transplanted patients with late pulmonary complications (mean 370 days after transplantation). The bronchoscopy was made meanly 9.5 days after recognizing pulmonary diseases, in that time 7 patients were mechanically ventilated. In 15 cases therapy guided by the cytological, histological and microbiological results has been hoped to improve outcome. This study suggest that bronchoscopy might be important in the diagnosis of the late pulmonary complications of kidney transplanted patients.

The results of 1009 kidney transplantations performed in Hungary

Kidney transplantation is a widely used method throughout the world for the treatment of end-stage renal disease. Following the pioneering work of Szeged Medical University Hospital and Miskolc District General Hospital, the first successful kidney transplantation in Hungary was performed at the Department of Transplantation and Surgery at Semmelweis Medical University on November 16, 1973. This patient is still alive with a functioning kidney graft after 21 years. We report herein our review of the global results of Hungarian kidney transplantation. Hungary is a medium-developed country with a population of over 10 million where the gross national product is about 4000 U.S. dollars per person per year. In Hungary there are 49 dialysis centers, 4 immunological laboratories, and 4 transplantation centers.

Tissue oxygenation: another aspect of the Fick equation

Substituting the formulas of O2 delivery (DO2) and O2 extraction ratio (O2ER) into the Fick equation, a new equation representing tissue oxygenation is obtained: VO2 = DO2 X O2ER. This aspect of the Fick equation is important in clinical practice as it provides a reliable picture of tissue oxygenation if all related variables are examined together.