Acute reactions to polysulfone/polyethersulfone dialysers: literature review and management.

Acute dialyser reactions in patients treated by haemodialysis are uncommon. We present two cases of such reactions, both in patients using a polysulfone, steam-sterilised dialyser. Patient 1 suffered from recurrent attacks of acute dyspnoea, hypoxia and hypotension that occurred early in dialysis sessions, whereas patient 2 presented with unexplained episodes of severe hypotension and vomiting in the initial phases of dialysis. After switching to a cellulose triacetate dialyser, both patients became asymptomatic during all subsequent dialysis sessions, but intentional (patient 1) and accidental (patient 2) rechallenge with the polysulfone dialyser induced an immediate recurrence of the symptoms. A literature search yielded 30 additional cases that have been reported since the turn of the century. All dialysers that provoked acute reactions contained membranes belonging to the polyarylsulfone family (polysulfone/polyethersulfone, PSu/PESu). Manifestations, usually occurring within the first 30 minutes of dialysis, included dyspnoea (69%), hypotension (66%), hypoxia (44%), bronchospasm (25%), chest pain (22%), pruritus and/or urticaria (22%) and abdominal symptoms (22%). Of the 32 patients, 14 were switched to a different PSu/PESu containing dialyser, which resulted in cross-reactivity in 12 of them (~85%). They could be treated safely with dialysers containing substituted cellulose (n = 8) or polyacrylonitrile (n = 4). Sixteen patients were successfully switched directly to a dialyser containing substituted cellulose (n = 11), polymethylmethacrylate (n = 4) or polyacrylonitrile (n = 1). Two patients were lost to follow-up. As rechallenges may be harmful, patients with acute reactions to PSu/PESu membranes should not be further tested in a trial-and-error fashion with similar membranes, but be switched directly to a non-PSu/PESu dialyser.

Fluoxetine combined with a serotonin-1A receptor antagonist reversed reward deficits observed during nicotine and amphetamine withdrawal in rats.

The symptom of "diminished interest or pleasure" in rewarding stimuli is an affective symptom of nicotine and amphetamine withdrawal, and a core symptom of depression. An operational measure of this symptom is elevation of brain reward thresholds during drug withdrawal. We report here that acute co-administration of fluoxetine, a selective serotonin reuptake inhibitor, and p-MPPI, a serotonin-1A receptor antagonist, alleviated the diminished interest in brain stimulation reward observed during withdrawal from nicotine or amphetamine in rats (i.e., increased reward). By contrast, the same drug combination treatment did not reduce the somatic signs of nicotine withdrawal indicating symptom-specific neurobiological abnormalities. Surprisingly, the same treatment had opposite effects in control rats where reductions in reward were produced, suggesting that animal models should be based primarily on studying specific deficits that are pathognomic of a psychiatric disorder. The reversal of the affective aspects of drug withdrawal by a treatment that enhances serotonin neurotransmission indicates that decreased serotonergic function may mediate the reward decrements characterizing nicotine and amphetamine withdrawal, and that these symptoms may be homologous to a core symptom of non-drug-induced depressions.

Live donor nephrectomy and return to work: does the operative technique matter?

BACKGROUND: Several studies report an earlier return to work after minimal invasive kidney donation compared to open donor nephrectomy. However, this variation in outcome might be influenced by other factors than the surgical technique used, such as the advice given by the physician regarding return to work. In this study, we compare the absence from work after open (ODN), laparoscopic (LDN), and hand-assisted donor nephrectomy (HA) performed in the Netherlands, in relation to the advice given. METHODS: Questionnaires containing questions about return to work or return to daily activities were sent to 78 donors from three hospitals. In the HA and ODN hospitals, advice on full return to work was 3 months. In contrast, advice given in the LDN hospital was 6 weeks. RESULTS: After LDN, donors resumed their work after 6 weeks, 5 weeks faster compared to ODN (p = 0.002) and HA (p <0.001). Complete return to work occurred 9 weeks sooner in the LDN group compared to the ODN and HA groups (both p <0.001). In the unemployed group, there was no significant difference in length until full return to daily activities. CONCLUSION: Return to work is influenced by the advice on return to work given by the physician as well as the morbidity associated with the surgical approach.

Comparison of hemodialysis and peritoneal dialysis survival in The Netherlands.

Considerable geographic variation exists in the relative use of hemodialysis (HD) vs peritoneal dialysis (PD). Studies comparing survival between these modalities have yielded conflicting results. Our aim was to compare the survival of Dutch HD and PD patients. We developed Cox regression models using 16 643 patients from the Dutch End-Stage Renal Disease Registry (RENINE) adjusting for age, gender, primary renal disease, center of dialysis, year of start of renal replacement therapy, and included several interaction terms. We assumed definite treatment assignment at day 91 and performed an intention-to-treat analysis, censoring for transplantation. To account for time dependency, we stratified the analysis into three time periods, >3-6, >6-15, and >15 months. For the first period, the mortality hazard ratio (HR) of PD compared with HD patients was 0.26 (95% confidence interval (CI) 0.17-0.41) for 40-year-old non-diabetics, which increased with age and presence of diabetes to 0.95 (95% CI 0.64-1.39) for 70-year-old patients with diabetes as primary renal disease. The HRs of the second period were generally higher. After 15 months, the HR was 0.86 (95% CI 0.74-1.00) for 40-year-old non-diabetics and 1.42 (95% CI 1.23-1.65) for 70-year-old patients with diabetes as primary renal disease. We conclude that the survival advantage for Dutch PD compared with HD patients decreases over time, with age and in the presence of diabetes as primary disease.