Massimiliano Sorbello

Low-intensity body building exercise induced rhabdomyolysis: a case report

IntroductionRhabdomyolysis is a severe and debilitating condition that promotes muscle breakdown and is a relatively rare, not always diagnosed cause of acute renal failure (ARF) with an 8–20% reported incidence. Exertional rhabdomyolysis only appears in adult patients 24–48 h after strenuous activities as military basic training, weight lifting, and marathon running.Case presentationA 30-year-old man was admitted to our department because of weakness and painful swelling of the muscles as well as dark urine appearing 24 h after carrying out a body-building exercises of low intensity. The development of an acute exertional rhabdomyolysis was confirmed by the increased serum enzyme levels and myoglobinuria. The patient was treated with intravenous sodium chloride, and sodium bicarbonate. The nephrotoxicity of myoglobin was decreased by forced alkaline diuresis.ConclusionThe reported case emphasizes the occurrence of acute rhabdomyolysis even in those who underwent a low-intensity exercise. A proper treatment is mandatory to avoid a sudden worsening of clinical conditions eventually evolving to acute renal failure.

Two-as-one Monolateral Dual Kidney Transplantation

OBJECTIVES Dual kidney transplantation (DKT) of marginal kidneys could offer transplant candidates a very satisfactory kidney transplantation in terms of renal function. However, DKT might be considered a major surgical procedure and, in older recipients, has a potentially greater risk of surgical complications compared with single kidney transplantation. Because of these findings, some transplant centers have replaced the classic bilateral placement of 2 kidneys with the monolateral placement of both kidneys. METHODS In a group of 35 DKTs performed during a 5-year period, we applied a new technique of monolateral placement of DKT in 10 recipients. In these 10 patients, the arteries and veins of the 2 kidneys were joined through a running suture, and the joined kidneys were anastomosed into the external iliac vessels in the recipient. RESULTS The delayed graft function rate was 20%. No surgical complications developed in the entire series. One patient experienced late rejection with ureteral stricture. The graft and patient survival rate at a median follow-up of 30 months was 90%. CONCLUSIONS To reduce the surgical risk and morbidity rate, the monolateral placement of both kidneys seems the safest method to perform DKT. The joined monolateral DKT, by reducing the cold ischemia time and the surgical trauma, could represent a step forward in the delicate treatment of these patients.

Contamination of preservation fluid in kidney transplantation: single-center analysis.

INTRODUCTION Contamination of preservation fluid is common, with a reported incidence of 2.2% to 28.0%, and may be a major cause of early morbidity after transplantation. Herein, we report our experience with routine examination of preservation fluid collected just before implantation, focusing on the rate of contamination and the clinical consequences to recipients. MATERIALS AND METHODS We analyzed 62 samples of preservation fluid for microbial and fungal contamination. RESULTS Twenty-four samples (38.7%) were contaminated with at least 1 organism. Bacterial contamination alone was observed in 18 samples; all patients received prophylactic treatment with intravenous piperacillin/tazobactam, 4.5 g/d for 10 days, without clinical sequelae. Six samples were contaminated with Candida species; all patients received prophylactic treatment with fluconazole, 100 mg/d for 3 months. One patient developed reversible acute renal failure due to ureteral obstruction by fungus balls at 30 days after transplantation. CONCLUSION Contamination of preservation fluid occurs frequently after kidney transplantation. Bacterial contamination evolved without symptoms in most patients treated with prophylactic antibiotic therapy. Fungal contamination may be potentially life-threatening. However, graft nephrectomy is not mandatory if the involved Candida species is identified correctly and appropriate antifungal therapy is rapidly prescribed.

Anaesthesiological implications of Kimura's disease: a case report

IntroductionKimuras disease is a chronic inflammatory condition belonging to the angio-lymphatic proliferative group of disorders, usually affecting young men of Asian race, but is rare in Western countries. It is a benign but locally injurious disease, of unknown aetiology, whose classical clinical features are a tumour-like swelling, usually in the head and neck, with or without satellite lymphadenopathy, often accompanied by eosinophilia and elevated serum IgE.Case presentationWe report the case of a 33-year-old Caucasian woman with an atypical localization of Kimuras disease, discussing the anaesthesiological implications and reviewing the current literature on Kimuras disease.ConclusionsThe diagnosis of Kimuras disease can be difficult and misleading, and anaesthesiological precautions could be ignored. Patients with this disease are often evaluated for other disorders: unnecessary diagnostic tests and investigations, or even surgery, may be avoided by just being aware of Kimuras disease.

Successful combination of Rituximab and plasma exchange in the treatment of cryoglobulinemic vasculitis with skin ulcers: a case report

IntroductionType II mixed cryoglobulin syndrome is a systematic vasculitis mainly linked to immune complex deposition in several organs and to hepatitis C virus infection. Therapeutic strategies can target either the viral trigger hepatitis C virus if present, or pathogenic events downstream the triggering infection, e.g, the proliferation B-cells directly. Antiviral therapy should be considered as a first-line treatment in many HCV-positive patients. However, it may prove ineffective, contraindicated, or poorly tolerated. The other available treatment [such as cytotoxic agents, steroids] may lead to life-threatening complications and may be difficult to manage in the long term.Case presentationWe report on a 75-year-old patient with long-lasting hepatitis C virus infection [18 years], a long-lasting cryoglobulinemia [7 years] resistant to common antiviral therapy, diabetes mellitus and deep skin ulcers, successfully treated with the combination therapy of Rituximab and plasma exchange.ConclusionPlasma exchange in combination with Rituximab may be useful to heal skin in those patients who are non responsive to Rituximab alone, by avoiding a leg amputation.

Wound levobupivacaine continuous infusion for postoperative analgesia in living kidney donors: case-control study.

INTRODUCTION The objective of this study was to evaluate the efficacy of an analgesic regimen based on levobupivacaine continuous infusion into the surgical wound of living kidney donors (LKDs). PATIENTS AND METHODS Fifty adult LKDs (mean age, 53.1 +/- 5.3 years; age range, 52-68 years) were retrospectively assigned to a no wound infusion (NWI) group (n = 25) or a wound infusion (WI) group (n = 25). At the end of surgery, patients in the WI group received 10 mg intramuscular morphine; a peridural catheter was placed 10 cm between the intercostal muscles fibers close to the lower rib extremity, and a solution of levobupivacaine, 150 mg/100 mL, was started at 5 ml/h(-1). Patients in the NWI group received intramuscular morphine, 10 mg, every 8 hours; intravenous tramadole, 100 mg, was planned as a rescue drug for incidental pain. Pain was measured using a visual analog scale (VAS) ranging from 1 (no pain) to 10 (maximum pain) in both the basal condition (VASb) and during coughing (VASc) at 1 hour after leaving the operating room and 6, 12, and 24 hours thereafter. RESULTS At 1, 6, 12, and 24 hours, VASb values in the NWI vs the WI group were 5.2 vs 3.1, 6.8 vs 4.1, 5.8 vs 4.9 (all p < .01), and 5.4 vs 5.1, respectively, and VASc values were 8.2 vs 6.3, 8.8 vs 5.9, 7.1 vs 5.3, and 6.8 vs 5.1 (all p < .01). Mean VAS score was significantly higher between 1 and 6 hours in the NWI group for all VASb measurements vs VASc values. Tramadole consumption was higher in the NWI group than in the WI group. CONCLUSIONS Continuous wound infusion with 5 mL/h(-1) levobupivacaine, 1.5 mg/mL(-1), resulted in a safe and effective analgesic protocol in LKDs both in the immediate postoperative period and in the first day after surgery, a result that was more effective than a morphine-tramadole regimen. No adverse effects were recorded, which confirmed the safety of the technique. It is probable that better results could be achieved with dedicated administration devices.

Effect of N-Acetyl-Cysteine (NAC) Added to Fenoldopam or Dopamine on End-Tidal Carbon Dioxide and Mean Arterial Pressure at Time of Renal Artery Declamping During Cadaveric Kidney Transplantation

N-acetyl-cysteine (NAC) is known to be a powerful antioxidant used to prevent renal damage. Our deceased-donor kidney transplantation protocol administered an NAC bolus at the time of declamping of the renal artery to reduce the potential oxidative damage with ischemia-reperfusion. The aim of injury this study was to compare the effects of NAC added to a continuous infusion of either fenoldopam or dopamine during kidney recipient anesthesia on mean arterial pressure (MAP) and end-tidal carbon dioxide (ECO(2)), which were assumed to be expressions of oxidative and acid-base status. One hundred forty patients undergoing deceased donor kidney transplantation were enrolled in the study. Using a standardized perioperative anesthesia protocol, the patients were divided into 4 groups: group N, receiving an NAC (50 mg/kg) bolus just before renal artery declamping (n = 40); group C, not receiving any NAC or other infusion (n = 20); group NF, same treatment as group N plus fenoldopam (0.1 microg/kg/min) continuous infusion (n = 40); and group ND, same treatment as group N plus dopamine (3 microg/kg/min) continuous infusion (n = 40). We recorded the duration of kidney cold and warm ischemia and EtCO(2) and MAP values before and after arterial declamping, as well as subjective evaluations of graft perfusion and the incidence of early or delayed graft function and adverse events. EtCO(2) was higher and MAP lower in group C compared with group N; comparing groups N, ND, and NF, the NF regimen resulted in lower EtCO(2) and higher MAP values and a greater incidence of early graft function. Subjective evaluation of graft perfusion was more favorable for groups N, ND, and NC, particularly for NF. No significant periprocedural adverse events were recorded in the groups. In our experience, the association of an NAC bolus at the time of renal artery declamping and continuous infusion of fenoldopam resulted in a minor, though non-significant, increase in EtCO(2) values, higher MAP, and greater incidence of early graft function during deceased-donor kidney transplantation compared with no NAC or NAC plus renal-dose dopamine. Further studies are necessary to better define the potential role of oxidative damage in renal ischemia- reperfusion injury, including implications for outcome, as well as the potential role of the combination of NAC plus fenoldopam as a nephroprotective and outcome-modulating regimen.

Sirolimus-Based Immunosuppression in Kidney Transplantation for Type 2 Diabetic Nephropathy

Introduction: Kidney transplantation is the best replacement therapy of type 2 diabetic patients and recently similar graft and patient survival between diabetic and nondiabetic recipients has been reported. However, standard immunosuppressive protocols are lacking. We present our experience with sirolimus-based immunosuppression in a population of 24 type 2 diabetic patients who underwent a kidney transplantation. Patients and Methods: From January 2001 to December 2006, 396 kidney transplantations were performed. Twenty-four patients had type 2 diabetes mellitus as a cause of end-stage renal disease. They were randomized in two groups: thirteen patients (group A) received an immunosuppressive treatment with sirolimus, low-dose tacrolimus and steroids, while 11 patients (group B) received sirolimus, mycophenolate mofetil and steroids. Results: Clinical characteristics were similar between the two groups. A slightly better kidney functionality was observed in group B patients. There were neither acute rejection episodes nor severe infectious complications in both groups. One patient in each group underwent a foot amputation. Graft and patient survival was 100% for both groups at a median follow-up of 29 months. Conclusions: Sirolimus-based immunosuppression is safe and efficacious in type 2 diabetic patients who underwent a kidney transplantation, allowing a better glucose metabolism control.

Anaesthesiologic protocol for kidney transplantation in two patients with Fabry Disease: a case series

Fabrys Disease is a rare genetic syndrome, with a classic X-linked alpha -galactosidase A deficiency phenotype, responsible for glico-sphyngolypids metabolism impairment with clinical effects in several organs and functions. We describe the anaesthesiologic implications of two patients with Fabry disease who underwent a kidney transplantation from a deceased donor. We recommend careful preoperative evaluation, including cardiac sonography study and spirometry for Fabry disease patients, and according to our experience, we recommend advanced haemodynamic monitoring during surgery. Careful airway examination should be further performed, with particular attention to patient ventilability prediction and available alternative strategies for airway management in case of difficulties. A nephroprotective strategy and a particular care to the associated end-stage organ disease may significantly improve the long-term outcome of patients with Fabry Disease.