bluuebunny/crossref_metadata_2025 huggingface dataset:
Treatment monitoring for dialysis adequacy
Authors: Goux N.
Published: July 2012

Dialysis treatment monitoring is becoming a more common feature of recent dialysis machines, generally aimed at improving treatment tolerance and dialysis adequacy. In addition, measured parameters can give reliable information on the treatment in progress and could deliver a great help in checking whether the prescription is being delivered effectively.
Perceptions of renal nursing
Authors: Keogh A.M. , Pope J. , Anthony I. , Arnell‐Cullen V. , Hamilton M.
Published: July 2012

Recruitment and retention of nursing staff in general, but renal nurses in particular has become an increasing problem in Britain in recent years. This study set out to measure nurses' attitudes to and understanding of renal nursing and explore the image of renal nursing. The methodology used included focus group discussion and telephone interviews with both renal and non‐renal nurses. Strategies and factors, which may influence recruitment and retention of staff, are recommended.
The care of the elderly renal patient
Authors: Ashwanden C.
Published: July 2012

Do we who deliver renal care understand how old age alters mental and physical perspectives and are we able to meet the changing needs of our increasing elderly dialysis population? This paper examines the need for a review of the care of our ageing renal population and how the physiological and the psycho‐social needs of the elderly change and asks how far do we understand these changes. How can we as nurses support our elderly patients through the changes that affect them, as they grow older? The findings of this paper show that the Renal Health Care team is not fully conversant with the physiological or mental changes that old age makes to the body. The conclusion is that because the renal population is growing older, the Renal Team needs to be more aware of the changes which occur as people grow older and to deliver care acknowledging these changes.
Competency based standards for advanced practice in nephrology nursing
Authors: Stewart G. , Bonner A.
Published: July 2012

The purpose of this paper is to present the outcomes of a nationwide nursing research project in Australia. Utilising the Delphi technique, ninety‐four clinically based nephrology nurses reviewed a series of competency based standards documents. The purpose of this research was to reveal the ways in which nephrology nurses practice at an advanced level. The results will facilitate the way in which advanced practice nephrology nursing is understood and inform nursing curricula development.
Preventing hypoxaemia during haemodialysis: Oxygen therapy and bicarbonate profiling
Authors: Leggate P.
Published: July 2012

summary

This study was undertaken, because in the Haemodialysis Unit, where this author practices, patients with a history of cardiovascular disease and who undergo routine maintenance haemodialysis were exhibiting signs and symptoms of hypoxaemia, such as agitation, restlessness, yawning and eventual collapse. The experience itself is described by the patients involved as terrifying and therefore should be a priority in their Nursing Care Plan. It should be remembered however that the bicarbonate profile used in the programme should reflect the results of predialysis blood samples and altered accordingly. Haemodialysis induced hypoxaemia has been reported many times and several investigations have confirmed the occurrence of this phenomenon. In this study, the concern is how to prevent patients from experiencing this event.
A nursing view of future haemodialysis anticoagulation treatments
Authors: de Vos J‐Y.
Published: July 2012

summary

The purpose of prescribing anticoagulation therapy in haemodialysis treatments ‐ extracorporeal treatments in general ‐ is to avoid coagulation of blood within the extracorporeal circuit. I.e. catheter/needle(s), bloodlines, artificial kidney/haemofilter. In this paper we differentiate between chronic treatments and acute treatments. The methods of anticoagulation are quite similar in both groups, except for specific preferences and adapted dose.
The access flowmonitor: A great step forward
Authors: van Loon M.
Published: July 2012

summary

Access to the circulation is of vital importance to haemodialysis patients. Proper care and monitoring of fistulas therefore has a positive effect on their quality of life. The dialysis nurse has an important role in the care and monitoring of access. With little effort and means she or he can obtain information on the functioning of fistulas. Others cannot ignore this information, and each coagulated fistula can be considered a missed opportunity. In the monitoring of fistulas the access flowmonitor is a valuable tool: it measures in a direct way how much blood flows through the fistula and that is exactly the information that is necessary to determine the functioning of the fistula. This instrument therefore deserves a solid embedding in the integrated care of fistulas.
Post‐implantation events of swan‐neck catheters for PD
Authors: Picó‐Vicent L. , Cases JM. , Picó‐Mira L. , Contreras JP.
Published: July 2012

summary

The first step in PD is the implantation of a peritoneal catheter, a technique that is subject to different possible incidences. We have studied the non‐infectious events or incidences (pericatheter leakage, blood tinged dialysate, catheter displacement, omental wrapping and extra‐peritoneal placement) registered in our unit during a five‐year period (1992–1996) after the implantation of 144 swan‐neck curled catheters in 100 peritoneal dialysis patients, 49 males and 51 females. 70 catheters (48.61 %) were implanted using the blind puncture method and 74 (51.39 %) with the surgical method. All the incidence rates were compared between the two methods to analyse the possible influence of the implantation technique. 21 pericatheter leaks, 19 episodes of blood tinged dialysate, 10 displacements, 7 cases of omental wrapping and 4 extra‐peritoneal placements (all of them after blind punctures carried out by young assistant doctors) were registered, with a total number of 61 incidences (0.42 per catheter). Statistically significant differences were not found either globally or for each type of event when comparing the incidence rates between the two implantation techniques, although extra‐peritoneal placement was close to significant (p = 0.053). None of the incidences were severe. 25 catheters (17.4%) had to be replaced with the removal rates being similar for both techniques. In conclusion, in our experience neither technique shows a clear advantage over the other. Experienced staff members should implant PD catheters.
An adequacy improves adequacy of dialysis
Authors: Thomson T.
Published: July 2012

summary

The role of the Adequacy Nurse is concerned with the adequacy of dialysis and nutritional status in both haemodialysis and peritoneal dialysis patients. This relatively new and unique post incorporates diverse roles, including that of practitioner, educator, researcher and change agent. The purpose of this work is to educate both staff and patients about the importance of Urea Kinetic Modelling, to enable them to participate in the process, to ensure that standards set are research based and to act as a change agent when necessary. The creation of this post has resulted in improved communication amongst nurses and the multidisciplinary team and with this increased knowledge a higher standard of care has been observed.
Treatment of water for dialysis ‐ A European survey
Authors:   For the EDTNA/ERCA Collaborative Research Programme, Lindley EJ , Lopot F , Harrington M , Elseviers MM
Published: July 2012

summary

The EDTNA/ERCA survey of the treatment of water for dialysis was the third project organised through the Collaborative Research Programme (CRP). Data was collected from 69 haemodialysis facilities in 14 countries. Water quality in European dialysis units was mainly self‐regulated. The majority of centres aimed to meet the requirements of the European Pharmacopoeia, but only 50% carried out tests to check compliance. All facilities used reverse osmosis to treat water for dialysis, most also used softening and carbon adsorption. There was a wide variation in policies for the maintenance of carbon filters, and for the control and monitoring of contamination in the distribution system. Endotoxin tests carried out in 27 facilities showed that higher levels of contamination are associated with systems that are infrequently disinfected, and also with older system designs. The survey indicated that guidelines for water treatment are urgently needed. EDTNA/ERCA guidelines for microbiological monitoring are now being drafted, additional guidelines are under consideration.
Using and developing your EDTNA/ERCA Professional Portfolio
Authors: Thomas N.
Published: July 2012

summary

A Portfolio is an instrument for continuing professional development, which can be used by all members of the multidisciplinary team. This paper describes the development of the EDTNA/ERCA Professional Portfolio and discusses how health care professionals are able to complete and utilise the Portfolio in everyday practice. A discussion on reflective practice is presented and a short example of reflective writing is given. The paper concludes with an evaluation of possible Portfolio use in teaching and management and plans for future development.
Quality assessment in nephrology nursing
Authors: van Waeleghem J.P. , Elseviers M.M. , de Vos J.Y. , van Malderen P.
Published: July 2012

summary

In order to evaluate the quality of nephrology nursing in Flanders, three quality indicators (anaemia, dialysis dose and patient satisfaction) were studied in 11 Flemish dialysis centres, including 521 haemodialysis patients. Median haematocrit (Hct) was 33.7 with 42% of patients not reaching the target level of 33. Median percentage removal of urea (PRU) was 64.8 with 52% of patients showing values below the target level of 65. PRU levels were significantly influenced by needle technique, type of vascular access, sex, duration of dialysis and diabetes The patient satisfaction questionnaire showed that most patients particularly appreciated the professional skills of the health care workers. On completing this study, we ex perienced that the regular use of well‐established indicators to assess the quality of nephrology nursing, is mandatory.
The influence of staff‐patient interactions on adherence behaviours
Authors: Zrinyi M.
Published: July 2012

The research assessed the influence of staff‐patient interactions on adherence to a dietary regimen in dialysis patients. A random sample of 147 subjects provided data on clinical, psychosocial, and demographic measures. Results indicated that staff‐patient interactions determine and predict adherence behaviours. However, the lack of association between the laboratory data and either individual adherence behaviours or staff‐patient interactions raised questions about the validity of these proxy measures of adherence. To better understand the nature of these determinant variables of adherence, more extensive research is suggested.
Investigation: Basis for nursing practice
Authors: Barrio A. Cuñado , López F. García
Published: July 2012

The term evidence based nursing signifies a systematic process of search, assessment and application of the most up‐to‐date investigation for decision taking. In practice the process can be applied in four steps: formulation of the question, a search of the bibliography, a critical analysis of the validity of the results, and putting the obtained findings into practice.

Nursing practise must be based on the best available scientific results. Professional nurses are more accustomed to acting according to tradition with scarce scientific rigour. It is necessary to introduce investigation as an instrument to allow resolution of problems with practice and to offer the best possible care alternative.

The evidence contributed by investigation is evaluated according to criteria of validity and utility. There are several scales to assess the methodological rigour of investigation studies as well as to recommend a practice or technique as appropriate, or not, according to the scientific evidence available.
Quantity versus quality: Ethics and provision of renal replacement therapy
Authors: Ashwanden Cordelia
Published: July 2012

50 years ago if one had renal failure the prognosis was certain death within a short timeframe. Now if one receives renal replacement therapy the prognosis has dramatically changed. But in this time of economic constraints and ever decreasing human resources are we now to be faced with the necessity to make choices about who receives replacement therapy?

This paper looks at the ethics of providing treatment for large numbers but at the risk of 2nd class treatment, or selection of a few to receive the best treatment possible. The author asks what is the point of choice for the provision of therapy; before treatment has begun or having started who has the right to stop treatment and should there be criteria for discontinuing this treatment? The paper examines the ethical issues facing all the health care team especially those caring for the chronically ill. The financial benefits of one kind of therapy over the other are examined and again the author puts the question, is it economics that governs the treatment prescribed, or a real choice made with knowledge? The author has found that “hands on” health care teams are still aiming to treat the ever increasing workload but at what cost? How long can we continue to accept patients for treatment when we may be putting at risk other patients and the very people who are providing the care?
Pre‐training assessment tool (JPAT) ‐ A pilot study
Authors: Chow J. , Bennett L.
Published: July 2012

A tool for assessing the suitability of candidates for home dialysis (Jo‐Pre‐training Assessment Tool ‐ JPAT) was developed. JPAT acts as a screening instrument to identify suitable candidates for the home dialysis programme, and therefore increases a patient's chance of learning to manage the programme. JPAT is in the form of an interview questionnaire consisting of 38 assessment items in six domains: physical stability, nutritional status, communication, ability to maintain self‐care, psychological suitability and social support. A pilot study was conducted (n = 20, 1996–1997) using a descriptive study design, with subjects randomly selected from an existing dialysis programme. Pearson correlation and 2‐tailed tests were employed to explore the relationship between the assessment outcome (i.e. the initial JPAT scores) and the follow up data (i.e. data collected within the seven days following the initial JPAT assessment). Many of the variables attained statistical significance (p < 0.05). The inter‐rater reliability was calculated at an average Kappa value of 0.909. Overall, results suggest that JPAT is sufficiently reliable to be used as a tool for assessing patients who suffer from ESRD.
Restless Legs Syndrome: A review for the Renal Care Professionals
Authors: Wetter Thomas C.
Published: July 2012

Restless legs syndrome is a common neurological disorder with an estimated prevalence between 2 and 10 %. It is characterised by an imperative desire to move the extremities associated with paraesthesias, motor restlessness, worsening of symptoms at rest with at least partial relief by activity, and worsening of symptoms in the evening or at night. As a consequence, patients suffer from severe sleep disturbances and, less frequently, from daytime sleepiness. The cause of restless legs syndrome remains unknown. It has been divided into idiopathic and symptomatic (secondary, e.g. uraemic restless legs syndrome) forms. Based on pharmacological, neurophysiological and imaging studies it is suggested that it is a disease of the subcortical central nervous system with involvement of the brainstem and spinal chord. Dopaminergic agents are regarded as the first choice of treatment; however, the development of augmentation of symptoms especially under levodopa therapy may be a major problem. Alternative medications are opioids and benzodiazepines.

In secondary restless legs syndrome the underlying illness should be treated first, but dopaminergic drugs may also be helpful.
The Pre‐dialysis Experience ‐ Are individual needs being met?
Authors: Andrew J.
Published: July 2012

The pre‐dialysis experience is a time of change. Individuals and their families are able to adapt to this change and altered lifestyle if their specific needs are met. This qualitative study aims to gain an understanding of the patient's perspective and identify how they manage the pre‐dialysis experience. This knowledge will enable renal unit teams to plan effective holistic programmes, which meet the needs of the individual. The emergent theory identified that predialysis patient's and their families have to accept a different view of life before they can move forward and make a decision regarding treatment. The adoption of a model for good practice aids the transition.
21st Century Home Haemodialysis: A new approach to an old treatment
Authors: Lunts P.
Published: July 2012

Home therapies are increasingly being demonstrated to be the best treatments for the early stages of the dialysis lifecycle. Although home haemodialysis has declined dramatically over the last 20 years from 41% in 1983 (1) to 3.2% in 1998 in the UK alone (2), many studies have suggested that it offers the optimum dialysis in terms of outcomes (3,4,5). Evidence from a 1998 survey of UK dialysis staff indicates that the major perceived drawbacks of home haemodialysis were lack of suitable patients, family stress, cost of machines and training time (6). The study also strongly indicated that a lack of familiarity with the treatment was a major cause of its decline in many units.

We set out to redesign our approach to home haemodialysis to make it suitable for many more patients.
Maintaining an optimum haemocatheter exit site
Authors: Wittich E.
Published: July 2012

As a result of crusty growths over some haemocatheter exit sites, it was decided to explore why these crusty scabs occur and how they could be eradicated. It is concluded that a haemocatheter exit site requires a dressing, which will maintain an optimum environment, and avoid contamination from Staphylococcus aureus. Inadine (Johnson & Johnson) a povidine iodine product, applied before the final dressing of Tielle (Johnson & Johnson Medical), a hydropolymer adhesive dressing creates an ideal environment for healing. The haemocatheter exit site can also be inspected at each dialysis session, but can in fact be left insitu for seven days.
Nutritional status, delaying progression and risks associated with protein restriction
Authors: Hartley G. H.
Published: July 2012

Low protein diets (LPD), providing ≥ 0.6 g protein/kg body weight daily, have traditionally been used in the nutritional management of chronic renal failure (CRF). Initially they were advocated when dialysis availability was limited. More recently LPD have been proposed as a means of delaying the rate of CRF progression. Despite much research in this area, the value of protein restriction remains contentious. A major concern over their use is that they may induce malnutrition. This is of critical importance since mortality rates are significantly increased in individuals who are malnourished when dialysis is initiated. Other approaches to the nutritional management of CRF may be more appropriate. The primary goal of any nutritional therapy should be to optimise the patient's nutritional status.

In the UK LPD are used in a minority of units. An alternative approach to the use of these diets is to view the prevention of malnutrition as being of paramount importance. For uraemic patients, dialysis is the best treatment.
Bye bye chemical desinfection with canisters
Authors: Pancíř;ová J.
Published: July 2012

This paper describes and evaluates disinfection techniques of dialysis monitors available in our dialysis unit. We demonstrate disinfection techniques with regards to the risk of human error. To achieve a high hygienic standard and to support the safety and efficiency of each disinfection procedure, we emphasise the use of single‐use‐disinfection cartridges.
Self‐monitoring of microbiological levels in dialysis fluids
Authors: Träger H.
Published: July 2012

Self monitoring of dialysis fluids is important. The dialysis technician has experience of the microbiological situation of the fluid systems and can make more tests for personnel safety. The tests are not expensive and are very easy to learn. It seems that the cells, which generate endotoxins, cannot be determined by the plate count system. No tanks or permanent water flow UV sterilisation in the pipeline to the dialysis machines can prevent the build up of biofilms and higher endotoxin amounts in water.
Containers for waste causing peritonitis in CAPD patients
Authors: Alscher DM. , Pfinder‐Nohe E. , Rumpf D. , Pauli‐Magnus C. , Knabbe C. , Kuhlmann U. , Mettang T. , Krankenhaus Robert‐Bosch
Published: July 2012

Fungal infection is a rare cause of peritonitis in patients on chronic peritoneal dialysis. In this population, fungi are found in less than 2 percent of all cases of primary episodes of peritonitis (1). More often, a primary bacterial peritonitis treated with antibiotic therapy leads to secondary fungal infection (2). Candida species cause 74.5% of the episodes of fungal peritonitis (2). The fungi invade the peritoneal cavity from the skin peri‐ or intraluminally through the catheter (3). Filamentous fungi are rare (4,5). Treatment of fungal peritonitis commonly consists of removal of catheter and antifungal drugs (3). Here we describe two cases of fungal peritonitis caused by mycelial fungi, where the source of the micro‐organismn could be special containers used for biological waste, which are popular in Germany.
Job‐related stress among nursing personnel in Greek dialysis units
Authors: Brokalaki H. , Matziou V. , Thanou J. , Zirogiannis P. , Dafni U. , Papadatou D.
Published: July 2012

The purpose of this study was to describe specific work‐related factors that contribute to increased levels of stress experienced by nursing personnel, and to compare their impact on nurses and assistant nurses who work in Dialysis Units (DU) to those who work in Peritoneal Dialysis Units (PDU) in Greece. The sample of the study consisted of 682 members of nursing personnel working in DU and in PDU in Greek Hospitals. The collection of data was done by means of a questionnaire. The latter included questions about the motivation of nursing personnel for having chosen to work in these units along with questions about the stress factors related to the patients and their care, the role of the nurse in the unit, and the working conditions. According to the results of the study, the percentage of nursing personnel working in DU or PDU by their own choice was 71% and 8.3% respectively, whereas the rest of the staff were placed there irrespective of their preferences, by the Administrators. Among nursing personnel who had chosen to work in DU, the reported motives that contributed to their decision were the absence of a night shift (27.8%), and working in a closed unit. The main motive that incited nursing personnel to work in PDU was the acquisition and the application of specialized knowledge. The percentage of nursing personnel working in DU that expected high levels of job satisfaction was 77%, whereas the corresponding percentage for nursing personnel working in PDU was 65%. However, only 44% and 37% of the nursing personnel working in DU and PDU reported high levels of job satisfaction. The most important stressors related:

To the patient: were the risk of contamination (79% DU, 84% PDU) and the death of a patient (77% DU, 80% PDU).

To the role of nursing personnel in the unit: were increased responsibilities (65% DU, 37% PDU), low involvement of the nursing personnel in decision making (58% DU, 54% PDU), and low professional status of nursing personnel.

To the working conditions: were the shortage of nursing personnel (74% DU, 99% PDU), limited material (74% DU, 57% PDU), the closed environment (75% DU, 64% PDU) and the daily work routine (78% DU, 61% PDU).

In conclusion, we can say that working in DU and PDU provokes increased stress in nursing personnel, even though the implicated stress factors differ between these units.
The relationship between interdialytic weight gain and patient compliance. A single centred cohort study (n=21)
Authors: Casey J. , Johnson V. , McClelland P.
Published: July 2012

Haemodialysis patients are subject to many restrictions and face a lifetime attempting to adhere to various regimes. This small study was designed to explore the relationship between fluid gain, compliance and staff reinforcement. This was achieved by measuring dietetic and nursing educational input using interdialytic weight gain as a barometer of patient compliance. This study suggests renal nurses, dietitians and other members of the multi‐disciplinary team may have less influence than previously assumed.
Continuous venovenous haemodialysis: A study of 84 cases
Authors: Ureña Galipienzo T.
Published: July 2012

Slow continuous therapies are the choice treatment in critically ill patients with acute renal failure (ARF). Over 4 years (1994‐97) we retrospectively studied 84 intensive‐care unit patients suffering from ARF and multiple organ failure, and treated with continuous venonenous haemodialysis (CVV‐HD). The main cause of ARF was sepsis (59.3%). The global mortality was 88% and the patients who died were older than the survivors (p = 0.004). The main cause of dialyser change was the ratio FUN/BUN ≤ 0.8 (61.6%); this ratio was calculated from the quotient filtrate urea nitrogen / blood urea nitrogen (urea nitrogen = urea / 2.14). Most patients (94.8%) treated with initial replacement fluid infusion didn't show falls in blood pressure (BP).

Conclusions: 1. The mortality was higher in elderly patients. 2. In most cases the monitoring FUN/BUN ratio allowed recovery of the patient's blood before clotting in the extracorporeal circuit. 3. The replacement fluid infusion at the beginning of the CVV‐HD procedure contributes to patient's haemodynamic stability, because BP usually falls due to excessive ultrafiltration.
Vascular Access: A role for a renal nurse clinician
Authors: Waterhouse D.
Published: July 2012

The team approach to the delivery of healthcare is important and has become more so since the boundaries between professional groups have become blurred. Renal replacement therapy requires that patients have adequate access. This could be in the form of an arterio‐venous fistula, a graft, or a vascular catheter. Doctors have historically always provided access for patients. Placement of vascular access is a lengthy process often causing long delays and anxiety. Due to the reduction in junior doctors hours and the further demands on senior medical staff, a nurse was nominated and developed the role of vascular access specialist and clinician.

Before the development of the nurse clinicians' role, the situation in this centre regarding venous access for haemodialysis was based on an ad hoc arrangement between junior doctors. Historically surgeons and medical staff have always provided vascular access for haemodialysis. However, it was felt that a suitably educated renal nurse would be more suitable to develop this role, and a relevant course, (MSc in Advanced Nursing Practice) had been developed at a nearby university.

The access role included the insertion of both short and long‐term vascular access catheters. An access referral pathway is now in place, giving a streamlined service. A designated access specialist nurse now inserts vascular access, providing focused individualised care specifically targeted at the renal patients' needs.

Because of the success of this role, four more nurses are being supported to undertake the clinical MSc. The aim is to develop other areas of renal provision and to provide a nurse led specialist individualised service in line with the future National Service Framework. The role has also provided scope for nursing career development, giving motivation to experienced clinical nurses who wish to remain clinically involved, improve the care for patients and progress their career.
The Renal Diabetic Nurse Specialist… A luxury or an essential player?
Authors: Marchant K.
Published: July 2012

Diabetic Nephropathy is the single largest cause of Chronic Renal Failure. As the number of patients referred to a nephrologist increase, the needs of many diabetic nephropaths are not being met.

The post of Renal Diabetes Nurse Specialist (DNS) was instituted in September 1999 to organise the management of and to meet all aspects of need of this group of patients.

The role currently incorporates a daily ward round with the aim of reviewing all patients at least once during every admission to hospital. Ward‐based teaching with the patients occurs and six nurse‐led clinics covering all modalities are now in place and run alongside the Nephrologist. Patients are either referred directly to the nurse‐led clinic or are approached by the renal DNS whilst the patient is in the nephrology clinic.

71.4% of our diabetic patients have an improvement in their HbA1c after 21 months of working closely with the Renal DNS and multidisciplinary team. The average HbA1c at the beginning was 9.7%; the average is now 8%.

It is clear that the role is being continuously stretched to its absolute limit. Our aim is to develop a broader service over time and we will, in the near future be employing a renal nurse with an interest in diabetes to work alongside the DNS for six months to particularly learn about the needs of our in‐patients.
N = the sample size: please handle with respect!
Authors: Elseviers Monique M.
Published: July 2012

During the study period of one year, all new patients (n = 251) starting chronic renal failure treatment were included… This sentence can be the start of a study report and the most basic information is already given: n = 251. The sample size of this study was 251, meaning that 251 new dialysis patients were investigated within the framework of this study.
A practical approach to the molecular biology of kidney diseases: From basic science to bed side
Authors: Garrido P. , Vélez E. , Izquierdo A. , Matthews J. , Gutiérrez‐Tarrés Ma. A. , Luna P. López , Bover J. , Bosch R. J.
Published: July 2012

Nowadays, the term “Molecular Biology”(MB) is generally applied to the biochemical processes that involve genes and the expression of proteins for which specific genes code. In recent years, astonishing advances have occurred in this field. Currently, there are many important powerful techniques allowing scientists to study the molecular mechanisms involved in many human genetic diseases. Furthermore, it is important to underline that the possibilities are not limited to the diagnosis and study of these genetic diseases. Indeed, by studying gene expression, MB also allows the molecular study of many acquired diseases such as viral hepatitis and cancer. Therefore, these major advances in the knowledge of gene biology are facilitating the arrival of a new era of gene therapy.

This article will describe the most important techniques currently used in MB. Firstly, techniques involved in recombinant DNA technology will be discussed and these will include the study of DNA and the possibility of identifying the expression of abnormal genes, e.g. to identify individuals for paternity. Secondly, a description of techniques designed to study the expression of genes and their regulation will follow and they involve the study of RNA. Thirdly, the impact of genetic molecular studies as tools for medical diagnosis will be discussed and analysed. Finally, a discussion concerning the rational basis for gene therapy and its future perspectives is included.

In this article, we have focused on technical or diagnostic aspects of Molecular Biology. Although Ethics are also an interesting issue to deal with, theseissues are far beyond the scope of this review.
Chemical additives in new RO systems
Authors: Gietman H.
Published: July 2012

Recent analysis of water and dialysate samples shows that due to new RO systems chemical substances can migrate into the osmotic water. A large number of tests have shown that there are no additives in drinking and softened water, but that the problem arises after the RO system. For the tests, samples were taken in the drinking water, after the softener and after the RO system. When the problem was located there were also samples taken from a similar water treatment system, and further samples were taken from two identical RO systems from another supplier. Instead of an RO system that removes all kind of substances, we're now confronted with systems that add volatile aromatic carbon hydrogens. Further tests have shown that dialysate contains the same level of these carbon hydrogens. It seems that even after having primed the artificial kidney in the blood compartment carbon hydrogens are present.

The effects of these substances can be alarming because levels have been found equal to limits that are being proposed for drinking water under new European legislation.

Is this the moment to look at our RO water quality level, and state new limits for new additives, should we work out new prescriptions for water quality or should we let the rules remain as they are?
The influence of bacteria in dialysis water on its endotoxin level
Authors: Träger H.
Published: July 2012

The influence of bacteria in dialysis water and its endotoxin level is one of the main important issues of purified water for haemodialysis. The current methods, assessing the number of water bacteria, are insufficient; due to their large diversity, only a small fraction of them grow on our used culture agars. Bacterial cells are classified into three categories: the A cells represent cultivable cells, B cells are living though not cultivable whereas the C cells are dead cells. Methods assessing these different cell categories are discussed. Endotoxin is only released from the C‐type cells and is removed by the Reverse Osmosis membranes. It is our task to ensure that we keep the A‐cell level low after the Reverse Osmosis. The purified water must not remain very long in the pipe system and the use of Permeate tanks should be avoided.
Patient flow analysis and referrals — how 1,137 ESRD patients started dialysis during 1998–1999
Authors: Paris V. , Ballerini L.
Published: July 2012

The study consisted in collecting and analysing data from 15 dialysis centres on referral modalities of 1,137 patients with end‐stage renal failure starting renal replacement therapy. All the centres in question had implemented PFA Patient Flow Analysis®, a management programme for pre‐dialysis care from Baxter designed to help improve the collection of data on dialysis patients, from the first visit to a centre through to the start of renal replacement therapy.

The aims of the study were threefold:

describe patient referral modalities and the eligibility of patients for renal replacement treatment;

determine how many early referrals (ERs)* and late referrals (LRs)* have a permanent PD (Peritoneal Dialysis) or HD (Haemodialysis) access at the first treatment;

for the main outcomes (permanent access at the first treatment and permanent dialysis treatment), compare the performance of centres that offer enhanced education with those that do not.

The main characteristics (sex and age) of ERs (54%) are comparable to those of LRs. However, ERs generally have greater access to PD or the opportunity to choose the dialysis treatment. The vast majority (86%) have permanent access at the first dialysis treatment and a large number (44%) have PD as permanent dialysis treatment. Centres with structured pre‐dialysis educational programmes experience a larger number of ERs, therefore ensuring better outcomes. For example, 66.3% of patients at centres with structured pre‐dialysis educational programmes (compared to 48.2% at centres without enhanced education) start the dialysis treatment with permanent access; and more patients (40% vs. 22%) receive permanent PD.
Evaluation of blood recirculation in catheters for haemodialysis and its relation to blood circuit pressures
Authors: Montero R. Crespo , Cuesta R. Casas , Muñoz Navarro Ma.C. , Contreras Ma.D. , Garrido I. Alguacil , Bermúdez E. López
Published: July 2012

The objectives of this study were to evaluate the degree of blood recirculation (REC) in venous catheters for dual lumen haemodialysis, and its relation to the drop in arterial line pressure and return venous pressure during haemodialysis. A total of 25 catheters were evaluated (15 temporary 15 cm catheters, and 10 permanent tunnelled 32 cm catheters). REC was calculated using a blood temperature monitor. With blood flow stabilised at 250 ml/min, the session was initiated and the following was determined: real blood flow, drop in arterial line pressure (pre‐pump pressure), positive pressure and blood recirculation.

Mean blood recirculation in the total of catheters was 6.4 ± 3%, mean real blood flow was 230 ± 9 ml/min. Mean blood pressure was −146 ± 52 mmHG. Mean positive pressure was 127 ± 47 mmHG. A strong correlation was found between real flow and arterial pressure (r = 0.79, p < 0.01), and between arterial pressure and blood recirculation (r = −0.57, p < 0.01). Comparing the variables studied, a lower degree of REC (5.2±2 vs. 8.5±3, p < 0.01), a higher real blood flow (234 ± 7 vs. 223 ± 7, p < 0.01) and a lower drop in arterial pressure (–127 ± 49 vs. −180 ± 40, p < 0.05) were found in temporary catheters than in permanent catheters. No differences were observed in positive pressure.

As a conclusion, these results suggest that blood recirculation is lower in temporary catheters than in permanent tunnelled catheters. This is related to a lower drop in pre‐pump blood pressure and a higher real blood flow. However, positive pressure does not seem to influence the degree of blood recirculation in venous dual lumen catheters for haemodialysis.
Causes of late leaks in peritoneal dialysis patients
Authors: Albaz M. , Kantarcı G. , Tuglular S. , Tercüman N. , Tetik G. , Özener C.
Published: July 2012

Background/Aims: Late dialysis leakage is an important complication of peritoneal dialysis. The aim of our study was to investigate the causes of late leaks in patients on peritoneal dialysis.

Methods: 25 patients (19 F: 6 M; mean age: 56 ± 14) with and 25 patients (10 F: 15 M; mean age: 57 ± 12) without dialysis leakage on maintenance peritoneal dialysis treatment were included in the study. Data on demographic characteristics including age, sex, body mass index, body surface area, primary renal disease and peritoneal dialysis characteristics including implantation technique of the catheter, site of the catheter, time from catheter implantation to initiation of peritoneal dialysis, daily total filling volumes, use of hypertonic solutions, membrane transport properties and total and peritoneal creatinine clearances were retrospectively collected for both groups.

Results: The number of female vs. male patients (76% vs. 40%, p < 0.05) and patients on CAPD vs. APD (68% vs. 56%, p < 0.05) were significantly higher in the group with dialysis leakage. Patients with leakage also had lower average transport properties (p < 0.05) and lower total creatinine clearances (p < 0.05). Other demographic and peritoneal dialysis characteristics were similar in both groups.

Conclusions: Female gender and CAPD as opposed to male gender and APD are the risk factors involved in the development of late dialysis leaks. Peritoneal membrane transport characteristics as well as total creatinine clearance also seems to influence the development of complications.
Continuing CAPD after herniotomy
Authors: Tast C. , Kuhlmann U. , Stölzing H. , Alscher D. , Mettang T.
Published: July 2012

There is still controversy as to whether PD‐treatment can be safely continued after herniotomy (HT). Many nephrologists withhold PD‐treatment for several weeks after HT in fear of dialysate leakage and/or hernia recurrence.

We report on 12 patients (2 women, 10 men) in whom HT was performed either for umbilical (n = 6), inguinal (n = 6) or open processus vaginalis (n = 3). Surgery was performed according to the Lichtenstein method with insertion of a Marlex‐mesh and ligation of the hernia sac. In all patients PD treatment was paused for the day of surgery and 1 to 3 days postoperatively, depending on RRF. Low volume (1.0 to 1.5 l) and high frequency exchanges (6 exchanges per day) were started for several days with a gradual reinstitution of the former PD‐regimen within the next 2 to 4 weeks.

All patients did well rapidly with no uraemia‐or dialysis‐related complications. No leakage and no hernia recurrence could be observed 3 months thereafter. None of the patients had to be haemodialysed intercurrently. In conclusion, continuing a modified regimen of PD‐treatment after HT seems to be safe and comfortable for the patient.
Anticoagulation therapy in acute renal failure extracorporeal treated patients
Authors: De Vos J‐Y.
Published: July 2012

In extracorporeal techniques, as used for Acute Renal Failure (ARF) treatments, blood is constantly exposed to foreign surfaces. These foreign surfaces include the catheter(s), blood tubings, the dialyser membrane and all artificial materials used for such techniques in general.

Blood begins to clot as soon as it strikes a foreign surface. The foreign surface initiates the clotting process. The extracorporeal circuit is prone to clotting during acute treatments unless some form of anticoagulation is employed. On the other hand, this specific group of patients is often at increased risk of bleeding (cfr. Post‐operative patients and post‐renal‐transplant patients, patients with Multiple Organ Failure (MOF) often including liver disturbances). It should be kept in mind that patients with renal failure have a defect in platelet function resulting in altered platelet‐vessel wall interaction. Over time, as the extracorporeal treatment progresses, the platelets become more adhesive or sticky. The blood becomes more likely to clot.

Performing effective therapy with low bleeding risk in ARF patients is a challenge requiring knowledge, skills and experience.
Ethical aspects of withdrawing/withholding renal replacement therapies on patients in acute renal failure in an intensive care unit
Authors: Draper H.
Published: July 2012

The majority of patients being treated for acute renal failure in intensive care units have multiple medical problems. Accordingly, the withdrawal of renal replacement therapies should be considered as part of a general decision about whether to initiate or continue with treatment per se. Several guidelines on withdrawing and withholding therapy have been produced and some common themes emerge: concerns to avoid euthanasia, potential for benefit, patient consent (shared decision‐making), team consensus/decision‐making, and the provision of appropriate palliative care and resource implications. Each of these is considered in turn, although the word limit for this paper does not permit detailed exposition.
Nutritional aspects of Acute Renal Failure
Authors: Hoogerwerf M.
Published: July 2012

The patient with acute renal failure is a very ill patient suffering from high urea levels causing poor appetite, nausea and vomiting. These patients are usually treated with a low sodium, low protein and, if the potassium in the blood is high, with a low potassium diet (1). This paper discusses whether or not this is the correct treatment.

The symptoms of high urea levels in the blood together with increased needs for energy and protein makes it very hard to prevent the patient becoming malnourished. Often energy‐enriched drinks are necessary to achieve recommendations and it is prudent to let the patient eat and drink what they desire. By calculating the energy and protein needs and comparing these with the intake and the state of illness and by following the patient's body weight over time we can obtain information about the state of nourishment. When we alter the food that's offered we achieve better intake and reduce the risk of malnourishment.
RISING TO THE CHALLENGE OF EFFECTIVE LEADERSHIP
Authors: Maclean M.
Published: July 2012

Taking on the role of Senior Sister within a rapidly developing haemodialysis unit has been an inspiring challenge. The role inherited minimal numbers of staff, many of who were overworked and disgruntled with no clear direction. The increase in patient activity and the growing demand for renal replacement therapy had the potential to effect the quality of patient care. The need to provide effective leadership for staff, whilst maintaining a ‘hands‐on’ clinical influence within the role had become evident.

A transformational leadership style as described by Bass (1) was adopted. Bass believed that transformational leaders envisage organisational goals in order to motivate followers to do their best and perform beyond their own expectation. The inspiration of a shared vision was paramount in order to build a nursing team enthused, uplifted and enabled to rise to the challenge of local reform. The role boundaries of the senior nursing staff were reviewed with a focus on supporting the development and clarification of the role of Team Leader.

A strategy was successfully implemented to strengthen leadership. Through providing a support network for all grades of staff, a team culture has been fostered, improving morale and job satisfaction.

Without effective leadership, support and encouragement, nurses could potentially withdraw from the emotional demands of the patients and loose sight of the intellectual challenges of everyday practice. Furthermore, this strategy has been a useful tool to encourage recruitment of staff, whilst providing a structure to develop today's skills in preparation for tomorrow's leaders.
PITY? WHAT CHRONICALLY ILL CHILDREN REALLY NEED
Authors: Rauch‐Elnekave H. , Gabbai N. , Spitz M. , Weissman I.
Published: July 2012

It is difficult not to ‘pity’ children who suffer from a chronic illness. It is, indeed, heartbreaking to see an innocent child suffer. What motivates this almost universal response? Is it useful and/or helpful? In this paper we propose that ‘pitying’ chronically ill children — i.e., lowering expectations, reducing reasonable demands, excessive gift‐giving, etc. — serve primarily to assuage adults' feelings of helplessness and guilt and result in children who are unhappy and have difficulty living up to their true potential. To illustrate our point, we present three examples of children with end‐stage renal disease (ESRD), two whom pity weakened and one whom lack of pity strengthened.

The children we discuss below are patients in the Division of Paediatric Nephrology at Western Galilee Hospital in Nahariya, Israel where a collaborative project was established to meet the psychosocial needs of children on dialysis, children who have undergone transplantation and their families. The project, whose goal is to improve children's quality of life and to help them to grow up to be productive adults, provides psychological consultation to children, families and staff as well as social work interventions within medical settings and in the community (1).