H. Noble and K. Rees, Barts and The London NHS Trust, London, UK

Address for correspondence
Helen Noble
C/O Devonshire Ward
The Royal London Hospital
Whitechapel Rd
London E.1 1BB

Biodatas
Helen Noble BSc, DMS has experience with renal patients dating back to 1990. In 1995 she completed her degree in nursing and a diploma in management. She has also completed a certificate in counseling. Helen has been a Senior Sister on a renal ward, Modern Matron of renal in-patient services and more recently has taken on the role of Specialist Practitioner Renal Supportive Care. Part of her role has been the establishment of a Supportive Care Service for those renal patients who have opted not to have dialysis. Helen has been editor of the EDTNA Journal since 2004 and English co-editor since 2000. She is presently undertaking her PhD.

Katy Rees has been working in nephrology for 14 years and commenced her career in Cardiff, University Hospital of Wales. She then moved to The Royal London Hospital in 1997 where she joined the Renal Directorate. She worked as the senior ward sister on the transplant ward, and then took on the role of Discharge Liaison Sister. She has an interest in Renal Supportive care. Presently Katy is seconded to the anaemia team.

Key words
Supportive care; Palliative care; Audit; Recommendations; Advance directives; Dying

R. James, Dialysis Unit, Barts and The London NHS Trust, London, UK

Address for correspondence
Ray James
Hanbury Dialysis Unit
The Royal London Hospital
Whitechapel
London , E1 1BB
UK

Biodata
Ray James, BSc, PGDip (EDM), Dip. Pol. Con. is the renal technical manager at Barts and The London NHS Trust, London and has worked in renal technology since 1978. He has been actively involved in the UK Association of Renal Technologists with particular interest in developing and promoting technician education.

Key Words
Core Curriculum; Design; Outcomes; Technology

Summary
Working within the multi-professional team, the renal technicians play a greater part in the functioning of renal units than in other less technical areas of care. The role of the renal technician has been changing and, is now one that often combines technical, scientific and clinical knowledge in utilizing technology so that the long-term outcomes of the patient are optimised and complications reduced. Therefore a sound knowledge base is vital in ensuring patients' safety.

Whilst still centered on the traditional engineering functions such as equipment repair and maintenance, the curriculum is structured to give a broad overview of renal related physiology, chemistry, treatment modalities and technology.  The inclusion of these more clinical aspects in the curriculum reflects the change in the technician’s role to a more science-based approach.

Y. White^* and G. Fitzpatrick^+
* Lecturer, Department of Nursing, University of Wollongong, Wollongong New South Wales, Australia
⁺ Clinical Nurse Specialist, Oncology, Illawarra Health Service, Shoalhaven Sector, Community Health, Wollongong New South Wales, Australia

Address for correspondence
Yvonne White,
Department of Nursing,
The University of Wollongong,
Wollongon,
NSW 2522.
Australia
White@uow.edu.au

Biodatas
Yvonne White, RN, Renal Certificate, BN, MN (Hons) is a full time academic and maintains her clinical practice as a renal nurse on a casual basis. Currently she is undertaking her PhD studies, and is a member of the Renal Society of Australasia. Yvonne’s research interests are the emotional well-being and quality of life in those people with established renal failure.

Genevieve Fitzpatrick RN, BHSc (Nurs) is a community based nurse and has been employed as a Clinical Nurse Consultant in Palliative Care, and is now the Clinical Nurse Specialist for Oncology.

Key words
Dialysis; Supportive care; Palliative care; Decision making

Summary
There are over 7,000 people on dialysis in Australia and this is predicted to increase due to the ageing population and the high incidence of diabetes mellitus. Discontinuation of dialysis is the second most frequent cause of death in dialysis patients in Australia. Risk factors for the discontinuation of dialysis include: co-morbidities (especially diabetes mellitus) and being older. Because the decision to discontinue dialysis is a major life choice, collaborative decision making should be encouraged, and the patient needs assurances of the continuation of care and kindness, a palliative care plan, and the alleviation of suffering. Patients decide to discontinue dialysis because of an unacceptable quality of life, depression and a chronic failure to thrive. Health professionals need to support end of life decision making using an ethical decision framework. A review of current literature was undertaken and revealed a paucity of information in regard to palliation in those with end stage renal disease who had discontinued from dialysis. The fear of dying, pain, suffering, and abandonment that a patient and/or their family may perceive as being associated with death may create barriers to decisions to discontinue with dialysis treatments. Therefore health care personnel should provide information with honesty to allow the patients to predict their quality of life and death. Support for the patient and family during the dying period should be multi-disciplinary, with clear and timely communication between all members of the team.

Roland Van Dam, Kliniek St Jan, Renal unit, Brussels, Belgium

Address for correspondence
Roland Van Dam
Kliniek St. Jan
Kruidtuin, 32
1000 Brussels
Belgium
E-mail: roland.vandam@advalvas.be

Biodata
Roland Van Dam has worked as a renal nurse since 1984. He is in charge of the low care renal unit AZ St Maria – Halle, Belgium. Roland participated in one of the previous Renal Disaster Relief Task Force (RDRTF) missions (third group) in Turkey, in 1999.

Key Words
Earthquake; Renal Disaster Relief Task force; Acute Renal Failure; Rhabdomyolisis; Scouting team

Summary
Following an earthquake, an International stream of help is launched. Teams of nephrologists, renal nurses and technicians from many European countries are ready as volunteers to come into action when needed. Basic help is necessary but what is the benefit of nephrologists and renal nurses, as the Renal Disaster Relief Task Force comes into action? The scouting team assesses the situation in the disaster area. Treatment of acute renal failure, hyperkalemia and Crush syndrome is life saving. The ability to accommodate dialysis treatment is investigated, in collaboration with local nephrologists.

Belgian, French, Irish and Turkish colleagues who made up two teams, with Médecins sans Frontières (MsF) left for Pakistan following the devastating earthquake in October 2005. This is a report from one of the volunteers from the first team explaining the individual contribution that his mission made to the disaster.

Althea Mahon, EDTNA/ERCA President (2004–2006), London, UK

The number of patients with chronic kidney disease (CKD) has reached epidemic proportion and is anticipated to rise further. CKD affects approximately 10% of the population^1,2. Worldwide, it is estimated that over 1.1 million patients with end stage renal disease (ESRD) currently require maintenance dialysis and this number is increasing at a rate of 7% per year³. The most common cause of chronic renal failure is diabetic nephropathy. In the UK the incidence of ESRD has doubled over the last ten years and has now reached 101 patients per million of population (pmp). This is below the European and USA averages of approximately 135 and 336 pmp respectively⁴. Studies such as the NHANES (National Health and Nutrition Examination Survey), which provided data on an adult unselected population, estimate that 4.7% of US adults have CKD stage 3 or higher (defined as estimated glomerular filtration rate (eGFR) < 60ml/min/1.73m2). They also estimate that up to 11% of the general population (19.2 million) has some degree of CKD1. Similarly, a study of 112,215 UK General Practice patients gave a prevalence at 4.9%^5,6.

The rise in diagnosis of CKD is multifactorial. With improvements in technology and medical interventions, people are living longer and this is impacting on all chronic disease populations. CKD prevalence increases with age⁷ and men with CKD have a more rapid decline in renal function and progression of their renal disease than women⁸. The incidence of diabetes has reached epidemic proportions throughout the world with an expected to almost double in the number of patients with type 2 diabetes in the next 25 years. This in turn will lead to an increased incidence of diabetic nephropathy, with approximately 30% of people progressing to stage 5 CKD. Some ethnic populations have a higher prevalence and incidence of CKD, such as South Asians in the UK⁹ and Afro-Carribeans¹⁰. Afro-Caribbeans and Africans are at greater risk of CKD due to their higher prevalence of hypertension¹¹. Lastly the rise may also be due to the development of guidelines and simple blood test-based formulae (e.g. eGFR) that allow for easier and earlier diagnosis of CKD and therefore increased reporting.

Risk factors for CKD include diabetes, cardiovascular disease, smoking, obesity, sedentary lifestyle, and low socio-economic status. UK, USA and Swedish studies have shown a higher incidence of CKD in deprived areas^12-15. Obesity has become a global issue in developed countries adding to the population of people with chronic disease. Those with diabetes and hypertension are at greatest risk and have a higher rate of renal problems than those in the normal population¹⁶. In the UK diabetic nephropathy accounts for 18% of new patients commencing renal replacement therapy and makes up 11% of the prevalent patient population. Use of the internationally accepted NKF-K/KDOQI (Kidney Disease Outcome Quality Initiative) classification system facilitates diagnosis and management¹⁷. Until recently the serum creatinine had been used as the standard test of renal excretory function. The serum creatinine is not, however, reliable as a screening test as the relationship between glomerular filtration rate (GFR) and serum creatinine is not linear. By the time the creatinine becomes elevated, there may already be a 50% reduction in kidney function. The most effective way to assess renal function, and therefore gauge the need for further investigation or referral, is by using estimated GFR (eGFR), a formula-based calculation of GFR. There are two ways of calculating eGFR, Cockcroft and Gault (C&G) and MDRD (Modified Modification of Diet in Renal Disease). Based on current evidence the MDRD formula is the recommended equation as it gives an eGFR that is normalized to a body surface area of 1.73m² and does not require the patient’s weight. The eGFR is then multiplied by 1.21 for Afro-Caribbean patients. It is important to note that the eGFR is not useful in a patient with acute renal failure, as it relies on a stable serum creatinine for its predictive accuracy^18,19. The categories recommended for the KDOQI staging of CKD¹⁷ are available on the following websites: http://www.renal.org/eGFR/eguide.html or http://www.kdigo.org/welcome.htm .

Prevention
CKD is progressive, however, with good management focusing on blood pressure, lipid and glycaemic control, together with smoking cessation and the avoidance of nephrotoxic drugs, the progression can be slowed down. It has also been demonstrated that patients referred early have better outcomes^20,21. Diabetic nephropathy progression can be slowed by effective tightening of glycaemic control, and several studies have shown that good glycaemic control can decrease the risk of macrovascular disease in both type 1 and 2 diabetes^22-24. There is also evidence that tight control in patients with CKD can slow the progression from microalbuminuria to macroalbuminuria. It has also been shown that by lowering blood pressure to a minimum of 130/75 mmHg with angiotensin-converting enzymes (ACE inhibitors) or angiotensin receptor blockers (ARB), lowering cholesterol and educating patients on leading a healthy lifestyle there is an impact on progression. Interventions to minimise progression of CKD include lifestyle changes and reduction of blood pressure irrespective of the diagnosis of hypertension or diabetes. The use of ACE inhibitors or ARBs is effective at reducing progression when there is concurrent proteinuria. Target blood pressure is now below 130/75 mmHg, which in the UK is supported by the National Institute of Clinical Excellence (NICE) who found that by reducing the BP to less than this level resulted in a reduction in the progression of renal disease in type 2 diabetics with albuminuria²⁴.

Implementation of Guidelines
Locally agreed referral guidelines from primary care and agreed guidelines between diabetic and nephrology teams will improve the detection and management of CKD. Our main aim must be to ensure the implementation of such guidelines and to develop a global preventative approach. The International Society of Nephrology (ISN) has for some time had a focus on prevention, and the COMGAN group believe in improving global outcomes of kidney disease. The new initiative by the Kidney Disease: Improving Global Outcomes (KDIGO) group aims to develop a global approach to managing the CKD epidemic. Their mission statement is ‘Improve the care and outcomes of kidney disease patients worldwide through promoting coordination, collaboration and integration of initiatives to develop and implement clinical practice guidelines’. KDIGO and the ISN are now working together on developing a CKD strategy^25,26.

The role of nursing in the care and prevention of CKD is expanding due to the large number of patients being detected. Emphasis on educating community providers is paramount and also the effective management of those identified with CKD 3 and below in order to delay and prevent progression of renal disease. There is scope for the implementation and expansion of nurse led clinics to manage hypertension, health promotion clinics, screening programmes for detection and develop management plans for CKD patients. In the UK these services have already been implemented in many centres as a direct result of the rise in detection.

Summary
The reality is that the majority of the CKD population have one or more co-morbid conditions with a known higher prevalence in ethnic minorities and lower socio-economic groups; combine this with the increase in childhood obesity and prevalence of diabetes and it is clear why we have an epidemic of CKD. Without effective prevention and early detection programmes, this will continue to escalate. Early detection and referral of CKD patients to nephrology teams is pivotal in slowing the progression to ESRD and reducing the demand for dialysis.

Address for correspondence
Ki Lindqvist
Unit manager
HUCH Hospital for children and adolescents
Department of paediatric nephrology
Kidney and transplantation ward K3
PB 281, 00029 HUS,
Finland
Tel +358 9 471 73713
kirsti.lindqvist@hus.fi

When a child gets life threatening illness adults will often become very upset and can imagine the worst. They cannot find anything to be happy about and it is unthinkable to laugh; it would al-most be a sin. Children usually think otherwise. They live in the present and cannot see that there has been a change in their life just because a diagnosis is made. They need to laugh, play and de-velop just as always. This is often the right moment to call the clown-doctors. When they come they often bring with them magical instruments that make the children strong and wise. The chil-dren succeed in doing tricks that others cannot do. They are relaxed and spontaneously express what they think and feel. The children undertake new initiatives instead of lying passively under their blankets and feeling sorry for themselves. The UN convention of the rights of the child says that children are entitled to the best possible health and the right to nursing and rehabilitation. Clown-doctors are a means to achieve this.

Clown-doctors are utilised in many European countries and in the USA. Our clown-doctors have chosen the USA model and have undertaken intense special training. They are professional, all having been actors/actresses and have already gained some life wisdom. They maintain confiden-tiality and have training in environmental issues including asepsis. They need to know important facts about the children – not the illness. Facts such as birthdays, fears, happy events etc. It is always the child who is in charge and makes the decisions about activities.

The nursing system sometimes forgets the responsibility of caring for a child’s normal develop-ment, encouraging confidence, learning, playing etc. In NOBAB’s (Nordic Association for the needs of sick children) standards for children in hospital and in the EACH (European Association for Children in Hospital) charter it specifically says:

”Children and parents shall have the right to be informed in a manner appropriate to age and un-derstanding”.
”Children shall have full opportunity for play, recreation and education suited to their age and condition and shall be in an environment designed, furnished, staffed and equipped to meet their needs”.
”Children shall be cared for by staff whose training and skills enables them to assist in the physi-cal, emotional and developmental needs of children and families”.
”Children shall be treated with tact and understanding and their privacy shall be respected at all times”.

These demands are much easier to meet with the help of clown-doctors.

Making it possible for the clown-doctors to do their work well requires cooperation with the nurs-ing staff and medical doctors. After the clown-doctors visit the children they are often easier to work with. This can continue for several days.

To summarise we can say that everyday life has been happier since the clown-doctor activity started. With their help the children get strong and wise. They look forward to the days the clowns visit the ward and also the staff have an enjoyable experience involved in healing laughter.

E. Velez and M. Ramasco, Dialysis Unit, Madrid, Spain

Address for correspondence
E. Vélez
Paseo Imperial 81
1F 28005
Madrid .
Spain
Tel; 3491 2218377
evelez@mi.madritel.es

Biodata
Esperanza Vélez is a Renal nurse. She completed her BSN degree in 2003 and is now studying for her PhD in psychopedagogy. Esperanza was the former EDTNA/ERCA Journal co-editor, responsible for the Spanish version. She has presented and published papers at national and international level.
Milagros Ramasco is a RN, Sociologist, Master in Public Health and Professor at the Escuela Universitaria de Enfermería de la Comunidad de Madrid. She has published many papers and written many books.

Summary
Introduction: A comprehensive study of Established Renal Failure (ERF) and haemodialysis (HD) must include the sociocultural dimension of illness and the experience of patients from their own perspective. It is critical for the caring team to know how the disease is lived and reinterpreted by the patient, as this knowledge could improve nursing staff/patient interaction. The meaning of their experience is also an influential factor on the caring methods utilised by the patient.
Framework: The Theory of Representations and Explanatory Model of Illness was utilised in the study.
Methodology: A narrative qualitative methodology, grounded in a constructivist paradigm was used. Twelve patients were interviewed. The interviews were audio taped and transcribed verbatim.
Results: Results revealed that patients have a range of beliefs about their illness and their treatment. Regarding identity, symptoms that arise at the outset of illness are not suspected to relate to renal failure. The inevitability of haemodialysis convinces patients of the presence of illness and it opens a wide range of metaphors and symbolic representations...
Conclusions: Representations of ERF and HD conform to a multidimensional corpus where different elements of scientific order and common sense converge and interact, such as beliefs and fears. All of these contribute to construct the meaning of this illness and its treatment. The attributed meaning is dynamic being continually elaborated based on illness outcomes, adaptation to treatment, particular events and the sociocultural environment

Key words
Meaning of illness; Social representation; Haemodialysis

Compiled by Elizabeth J Lindley ¹ based on contributions from Richard Ward ², Chris Pearson ³, Maurice Harrington ³, Frankie O’Kane ³, Bertrand Belot ⁴, Stanley Shaldon ⁵, Jean-Yves De Vos ⁶, Franta Lopot ⁷, Anahita Nikman ⁸, Jim Curtis ², Danny Schneditz ⁹, Martin Gerrish ³, Thomas Roy ¹⁰, James Tattersall ³ and Judith Dasselaar ¹¹.

¹ Department of Renal Medicine, Leeds Teaching Hospitals NHS Trust, UK; ² USA; ³UK ; ⁴ Switzerland ; ⁵Monaco; ⁶ Belgium; ⁷Czech Republic; ⁸Norway; ⁹Austria; ¹⁰Germany; ¹¹ The Netherlands.

Key words
Blood volume monitoring; Haemodialysis; Target weight; Symptom-free dialysis 

Summary
The discussion explored and expanded on the issues raised by Dasselaar et al in their review of the measurement of relative blood volume (RBV) changes during dialysis (NDT 2005). Dialysis machines incorporating blood volume monitoring and control are widely available in Europe. The use of continuous blood volume monitoring (CBVM) to help establish dry weight; problems with CBVM due to connection and use of single needle dialysis; the physiological processes that cause RBV changes during eating, exercise and posture changes; and the application of blood volume based biofeedback control were discussed by participants from ten countries.

The ‘take-home’ messages from the discussion were that CBVM can assist in setting target weight, but must be used together with traditional measures and experience. Biofeedback control may help to achieve symptom-free dialysis, but staff should be prepared to monitor patients systematically for several weeks to obtain individualised settings. Users of CBVM should be aware of factors that can alter the central haematocrit leading to apparent changes in RBV. Practical guidelines should be developed to help staff interpret CBVM data effectively.

Synopsis of the discussion paper
The publication selected for discussion by the EDTNA/ERCA Journal Club in November 2005 was a review entitled “Measurement of relative blood volume changes during haemodialysis: merits and limitations” [1]. The authors work in the University Medical Centre in Groningen, The Netherlands and the corresponding author, Judith Dasselaar kindly agreed to take part in the discussion and respond to any queries raised.

The authors note that most dialysis machine manufacturers have now incorporated devices that continuously monitor relative blood volume (RBV) changes during treatment. These devices are advocated as a tool to maintain the intravascular volume and avoid intradialytic hypotension (IDH), but evidence-based knowledge on using RBV changes to optimise the dialysis prescription is lacking. The paper describes the physiological mechanisms that compensate for reduction in blood volume during ultrafiltration and the factors that influence the compensatory response and may affect the blood volume reduction at which IDH will occur.

Although it is not possible to identify a RBV reduction at which IDH will occur, biofeedback systems, developed to adjust ultrafiltration rate (UFR) and dialysate conductivity in response to RBV changes, have been shown to improve haemodynamic stability. They may achieve this by avoiding rapid fluctuations and prolonged drops in RBV.

A number of problems related to the measurement of RBV changes are reviewed. The initial hydration status of the patient strongly influences the course of the RBV change during HD. Blood volume redistribution between the central and microcirculation affects the validity of the measured RBV change because of lower haematocrit (Hct) in capillaries and venules. Postural changes can lead to fluid shifts between the circulation and the interstitial tissue. Amongst the miscellaneous factors that influence RBV, the authors list splenic contraction (which would release red-cell rich blood into the circulation), food intake, exercise during HD, administration of IV fluids and changes in red cell volume due to changes in plasma osmolality.

The authors conclude that staff using devices that monitor RBV should be aware of the ‘pitfalls’ and they advocate the development of practical guidelines on how to interpret and use the information generated by these devices.

How widely used is continuous blood volume monitoring (CBVM)?
One of the first contributions to the discussion was from Dick Ward in the US who explained that, whilst their new Gambro Phoenix machines featured the ‘Hemoscan’ technology for CBVM, it was not enabled.

“Apparently”, said Dick, “Gambro’s US management do not think there would be sufficient interest in the device to warrant the cost of obtaining FDA approval. This is a ‘self-fulfilling prophecy’ - if the equipment is not available and people are not aware of it, of course there will be no demand.”

The structure of the dialysis industry in the US makes it hard to introduce new technology. Reimbursement for dialysis by Medicare/Medicaid is marginal, so dialysis providers will not usually spend money on new equipment unless it can be shown to reduce operating expenses or, at least, be cost neutral. In turn, the providers of equipment see a limited market and decide not to market the new technology, which means that there is no data to demonstrate benefit.

Dick explained that the Fresenius CBVM system is approved in the US, but said he felt it was not used widely. To find out how widely used CBVM is in Europe, a short questionnaire was e-mailed to the EDTNA/ERCA active volunteers. 27 volunteers in 14 countries responded. All of their units had CBVM devices, either the integrated Hemoscan (Gambro-Hospal) or BVM (Fresenius), or the free-standing CritLine (Hemametrics).

The majority of the volunteers’ units (18/27, 66%) use CBVM routinely. Eight of these (44%) use the ‘biofeedback’ option routinely. Five (19%) units have only used CBVM for research projects and four (15%) have never used their CBVM devices. Whilst this small survey is likely to over-represent units that interested in this technology, it does suggest relatively widespread use as the units using CBVM were located in all parts of Europe.

In most of the units (83%) with machine-integrated devices, some or all of them were provided free of charge. Chris Pearson from the UK felt that blood volume monitors were being ‘given away’ in the hope of future income from specialised disposables which are sold at a premium to recoup investment in research and development and certification costs.

The cost of lines was one reason given in the survey for not using CBVM. Maurice Harrington from the UK said that while the majority of the machines in his unit (Gambro AK200/AK200s) have CBVM and the staff do use it, the funding is not available to pay for the special blood lines for all treatments. As a result it is used occasionally as an aid to assessing dry weight, rather than during each session for preventing IDH.

The situation is different where the dialysis unit has a special contract with the company. Frankie O'Kane, also from the UK, works in a 43 station unit which will soon have CBVM on all machines. Under their agreement with Gambro, CBVM is provided with no extra charge under their contract so they use it frequently as a guide to fluid status (alongside the usual parameters such as oedema, blood pressure and breathlessness).

Dry weight determination
Like Maurice and Frankie, the majority (89%) of the volunteers whose units were using CBVM routinely said they used it to help set the patients’ target weight. Bertrand Belot from Switzerland described how he had seen patients with a RBV that is constant, or even rising, during dialysis. “There were no other signs, but these patients were overhydrated and we had to reduce their target weight for several sessions, or in some cases, dialyse them every day for a week.”

Bertrand felt that CBVM is not as widely used as it should be to detect fluid overload as many doctors don't accept it as a diagnostic tool. One reason for this may be the lack of published evidence linking CBVM to improved outcome. Stanley Shaldon from Monaco brought the club’s attention to the extraordinary results of the recent CLIMB study [2]. This was a prospective randomised controlled trial (RCT), which should give reliable results, but it appeared to show that patients who had an occasional session with CBVM were more likely to die or be hospitalised than those who didn’t. In fact patients in both the CBVM and control arm had lower mortality rates than expected (77% and 26% of the US mortality rate respectively).

One of the authors of the CLIMB paper (Dr Ed Lowrie) criticised the analysis of the study on the RenalWeb site because the conclusion that doing nothing instead of using CBVM dramatically improves clinical outcome is illogic and unreasonable. He called for RCTs to be tested for external validity (how the findings fit into the real clinical world). Prof Shaldon does not advocate basing practice exclusively on RCTs – he pointed out papers suggesting that stifles new ideas and impedes progress that can be based on deduction from existing knowledge – but he wondered if Dr Lowrie’s call for validity tests would have been made if the CLIMB study had demonstrated a benefit of CBVM.

None of the participants in the discussion thought that CBVM was harmful. Lizzi Lindley from the UK agreed with Bertrand that flat or rising RBV is a reliable indicator of fluid overload (provided fluid is being removed). Judith Dasselaar said that several publications she had reviewed reported that a patient is overhydrated when the RBV is constant or only mildly decreases. “But a patient still can be overhydrated when the RBV declines severely, simply because cardiovascular compliance is poor and the plasma refilling rate is very slow,” she said, “In using RBV for assessing dry weight we have to keep to whole patient in mind.”

Jean-Yves De Vos from Belgium agreed. “BVM is a helping hand in determining a patient’s dry weight, but it is a tool that is never to be supposed to be used alone. Defining dry weight is still a real art, needing many different tools, experience and continuous adaptation.”

R. James, Dialysis Unit, Barts and The London NHS Trust, London, UK

Address for correspondence
Ray James
Hanbury Dialysis Unit
The Royal London Hospital
Whitechapel
London , E1 1BB
UK

Biodata
Ray James is the technical manager at Barts and The London NHS Trust, London. and has worked in renal technology since 1978.

Summary
Water quality is one of the most important aspects of ensuring a safe and effective delivery of haemodialysis. An extensive microbiological survey of several water systems highlighted a contamination problem which routine sampling had failed to detect.

Current guidelines suggest that s amples for microbiological and endotoxin analysis should be taken from the outlet of water treatment plant and points expected to have the highest bacterial load, normally the end of the distribution loop and connections to the dialysis machines, where the flow is at its lowest. The survey extended sampling to include a large number of machine connection points.

Four systems were investigated. The samples from routine test points generally returned results within our operational limits (<10 CFU/ml and <0.06 IU/ml). However, results from several machine connection points exceeded these limits by a large margin. Several disinfection cycles were required in order to achieve results in keeping with our operational limits.

The conclusion is that sample results from the end of the distribution loop may give a false sense of security by not indicating a contamination problem at the machine connection points. Increasing the number and frequency of machine connection points tested should provide greater security in detecting contamination and allow for remedial action at an earlier stage.

Key Words
Bacteria; Endotoxin; Contamination; Water system; Dialysis

Murtagh F E M, Addington-Hall J M, Donohoe P, Higginson I J.

Dr F E M Murtagh, MRCGP, MSc,
Research Training Fellow,
Dept of Palliative Care & Policy, Kings College London, UK

Professor Julia M Addington-Hall, BA, PhD,
Professor of End of Life Care,
University of Southampton, Southampton, UK

Dr Paul Donohoe, FRCP, PhD,
Consultant Nephrologist
King’s College Hospital
London, UK

Professor Irene J Higginson, PhD, FFPHM, FRCP
Professor of Palliative Care and Policy
Kings College London, London, UK

Address for correspondence
F Murtagh
Dept of Palliative Care & Policy,
Weston Education Centre,
Cutcombe Rd,
London SE5 9RJ
UJ
Tel: 0207 848 5583 Fax: 0207 848 5517
fliss.murtagh@kcl.ac.uk

Biodata
Fliss Murtagh, MB BS, MRCGP, MSc, worked as a general practitioner in the UK for several years, before completing specialist training in palliative medicine. From 2002, she worked with nephrology and palliative care colleagues to develop clinical services for patients with end-stage renal disease at King's College Hospital. She is now working on a major research project in the Department of Palliative Care, Policy and Rehabilitation at King's College London, to identify and describe the health care needs of renal patients towards the end of life, and to improve the quality of that care.

Keywords
Kidney failure; Established Renal Failure; Symptoms; Conservative management; Supportive and Palliative Care

Summary
Increasing numbers of patients with chronic kidney disease Stage 5 (GFR < 15ml/minute) are being managed without dialysis, either through their own preference or because dialysis is unlikely to benefit them. This growing group of patients has extensive health care needs. Their overall symptom burden is high, and symptom prevalence matches or exceeds that in other end of life populations, both with cancer and other non-cancer diagnoses. These symptoms may often go unrecognised and under-treated. Regular symptom assessment is necessary, together with pro-active management of identified symptoms.

Pain can be managed using the principles of the World Health Organisation analgesic ladder. Not all opioid medications are recommended for these patients. Paracetamol, tramadol, and fentanyl are the most appropriate medications for steps 1, 2 and 3 respectively. There is limited evidence on use of buprenorphine, oxycodone and hydromorphone. Methadone is safe but should only be prescribed by a clinician experienced in its use. Morphine and diamorphine are not recommended because of metabolite accumulation.

Pruritus is also challenging to manage. The evidence for pharmacological interventions to alleviate pruritus is summarized, and a pragmatic approach to management suggested. Emollients, capsaisin ointment, antihistamines, thalidomide and ondansetron may be helpful, according to the extent and pattern of pruritus.

Symptoms may frequently be due to co-morbid conditions, not renal disease itself, and managing them is difficult because of the constraints on the use of medication which kidney failure imposes. Collaboration between renal and palliative specialists can help identify ways to achieve best care for these patients.

Y.K Yildirim, and C. Fadiloglu, Ege University Nursing School, Izmir, Turkey

Address for correspondence
Yasemin Kuzeyli Yildirim
Ege Universitesi Hemsirelik Yüksekokulu,
Ic Hastaliklari Hemsireligi AD,
Bornova, Izmir, TURKEY
Tel: 90 232 388 11 03/17374
Fax: 90 232 388 63 74
E-mail: ykuzeyli@mynet.com

Key Words
Dialysis; Progressive Muscle Relaxation Training; State and Trait Anxiety; Quality of Life

Summary
AIM: To determine the effect of progressive muscle relaxation training (PMRT) on anxiety levels and quality of life (QoL) in dialysis patients.
METHODS: A total of 46 patients who had been treated with dialysis in the Dialysis Center of Ege University Medical Faculty Hospital were recruited. The data was collected by means of a questionnaire. Patients’ Recognition Form (PRF), State and Trait Anxiety Inventory (STAI), and QoL-index for dialysis patients (QoLI-dialysis) were used to collect the necessary data. All three forms were utilised prior to PMRT and 6 weeks after completion of PMRT.
RESULTS: The mean state-anxiety score before and after PMRT was found as 43.4±4.3 and 28.9±2.8, respectively (P<0.001). Similarly, the mean trait-anxiety scores before and after PMRT were found as 43.6±9.5 and 31.1±6.5, respectively (P<0.001). When the QoLI-dialysis score was examined it was 28.7±3.2 before PMRT and 29.6±2.3 after PMRT (P<0.01).
CONCLUSION: The results of the study demonstrate that PMRT for dialysis patients helps decrease state- and trait-anxiety levels and has a positive impact on QoL.