S.Bhandari, MBChB, PhD, MRCP (UK), FRCP (Edin), Dipl Med Edu.  J.Armitage RN, M.Chintu MBBS, MRCP (UK),. S.Chinnappa MBBS, MRCP (UK),. P.Kendrew BSc.

Dr Sunil Bhandari
Department of Renal Medicine
Hull and East Yorkshire Hospitals NHS Trust and Hull York Medical School
Kingston upon Hull
HU3 2JZ
Email: sunil.bhandari@hey.nhs.uk

Medication allergies are potentially important but usually poorly documented in patient medical records. Allergy awareness by clinical staff may be low in the haemodialysis population despite their regular attendance for treatment sessions.  A cross-sectional study of 25 patients in a satellite unit was performed. All known allergies were not documented in 36% of patients despite the patients being known to the renal service for more than 5years. 81% of allergies were medication allergies. The rest were due to topical agents. 57% (affecting 8 patients) of the medication allergies related to antibiotics (especially penicillin). Four patients had multiple antibiotic allergies. The nature and severity of these allergies was not well documented.  This study demonstrates that despite being under the long term care there remains incomplete information which is vital for optimal safe practice. Without such information the potential for adverse events and anaphylaxis is significant in a population that is exposed to numerous pharmaceutical agents and are frequently prescribed antibiotics. Medication histories should be comprehensively re-evaluated regularly and prescribing should not occur unless the allergy box is completed.

Josephine Chow, MBA, PhD, Master Clinical Nursing, Graduate Certificate in Adult Education, Bachelar of Applied Science
Susana Sanmiguel, Graduate Certificate in Adult Education, Graduate Certificate in Renal Nursing

Josephine Chow
Renal Unit, Liverpool Health Service
Locked Bag 7103
Liverpool BC 1870
NSW Australia
josephine.chow@sswahs.nsw.gov.au
Susana.sanmiguel@sswahs.nsw.gov.au

Large public health interventions to control infectious disease outbreaks are common, but rigorous evaluation to improve the quality and effectiveness of these is rarely undertaken. This project aimed. Following an incident concerning the diagnosis of acute Hepatitis B in a haemodialysis patient, possibly from healthcare associated acquisition, a multifaceted and multidisciplinary investigation was conducted involving consumers, health professionals and administrations. The results of this investigation were then used to produce practical operational guidelines for planning and future interventions. To date, there has been no incidence reported of any cross- transmission of BBV amongst our dialysis population. The actions implemented can be utilized by other departments in preventing other bacterial or viral outbreaks.

Constantina Chrysochou, Philip A Kalra

Renal Department,
Salford Royal Hospitals NHS Foundation Trust,
Stott Lane,
Salford,
Manchester, M6 8HD, UK

Atheromatous renovascular disease (ARVD) is a common and challenging disease. It is increasingly associated with chronic kidney disease (CKD) and end-stage renal disease (ESRD), hypertension and cardiovascular burden. Controversy exists regarding the safest investigative methods as well as optimum treatment of this condition. In this review we provide an overview of ARVD and discuss the challenges still remaining.

Ana E. Figueiredo RN, ENB136, MSc, PhD,  Ariani Viegas RN,  Mara Monteiro RN,  Carlos E. Poli-de-Figueiredo MD, PhD, CNPq researcher

Ana Figueiredo.
Rua Miracema 407
Porto Alegre, CEP 91330.490, RS, Brazil
e-mail: anaef@pucrs.br

Patients with end-stage renal failure (ESRF) undergoing haemodialysis (HD) are repeatedly exposed to stress and pain from approximately 300 punctures per year to their arteriovenous fistula (AVF). Repeated AVF punctures lead to a considerable degree of pain, due to the calibre and length of the bevel of fistula needles. Pain is a sensitive, emotional and subjective experience, which is personal and difficult even for the person suffering the pain, to give a rating.  The objective of this study is to measure pain associated with AVF needling.  The Analogue Visual Scale (AVS) divided into 10 equal parts (0 indicating lack of pain, and 10 unbearable pain) was used. Patient’s perceptions were measured in 3 different HD sessions.  Pain was considered mild during AVF needling. The buttonhole technique caused a mean degree of pain of 2.4 (+1.7), compared to 3.1(+2.3) using the conventional rope-ladder technique. Although without reaching a statistically significant difference, diminished pain was associated with the buttonhole technique.

Neerja Jain, RGN, BSc (Hons), MSc  Project Manager, Kidney Research UK
Professor Azhar Farooqi, OBE, FRCGP General Practitioner, East Leicester Medical Practice
Professor John Feehally, FRCP Professor of Renal Medicine, University Hospitals of Leicester

Neerja Jain,
Kidney Research UK,
Priestgate,
Peterborough,
PE1 1FG;
E mail: neerjajain@kidneyresearchuk.org.

Established Renal Failure as a complication of diabetes is ten times greater in South Asians than in Caucasians. The objectives were: a) develop methods to increase community awareness; b) support General Practices to improve CKD detection and management.
Methods included:

1. Action research approach
2. Public health education programme.
3. Audit in control and intervention practices
4. Post intervention focus-group study determining changes in knowledge
5. Evaluation and dissemination in community and Primary Care.

Results: Evaluation of innovative resources and the Peer Educator model demonstrated positive feedback, increased knowledge and evidence of positive lifestyle change. Intervention with practices has demonstrated the need to improve some aspects of CKD management.
Conclusion: This unique initiative has helped to identify practical strategies to address CKD awareness in these communities. However, the successful elements need to become part of mainstream NHS, and not just by short term projects.

¹Elizabeth J Lindley, ²Jean-Pierre Van Waeleghem, ³Melissa Chamney, and ⁴Jitka Pancírová.

¹Department of Renal Medicine, Leeds Teaching Hospitals NHS Trust, UK
²Department of Nephrology/Hypertension, Antwerp University Hospital, Belgium,
³School of Nursing and Midwifery, City University, London, UK
⁴EDTNA/ERCA, Pilatusstrasse 35, Luzerne, Switzerland

Although haemodialysis (HD) has become a routine treatment, adverse side effects, and occasionally life threatening clinical complications, still occur. Venous needle dislodgment is one of the most serious accidents that can occur during HD. If the blood pump is not stopped, either by activation of the protective system of the dialysis machine or manually, the patient can bleed to death within minutes.
Fatal and near-fatal blood loss due to venous needle dislodgement (VND) have been described in the literature (ECRI 1998, Sandroni 2005, Mactier and Worth 2007), but published reports represent only the tip of the ice berg, as such incidents are normally handled at a local or national level.
The European Dialysis and Transplant Nurses Association/ European Renal Care Association (EDTNA/ERCA) has produced twelve practice recommendations to help reduce the risk of VND and detect blood leakage as early as possible. A poster summarising these recommendations has been created (Van Waeleghem et al 2008).

M.J. Noordzij, J.D. Lefrandt, A.J. Smit.
Department of Internal Medicine, division of vascular medicine, University Medical Center Groningen, University of Groningen

M.J. Noordzij
U3.129,
University Medical Center Groningen,
P.O. Box 30.001,
9700 RB Groningen,
The Netherlands,
E-mail: m.j.noordzij@int.umcg.nl

The article aims to present an overview of the existing knowledge on advanced glycation end products (AGE). They are moieties which bind to proteins, but also lipids and nuclear acids. AGE are formed during glycation and oxidative stress. Accumulation of AGE occurs especially in diabetes and chronic renal failure and plays a major pathogenetic role. The deleterious effects of AGE result from cross linking of proteins and activation of the receptor for advanced glycation end products. AGE accumulation can be non-invasively assessed by the skin autofluorescence reader. In diabetics, skin autofluorescence predicts cardiac mortality and the occurrence of macro- and microvascular complications. In patients on haemodialysis, skin autofluorescence is highly elevated and predicts mortality. After renal transplantation AGE accumulation is lower than during haemodialysis, but still remains elevated and is a strong risk factor for chronic renal transplant dysfunction. Some of the potential methods to intervene with AGE accumulation will be discussed.

Nazan Oran PhD, Ismet Izmir PhD

Nazan Oran
Izmir Ataturk School of Health,
Ege University,
35100 Izmir,
Turkey
e-mail: nazan.oran@ege.edu.tr

A prospective analysis was conducted comparing dysfunction attributable to catheter thrombosis in subjects who received a heparin catheter lock three times a week (n=15) to those who received a heparin lock six times a week (n=15) immediately after the insertion of a temporary haemodialysis catheter. Thrombus related catheter removal occurred in 2 patients in control but no patients in the experiment group. Heparin locking six times a week was found to be effective in prolonging the mean of the first day where difficulty was experienced in aspiration. It also prevented any possible difficulty in catheter flushing. Increased locking frequency prevents any thrombus accumulation within the temporary catheter, while it has limited but significant preventive effect on thrombus accumulated around the catheter.

Murphy, F.  Jenkins, K.  McCann, M. and Sedgewick, J.

Ms. Fiona Murphy
Lecturer
School of Nursing and Midwifery
Trinity College Dublin
24 D’Olier Street
Dublin 2
Ireland
Email: fiona.murphy@tcd.ie

This is the second article in a two part CE series on managing patients with Chronic Kidney Disease (CKD). The first CE article addressed the management of patients during CKD stages 1 to 3. This article will focus on the management of patients during CKD stages 4 to 5. Nephrology nurses and other health care professionals play an important role in the monitoring and management of the many physical symptoms that patients present with during stages 4 to 5. During these stages the health care team must provide psychological support along with educating patients and their families/ carers regarding their treatment options including renal replacement therapy, conservative treatment and withdrawal of dialysis.