2005 Vienna Conference Abstract Book

Transcription

EDTNA ERCA
ABSTRACTS
Journal XXXI 2, 2005
Supplement 1
English edition: ISSN 1019/083x
Abstracts
of the 34th International Conference
EDTNA/ERCA
Vienna, Austria
10-13 September 2005
Abstracts
Official Journal
of the European Dialysis
and Transplant
Nurses Association/
European Renal
Care Association
EDTNA/ERCA
Guest Lectures
Corporate Education
Education
Haemodialysis
Paediatrics
Peritoneal Dialysis
Psychosocial Care
Quality, Audit and Research
Renal Nutrition
Technology
Transplantation
Posters
ITNS Workshops
ABSTRACTS
34th EDTNA/ERCA Conference
European Dialysis and Transplant Nurses Association/
European Renal Care Association
10 - 13 September 2005
Vienna
Austria
Journal Editor
Helen Noble
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Spanish Edition: ISSN 1019-0872
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European Editorial Board
English Edition: ISSN 1019-083x
Responsible editor: Helen Noble
94 Horn Lane - Woodford Green
Essex, IG8 9AH - England
tel. +44/020 8506 1261
fax +44/020 8504 3593
[email protected]
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fax +30 267 102 4660
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German Edition: ISSN 1019-0856
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Responsible editor: Freddy Hardy
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Journal Advertising Management
EDTNA|ERCA Secretariat
24 rue Chauchat - F-75009 Paris - France
tel. +33 (0) 1 53 85 82 69
fax +33 (0) 1 53 85 82 83
[email protected]
Table of Contents
Forewords
Guest Speakers
EDTNA/ERCA Executive Committee
Finance Sub-Committee
Key Members
Link Members
Publications
Journal Editors
Newsletter Editors
Website
Public Relations
Education Board
Research Board
Anaemia Group
Hypertension Group
Nutrition Group
Paediatric Group
Social Workers Group
Technicians Group
Transplant Group
Scientific Programme Committee
2005 Chief Abstract Assessors
Vienna Conference
Organising Committee
EDTNA/ERCA Secretariat
Conference Programme
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11-16
Abstracts
EDTNA|ERCA Journal is published four times a year in seven languages indicated above and
delivered to all EDTNA|ERCA members. Individual non-members or institutional
subscription requests are to be sent to the EDTNA|ERCA Secretariat, 24 rue Chauchat,
75009 Paris, France, tel. +33 (0) 1 53 85 82 69, fax +33 (0) 153 85 82 83, e-mail:
[email protected]
Yearly subscription is 44 EURO (Europe) or 63 EURO (Overseas) and is payable to the
EDTNA|ERCA bank account : Union Bank of Switzerland, Pilatusstrasse 8, 6002 Luzern,
Switzerland. Account N° 0248.570.023.6EZ, SWIFT code : CHZH60A,
IBAN CH47 0024 8248 5700 236E Z. Changes of address are to be directed to the Head
Office too. Papers submitted for publication in the Journal must conform to Instructions for
Authors and are to be sent to the Journal Editor. Opinions, views, statements and
comments that are expressed by authors are solely their own. These expressions do not
necessarily concur with the positions and/or opinion of the EDTNA|ERCA. All the divergent
opinions and commentary are encouraged and welcomed. All letters to the Editor having
been submitted for publication will be published unless otherwise stated. EDTNA|ERCA
Journal content can be found on our Internet Homepage : www.edtna-erca.org
The EDTNA/ERCA Journal is available in electronic format via selected EBSCO Publishing
aggregated databases. EBSCO Publishing delivers full-text and bibliographic research
databases to the academic, medical, public, school, and government library marketplace
by subscription. The highest quality journals, reference books, periodicals, and
newspapers are available to library patrons via the EBSCO Host search engine.
© 2005 European Dialysis and Transplantation Nurses Association-European Renal Care
Association.
Guest Lectures
Corporate Education
Education
Haemodialysis
Peritoneal Dialysis
Psychosocial Care
Renal Nutrition
Technology
Transplantation
Education Posters
Haemodialysis Posters
Paediatrics Posters
Peritoneal Dialysis Posters
Psychosocial Care Posters
Quality, Audit and Research Posters
Renal Nutrition Posters
Technology Posters
Transplantation Posters
ITNS Workshops
17-21
21
22-24
24-30
30-31
32-35
35-38
39-40
40-42
42-43
43-45
46-51
51
52-56
56-57
57-58
58-60
61
62
63-65
Index
LISTED IN:
- EMBASF / Excerpta Medica
- CINAHL
- British Nursing lndex
- International Nursing Index Medline
- CUIDEN
F-TWEE publishers
Kuiperskaai 6, 9000 Ghent, Belgium
tel.: +32 / 9 265 97 20 fax : +32 / 9 265 97 22 www.f-twee.be
2
EDTNA ERCA Journal 2005 XXXI 2 Supplement 1 Abstracts 2005
Authors Email Addresses
Authors Index
66
67
Acknowledgment
We would like to acknowledge Cordelia
Ashwanden as the Scientific Programme
Co-ordinator in preparing the Abstract Book.
Foreword
Dear Friends and Colleagues,
Welcome to the 34th Conference of the EDTNA/ERCA. Once again the aim of this Conference is to further the progress of renal care through the presentation of papers and the discussions both formal and informal which occur during the Conference between the members of the multi-professional health
care teams. Each session has contributions from various professionals who comprise our multi-professional association, all reflecting our Conference
theme: Bridging the gap between patient and technology.
Abstracts submitted each year continue to increase both in subject matter and number. This year the Scientific Programme Committee has decided to
increase the number of sessions with abstracts only, which will be addressing a specialist subject, and reduce the number of abstracts in Guest Speaker
sessions. The abstracts chosen will be particularly appropriate for the sessions and of the quality to enhance those sessions. There will also be an
increased number of posters on show. Posters are an excellent way of sharing knowledge, and it is possible for everyone attending the Conference to
view these posters. Viewing and participation with the authors of these posters is encouraged; there are, as usual, special times set aside for the authors
to explain their work. To show a poster means a lot of hard work and there is much to be learnt from these very topical presentations.
Our reputation continues to grow and the standard of abstracts rises accordingly, these Conferences enjoy international world-wide appeal. Therefore, if
you did send an abstract, which has not been accepted this time, do not be discouraged and please go on sending your work. If you have queries about
how to write a good abstract ask your Key Member, he/she will be very willing to assist you.
The Abstract Book lists all selected abstracts submitted by members of our Association as well as those from our invited Guest Speakers. In this book
the abstracts are divided into sections of topics, the posters have their own section, which is also divided into topics. The programme gives the name of
the author of the abstract, which is listed alphabetically in the index where you can find the page on which the abstract is to be found.
The success of these Conferences depends upon you–the delegates. There would be no Conference without you. In this world of fast changing technology we have so much still to learn and we need to share our knowledge to promote better practice for the benefit of the renal patients.
Congratulations to all those who have had abstracts accepted and we hope you enjoy presenting your work. We welcome you and all the delegates to
Vienna the centre of Europe. We hope that inspired by the new knowledge and experiences received during the Conference, you will return to your units
ready to share your experiences with your colleagues and contribute to the well-being of our renal patients.
I would like to thank everyone who has contributed to this programme and look forward to seeing you in Vienna.
Cordelia Ashwanden
Scientific Programme Co-ordinator
Vienna September 2005
Vorwort
Liebe Freunde und Kollegen,
Willkommen zur 34. EDTNA/ERCA Konferenz. Wieder einmal ist das Ziel dieser Konferenz den Fortschritt der nephrologischen Pflege durch Vorträge und
Diskussionen zwischen den Angehörigen der verschiedenen medizinischen Berufsgruppen voranzubringen. Jeder Vortrag bietet Beiträge von verschiedenen Fachleuten unseres Verbandes und alle werden sich auf unser Konferenzthema beziehen: Überwinden der Kluft zwischen Patient und Technik.
Jedes Jahr nimmt sowohl die Zahl als auch die Themenvielfalt der übermittelten Abstracts zu. Dieses Jahr hat das wissenschaftliche Komitee entschieden,
die Zahl der Vorträge zu erhöhen, die nur aus Abstracts bestehen, die ein spezielles Thema ansprechen und die Zahl der Abstracts in Gastredner –
Vorträgen reduzieren. Die ausgewählten Abstracts werden für die Vorträge besonders geeignet sein und deren Qualität verbessern. Es werden auch mehr
Poster gezeigt werden. Poster sind ein ausgezeichnetes Medium zur Wissensvermittlung und jeder, der die Konferenz besucht, hat die Möglichkeit diese
Poster anzuschauen. Der Austausch mit den Autoren der Poster ist erwünscht, es gibt, wie üblich, spezielle Zeiten, wo die Autoren ihre Poster erklären
werden. Ein Poster zu zeigen bedeutet harte Arbeit und aus diesen sehr plakativen Präsentationen kann man eine Menge lernen.
Unser Ruf wächst weiter, ebenso wie der Standard der Abstracts. Diese Konferenzen genießen internationale Reputation. Wenn Sie also ein Abstract eingeschickt haben, das diesmal nicht angenommen wurde, seien Sie nicht entmutigt und schicken Sie uns weiter Ihre Arbeit ein. Wenn Sie Fragen haben,
wie man ein gutes Abstract schreibt, fragen Sie Ihr Keymember, er/sie wird Ihnen gerne dabei helfen.
Das Abstractbuch enthält alle ausgewählten Abstracts unserer Mitglieder und der Gastredner. In diesem Buch sind die Abstracts in Themenbereiche untergliedert, die Poster haben ihren eigenen Bereich, der ebenfalls in Themen eingeteilt ist. Im Programm findet man die Namen der Autoren der Abstracts,
die im Index alphabetisch mit den entsprechenden Seitenzahlen aufgelistet sind.
Der Erfolg dieser Konferenzen hängt von Ihnen ab – den Teilnehmern. Ohne Sie gäbe es keine Konferenz. In dieser Welt, wo sich Technologie so schnell
fortentwickelt, haben wir noch eine Menge zu lernen und wir müssen unser Wissen teilen, um es zum Wohl der Nierenpatienten einsetzen zu können.
Herzlichen Glückwunsch allen, deren Abstract angenommen worden ist und wir hoffen, dass Ihnen das Sie Freude am Vortragen Ihrer Arbeit haben werden. Wir begrüßen Sie und alle Teilnehmer in Wien, im Herzen Europas. Wir hoffen, dass Sie inspiriert von dieser Konferenz in Ihre Zentren zurückkehren
und Ihre Erfahrungen mit Ihren Kollegen teilen und zum Wohlbefinden Ihrer Patienten beitragen können.
Ich möchte allen danken, die ihren Beitrag zu diesem Programm geleistet haben und freue mich, Sie in Wien begrüßen zu dürfen.
Cordelia Ashwanden
Koordinatorin des wissenschaftlichen Programms
Wien September 2005
3
Avant-propos
Chers amis et collègues,
Bienvenue à la trente-quatrième conférence de l'EDTNA/ERCA. De nouveau le but de cette conférence est de promouvoir les progrès dans les soins en
néphrologie par la présentation d'articles et lors de discussions formelles ou informelles entre les membres des équipes de soins multi professionnelles
pendant la conférence. Chaque session a des contributions des divers professionnels qui composent notre association multi professionnelle, reflétant le
thème notre conférence : Établir le lien entre le patient et la technologie.
Les abstracts soumis continuent à augmenter chaque année en sujets et en nombre. Cette année, le Comité du programme scientifique a décidé
d'augmenter le nombre de sessions avec les abstracts qui parleront d'un sujet spécialisé, et réduit le nombre d'abstracts de présentateurs invités. Les
abstracts seront appropriés aux sessions et spécialement choisis pour augmenter la qualité ces sessions. Il y aura également un plus grand nombre de
posters. Les posters sont une excellente manière de partager les connaissances, et il est facile pour toute personne qui suit la conférence de consulter
ces affiches. La consultation et la discussion avec les auteurs de ces posters sont encouragées ; il y a, comme d'habitude des périodes où les auteurs
doivent être présents auprès de leur poster pour expliquer leur travail. Présenter un poster est l'aboutissement d'un très gros travail et il y a beaucoup à
apprendre de ces présentations souvent très pertinentes.
Notre réputation continue à se développer et le niveau des abstracts augmente en conséquence, ces conférences apprécient l'appel mondial international.
Par conséquent, si vous avez envoyé un abstract, qui n'a pas été accepté cette fois, ne soyez pas découragé et continuer à nous envoyer à vos
travaux. Si vous avez des questions sur la façon d'écrire un bon abstract, demandez de l'aide à votre Key Member, il ou elle vous aidera volontiers.
L'Abstract Book est le recueil de tous les abstracts choisis, soumis par des membres de notre association ainsi que ceux des orateurs invités. Dans cette
brochure les abstracts sont divisés en sections selon la spécialité, les posters ont leur propre section, qui est également divisée en spécialité. Le
programme donne le nom de l'auteur de l'abstract, qui est aussi dans l'index alphabétique où vous pouvez retrouver la page à laquelle l'abstract est
imprimé.
Le succès de ces conférences dépend de vous, les délégués. Il n'y aurait aucune conférence sans vous. En ce monde où la technologie change
rapidement, nous avons toujours beaucoup à apprendre et nous devons partager notre connaissance pour favoriser une meilleure pratique au bénéfice
des patients.
Félicitations à tous ceux qui ont eu un abstract choisi et à nous espérons que vous aurez beaucoup de plaisir à présenter vos travaux. Nous vous
souhaitons la bienvenue ainsi qu'à tous délégués à Vienne, au centre de l'Europe. Nous espérons que, inspirés par les nouvelles connaissances et les
expériences partagées pendant la conférence, vous reviendrez dans vos unités de soins, prêtes à partager vos expériences avec vos collègues et à
contribuer au bien-être des patients de néphrologie.
Je voudrais remercier tout ceux qui ont contribué à ce programme et vous saluer avant de vous voir à Vienne.
Cordelia Ashwanden
Coordonnatrice du programme scientifique
Vienne, septembre 2005
Voorwoord
Beste vrienden en collega’s,
Welkom op de 34 ste conferentie van EDTNA/ERCA. Eens te meer is het de bedoeling om, via het presenteren van papers en via discussies, zowel formeel
als informeel tussen de leden van het multiprofessioneel zorgteam, de vooruitgang van de nefrologische zorg te promoten. Iedere sessie bevat bijdragen
van verscheidene professionelen uit onze multiprofessionele vereniging en allen reflecteren zij het thema van de conferentie: een brug slaan tussen de
patiënt en de technologie.
Het aantal ingezonden abstracts neemt ieder jaar in aantal en in verscheidenheid van onderwerp toe. Het wetenschappelijk programmacomité heeft
besloten om dit jaar meer sessies met alleen maar abstracts over een gespecialiseerd onderwerp te voorzien. Daardoor zullen er ook minder gastsprekers aan bod komen. De gekozen abstracts zullen bijzonder toepasselijk zijn voor de sessies en het zal de kwaliteit van die sessies dan ook ten goede
komen. Er zal ook een hoger aantal posters mondeling gepresenteerd worden. Posters zijn het middel bij uitstek om kennis te delen en iedereen die de
conferentie meemaakt kan deze posters komen bekijken. Het overlopen en het uitwisselen van ideeën met de auteurs van deze posters wordt aangemoedigd; er zijn zoals gebruikelijk speciale tijdschema’s waarop de auteurs hun werk kunnen uitleggen. Een poster maken is hard werken en men kan van
deze zeer specifieke topics heel wat bijleren.
Onze reputatie blijft groeien en de standaard van de abstracts neemt van langsom meer toe, want deze conferenties zijn internationaal een aantrekkelijke gebeurtenis. Daarom moet je niet ontmoedigd raken als je een abstract instuurde dat niet aanvaard werd; ga gewoon door met je werk in te dienen.
Als je problemen hebt met het schrijven van een goed abstract, kan je altijd beroep doen op je keymember, hij/zij zal je zeker willen helpen.
In het abstractboek vind je alle geselecteerde abstracts van de leden van de vereniging alsook die van de uitgenodigde gastsprekers. De abstracts zijn
onderverdeeld in secties van topics; de posters hebben hun eigen sectie, die ook in hoofdstukken ondergebracht is. Het programma vermeldt alfabetisch
de naam van de auteur van het abstract, zodat je de pagina waarop het abstract staat, kan terugvinden.
Het succes van de conferentie hangt van jullie, de deelnemers, af. Zonder jullie is er geen conferentie. In deze wereld van snelgroeiende technologie moeten we nog zoveel leren en kunnen we zoveel kennis delen om zo een betere praktijk te promoten die dan onze nefrologische patiënten weer ten goede
komt.
Proficiat voor degenen van wie het abstract aanvaard is.We hopen dat jullie het leuk vinden om het te presenteren. We verwelkomen alle deelnemers in
Wenen, in het centrum van Europa. We hopen dat jullie doordrenkt van nieuwe kennis en ervaringen, dit alles zullen delen met de collega’s en zo bijdragen tot het welzijn van onze nefrologische patiënten.
Ik zou iedereen die tot dit programma bijgedragen heeft willen bedanken en ik kijk ernaar uit jullie in Wenen te ontmoeten.
Cordelia Ashwanden
Wetenschappelijk programma coördinatrice
Wenen September 2005
4
Prólogo
Queridos Amigos y Compañeros,
Bienvenidos al 34 Congreso de la EDTNA/ERCA. Una vez más, nuestro propósito es progresar en el cuidado renal mediante la presentación de trabajos
y la discusión tanto formal como informal entre miembros multidisciplinarios. Cada sesión cuenta con contribuciones de algunos de los profesionales
que componen nuestra multicultural asociación, reflejándose todas ellas en el Tema del Congreso: Salvando las distancias entre el paciente y la tecnología.
Los abstracts enviados cada año continúan aumentando tanto en número como en el número de temas tratados. Este año, el Comité del Programa
Científico ha decidido aumentar el número de sesiones de abstracts dirigidas por un especialista, y reducir el número de abstracts de las sesiones con
Ponente Invitado. Los abstracts elegidos resultarán especialmente apropiados para las sesiones por su calidad. También contaremos con un mayor número de posters en la exhibición. Los posters constituyen una excelente forma de compartir conocimientos, además de poder ser contemplados por todos
los asistentes al Congreso. Os animamos a verlos y a participar con sus autores; habrá, como es costumbre, momentos dedicados a que los autores expliquen su trabajo. Detrás de un poster hay mucho trabajo, por lo que hay mucho que aprender.
Nuestra reputación continúa creciendo, por lo que nuestras expectativas también lo hacen. Este Congreso goza de prestigio internacional. Por lo tanto,
si mandaste un abstract y esta vez no ha sido admitido, no te desanimes y, por favor, continúa enviándonos tu trabajo. Si tenéis alguna pregunta sobre
cómo escribir un buen abstract preguntad a vuestro Key Member. Él estará encantado de ayudaros.
El Libro de Abstracts muestra la lista de todos los abstracts seleccionados enviados por los miembros de nuestra Asociación y por nuestros Ponentes
Invitados. En este libro, los abstracts se encuentran divididos por temas. Los posters también cuentan con su propia sección, que a su vez también se
divide en temas. El programa muestra el nombre del autor del abstract. En el índice aparecen los nombres de los autores por orden alfabético, por lo que
es fácil encontrar la página en la que se encuentra el abstract.
El éxito de estos Congresos depende de vosotros, los asistentes. Sin vosotros no tendría sentido. Aún tenemos mucho que aprender en este mundo de
constantes cambios tecnológicos, por lo que debemos compartir nuestros conocimientos para promocionar la mejor práctica, ya que de esa manera beneficiaremos a nuestros pacientes renales.
Felicidades a todos aquellos cuyos abstracts han sido aceptados. Espero que disfrutéis presentando vuestro trabajo. Os damos la bienvenida a Viena, el
centro de Europa. Esperamos que, inspirados por los nuevos conocimientos y experiencias obtenidas durante el Congreso, volváis a vuestras unidades
listos para compartirlos con vuestros compañeros y que contribuyáis al bienestar del nuestros pacientes renales.
Me gustaría dar las gracias a todos los que habéis contribuido a este programa. Espero veros en Viena.
Cordelia Ashwanden
Coordinadora del Programa Científico.
Viena. Septiembre 2005
Prefazione
Cari amici e colleghi,
Benvenuti al trentaquattresimo congresso EDTNA/ERCA. Ancora una volta lo scopo di questo congresso è di seguire il progresso delle cure nefrologiche
con la presentazione di studi e dibattiti sia formali che informali che avranno luogo durante il congresso fra i membri dei team multiprofessionali che si
occupano di salute. Ogni sessione presenta contributi di vari professionisti che fanno parte della nostra associazione multiprofessionale, tutto nella prospettiva del tema del congresso: Colmare la lacuna fra il paziente e la tecnologia.
Gli estratti presentati ogni anno continuano ad aumentare sia come varietà di temi sia come numero. Quest’anno il comitato per il programma scientifico ha deciso di aumentare il numero di sessioni solo con gli estratti, che saranno indirizzati ad un soggetto specifico, e di ridurre il numero di estratti nelle
sessioni Guest speakers. Gli estratti scelti saranno ben mirati sugli argomenti per aumentare la qualità delle sessioni. Ci sarà inoltre un numero maggiore di poster all'esposizione. I poster rappresentano un ottimo modo di condividere le conoscenze ed è possibile per tutti i partecipanti al congresso osservarli. L'osservazione e il confronto con gli autori di questi poster è consigliata a tutti; ci sono di solito momenti dedicati agli autori per spiegare il loro
lavoro. Esporre un manifesto implica molto lavoro e c’è molto da imparare da questo tipo di presentazione.
La nostra reputazione continua a diffondersi ed il livello degli estratti aumenta di conseguenza; i nostri congressi sono conosciuti in tutto il mondo. Di
conseguenza, se avete inviate un estratto che non è stato accettato, non scoraggiatevi e continuate a farci avere i vostri lavori. Se avete domande su come
scrivere un buon estratto, chiedete al vostro Key member che sarà felice di aiutarvi.
Il libro degli estratti elenca tutti gli estratti presentati dai membri della nostra associazione, così come quelli dei nostri ospiti che sono intervenuti. In questo libro gli estratti sono divisi in sezioni a seconda dei soggetti, i manifesti hanno la loro propria sezione, divisa anch’essa per argomenti. Il programma
indica il nome dell'autore dell'estratto, che è elencato in ordine alfabetico nell'indice.
Il successo di questi congressi dipende dai voi, dai delegati. Non ci sarebbe congresso senza di voi. In questo mondo di tecnologia che si evolve rapidamente abbiamo ancora tanto imparare ed è giusto condividere la nostra conoscenza per promuovere la pratica migliore a favore dei pazienti nefrologici.
Complimenti a coloro che hanno avuto gli estratti accettati e speriamo che siate soddisfatti di poter presentare il vostro lavoro. Diamo il benvenuto a voi
e a tutti i delegati qui nella città di Vienna, il centro dell’Europa. Speriamo che, ispirati dalle nuove conoscenze ed esperienze fatte durante il congresso,
facciate ritorno alle vostre unità operative, pronti a condividere le vostre esperienze con i vostri colleghe ed a contribuire al benessere dei nostri pazienti nefrologici.
Vorrei ringraziare tutti coloro che hanno contribuito a questo programma e sarò felice di incontrarvi a Vienna.
Cordelia Ashwanden
Coordinatore del programma scientifico
Vienna, Settembre 2005
5
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ÓÂÊÚÔÏÔÁ›·˜ ÔÈ ÔÔ›ÔÈ fiÏÔÈ ı· ‰È·Ú·ÁÌ·ÙÂ‡ÔÓÙ·È ÙÔ ı¤Ì· ÙÔ˘ ÊÂÙÈÓÔ‡ Ì·˜ ™˘ÓÂ‰Ú›Ô˘: °ÂÊ˘ÚÒÓÔÓÙ·˜ ÙÔ ¯¿ÛÌ· ÌÂÙ·Í‡ ·ÛıÂÓ‹ Î·È ÙÂ¯ÓÔÏÔÁ›·˜.
√È ÂÚÈÏ‹„ÂÈ˜ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Î¿ıÂ ¯ÚfiÓÔ ·˘Í¿ÓÔÓÙ·È ÙfiÛÔ ÛÂ fi,ÙÈ ·ÊÔÚ¿ Ù· ÁÓˆÛÙÈÎ¿ ·ÓÙÈÎÂ›ÌÂÓ· fiÛÔ Î·È ÛÙÔÓ ·ÚÈıÌfi. º¤ÙÔ˜ Ë ∂ÈÙÚÔ‹ ÙÔ˘
∂ÈÛÙËÌÔÓÈÎÔ‡ ¶ÚÔÁÚ¿ÌÌ·ÙÔ˜ ·ÔÊ¿ÛÈÛÂ Ó· ·˘Í‹ÛÂÈ ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÔÌÈÏÒÓ ÌfiÓÔ ÌÂ ÂÚÈÏ‹„ÂÈ˜, ÔÈ ÔÔ›Â˜ ı· ·Ó·Ê¤ÚÔÓÙ·È ÛÂ ¤Ó· ÂÈ‰ÈÎfi ı¤Ì·,
ÂÓÒ ı· ÌÂÈÒÛÔ˘Ó ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÂÚÈÏ‹„ÂˆÓ ·fi ÙÈ˜ ÔÌÈÏ›Â˜ ÙˆÓ ¶ÚÔÛÎÂÎÏËÌ¤ÓˆÓ √ÌÈÏËÙÒÓ. √È ÂÚÈÏ‹„ÂÈ˜ Ô˘ ı· ÂÈÏ¤ÁÔÓÙ·È ı· Â›Ó·È
Î·Ù¿ÏÏËÏÂ˜ ÁÈ· Î¿ıÂ Û˘ÓÂ‰Ú›· ÔÌÈÏÈÒÓ Î·È ı· ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ˘„ËÏ‹ ÔÈfiÙËÙ· ÚÔÎÂÈÌ¤ÓÔ˘ Ó· ÌÂÁÈÛÙÔÔÈËıÂ› Ë ‰˘Ó·ÌÈÎ‹ ÙÔ˘ ÂÎ¿ÛÙÔÙÂ ˘fi
‰È·Ú·ÁÌ¿ÙÂ˘ÛË ı¤Ì·ÙÔ˜. ∂›ÛË˜ ı· ·˘ÍËıÂ› Î·È Ô ·ÚÈıÌfi˜ ÙˆÓ fiÛÙÂÚ. ∆· fiÛÙÂÚ ·ÔÙÂÏÔ‡Ó ¤Ó·Ó ÂÍ·ÈÚÂÙÈÎfi ÙÚfiÔ ÂÈÎÔÈÓˆÓ›·˜ Î·È ‰È·Î›ÓËÛË˜
ÁÓÒÛË˜, Î·È Â›Ó·È ‰˘Ó·ÙfiÓ fiÏÔÈ ÔÈ Û‡ÓÂ‰ÚÔÈ Ó· Ù· ‰Ô˘Ó Î·È Ó· Û˘˙ËÙ‹ÛÔ˘Ó ¿Óˆ ÛÂ ·˘Ù¿. Ÿˆ˜ ¿ÓÙ· ÂÍ·ÛÊ·Ï›˙ÂÙ·È Î¿ÔÈÔ˜ ¯ÚfiÓÔ˜ ÛÙÔÓ ÔÔ›Ô
ÔÈ Û˘ÁÁÚ·ÊÂ›˜ ÌÔÚÔ‡Ó Ó· ÌÈÏ‹ÛÔ˘Ó ÌÂ ÙÔ˘˜ ÂÓ‰È·ÊÂÚfiÌÂÓÔ˘˜ Î·È Ó· ‰ÒÛÔ˘Ó ÂÚÈÛÛfiÙÂÚÂ˜ ÂÍËÁ‹ÛÂÈ˜ ÁÈ· ÙÔ ı¤Ì· ÛÙÔ ÔÔ›Ô ·Ó·Ê¤ÚÔÓÙ·È. ∏
·ÚÔ˘Û›·ÛË ÌÂ fiÛÙÂÚ ··ÈÙÂ› ÔÏ‡ ÛÎÏËÚ‹ ‰Ô˘ÏÂ›· Î·È Â›Ó·È ·Ï‹ıÂÈ· fiÙÈ Î·ÓÂ›˜ ÌÔÚÂ› Ó· Ì¿ıÂÈ ·fi ·˘Ù¤˜ ÙÈ˜ ·ÚÔ˘ÛÈ¿ÛÂÈ˜.
∏ Ê‹ÌË Ì·˜ ÌÂÁ·ÏÒÓÂÈ Î·È ÔÈ ÚÔ‰È·ÁÚ·Ê¤˜ ÁÈ· ÙÈ˜ ÂÚÈÏ‹„ÂÈ˜ ÌÂÁ·ÏÒÓÔ˘Ó ÛÂ Î‡ÚÔ˜ ·ÓÙ›ÛÙÔÈ¯· ÛÂ ·ÁÎfiÛÌÈÔ Â›Â‰Ô. °È’ ·˘Ùfi ·Ó ÛÙÂ›Ï·ÙÂ
ÂÚ›ÏË„Ë Ô˘ ‰ÂÓ ¤ÁÈÓÂ ·Ô‰ÂÎÙ‹ ·fi ÙËÓ ∂ÈÙÚÔ‹ ·˘Ù‹ ÙË ÊÔÚ¿, ÌËÓ ·Ôı·ÚÚ˘ÓıÂ›ÙÂ Î·È Û·˜ ·Ú·Î·ÏÔ‡ÌÂ Ó· Û˘ÓÂ¯›ÛÂÙÂ ÙËÓ ÚÔÛ¿ıÂÈ·.
∂¿Ó ¤¯ÂÙÂ ÂÚˆÙ‹ÛÂÈ˜ ÁÈ· ÙÔÓ ÙÚfiÔ ÁÚ·Ê‹˜ ÌÈ·˜ Î·Ï‹˜ ÂÚ›ÏË„Ë˜, ÌËÓ ‰ÈÛÙ¿ÛÂÙÂ Ó· ˙ËÙ‹ÛÂÙÂ ‚Ô‹ıÂÈ· ·fi ÙÔ Key Member ÙË˜ ¯ÒÚ·˜ Û·˜, Î·È
·˘Ùfi˜ /·˘Ù‹ ı· ÚÔÛ·ı‹ÛÂÈ Ó· Û·˜ ‚ÔËı‹ÛÂÈ.
™ÙÔ µÈ‚Ï›Ô ÙˆÓ ¶ÂÚÈÏ‹„ÂˆÓ ı· ‚ÚÂ›ÙÂ fiÏÂ˜ ÙÈ˜ ÂÈÏÂÁÌ¤ÓÂ˜ ÂÚÈÏ‹„ÂÈ˜ Ô˘ ¤¯Ô˘Ó ˘Ô‚ÏËıÂ› ·fi Ù· Ì¤ÏË ÙË˜ ŒÓˆÛË˜ Ì·˜ Î·ıÒ˜ Â›ÛË˜ Î·È ·fi
ÙÔ˘˜ ¶ÚÔÛÎÂÎÏËÌ¤ÓÔ˘˜ √ÌÈÏËÙ¤˜. √È ÂÚÈÏ‹„ÂÈ˜ ·Ú·Ù›ıÂÓÙ·È ‚¿ÛÂÈ ÙˆÓ ıÂÌ·ÙÈÎÒÓ ÂÓÔÙ‹ÙˆÓ ÙÔ˘ Û˘ÓÂ‰Ú›Ô˘, Î·ıÒ˜ Î·È Ù· fiÛÙÂÚ Ù· ÔÔ›·
Â›ÛË˜ ·Ú·Ù›ıÂÓÙ·È ‚¿ÛÂÈ ıÂÌ·ÙÈÎÒÓ ÂÓÔÙ‹ÙˆÓ. ∆Ô ÚfiÁÚ·ÌÌ· ·Ó·Ê¤ÚÂÈ ÙÔ˘˜ Û˘ÁÁÚ·ÊÂ›˜ ÌÂ ·ÏÊ·‚ËÙÈÎ‹ ÛÂÈÚ¿, Ù· ÔÓfiÌ·Ù· ÙˆÓ ÔÔ›ˆÓ
·Ó·ÁÚ¿ÊÔÓÙ·È Â›ÛË˜ ÛÙÔÓ Î·Ù¿ÏÔÁÔ ÛÙÔ Ù¤ÏÔ˜ ÙÔ˘ ‚È‚Ï›Ô˘, ÚÔÎÂÈÌ¤ÓÔ˘ Ó· ÌÔÚÂ›ÙÂ Â˘ÎÔÏfiÙÂÚ· Ó· ·Ó·ÙÚ¤ÍÂÙÂ ÛÙÈ˜ ÂÚÈÏ‹„ÂÈ˜ ÙˆÓ
·ÚÔ˘ÛÈ¿ÛÂˆÓ Ô˘ ÂÈı˘ÌÂ›ÙÂ Ó· ·Ú·ÎÔÏÔ˘ı‹ÛÂÙÂ.
∏ ÂÈÙ˘¯›· ·˘ÙÒÓ ÙˆÓ ™˘ÓÂ‰Ú›ˆÓ ÂÍ·ÚÙ¿Ù·È ·fi ÂÛ¿˜ ÙÔ˘˜ Û˘Ó¤‰ÚÔ˘˜. ¢ÂÓ ı· ˘‹Ú¯Â Û˘Ó¤‰ÚÈÔ ¯ˆÚ›˜ fiÏÔ˘˜ ÂÛ¿˜. ™Â ·˘ÙfiÓ ÙÔÓ ÎfiÛÌÔ ÌÂ ÙËÓ
Ú·Á‰·›· ÂÍÂÏÈÛÛfiÌÂÓË ÙÂ¯ÓÔÏÔÁ›·, ¤¯Ô˘ÌÂ ·ÎfiÌË ÔÏÏ¿ Ó· Ì¿ıÔ˘ÌÂ Î·È Ó· ÌÔÈÚ·ÛÙÔ‡ÌÂ ÚÔÎÂÈÌ¤ÓÔ˘ Ó· ‚ÂÏÙÈÒÛÔ˘ÌÂ ÙËÓ ÎÏÈÓÈÎ‹ Ú·ÎÙÈÎ‹ ÚÔ˜
fiÊÂÏÔ˜ ÙˆÓ ·ÛıÂÓÒÓ Ì·˜.
™˘Á¯·ÚËÙ‹ÚÈ· ÛÂ fiÏÔ˘˜ ·˘ÙÔ‡˜ ÙˆÓ ÔÔ›ˆÓ ÔÈ ÂÚÈÏ‹„ÂÈ˜ ÙÔ˘˜ ¤ÁÈÓ·Ó ·Ô‰ÂÎÙ¤˜. ∫·ÏˆÛÔÚ›˙Ô˘ÌÂ fiÏÔ˘˜ ÂÛ¿˜ Î·È ÙÔ˘˜ Û˘Ó¤‰ÚÔ˘˜ ·fi ÙË ¯ÒÚ·
Û·˜ ÛÙË µÈ¤ÓÓË, ÛÙËÓ Î·Ú‰È¿ ÙË˜ ∂˘ÚÒË˜. ∂Ï›˙Ô˘ÌÂ ˆ˜ ÔÈ ÁÓÒÛÂÈ˜ Î·È Ù· Ó¤· ÂÚÂı›ÛÌ·Ù· Ô˘ ı· Ï¿‚ÂÙÂ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ Û˘ÓÂ‰Ú›Ô˘ ı·
·ÔÙÂÏ¤ÛÔ˘Ó ËÁ‹ ¤ÌÓÂ˘ÛË˜ ÁÈ· Û·˜, Î·È ÂÈÛÙÚ¤ÊÔÓÙ·˜ ÛÙÔ ‰ÈÎfi Û·˜ ¯ÒÚÔ ÂÚÁ·Û›·˜ ı· Â›ÛÙÂ ¤ÙÔÈÌÔÈ Ó· ÌÔÈÚ·ÛÙÂ›ÙÂ ÙÈ˜ ÂÌÂÈÚ›Â˜ Û·˜ ÌÂ ÙÔ˘˜
Û˘Ó·‰¤ÏÊÔ˘˜ Û·˜, Û˘Ì‚¿ÏÏÔÓÙ·˜ ¤ÙÛÈ ÛÙËÓ ·Ó·‚¿ıÌÈÛË ÙË˜ ·ÚÂ¯fiÌÂÓË˜ ÊÚÔÓÙ›‰·˜ ÛÙÔ˘˜ ·ÛıÂÓÂ›˜ Ì·˜.
£· ‹ıÂÏ· Ó· Â˘¯·ÚÈÛÙ‹Ûˆ fiÏÔ˘˜ fiÛÔ˘˜ Û˘Ó¤‚·ÏÏ·Ó ÛÙË ‰ËÌÈÔ˘ÚÁ›· ·˘ÙÔ‡ ÙÔ˘ ÚÔÁÚ¿ÌÌ·ÙÔ˜ Î·È ·Ó˘ÔÌÔÓÒ Ó· Û·˜ ‰ˆ fiÏÔ˘˜ ÛÙË µÈ¤ÓÓË.
Cordelia Ashwanden
™˘ÓÙÔÓ›ÛÙÚÈ· ∂ÈÛÙËÌÔÓÈÎÔ‡ ¶ÚÔÁÚ¿ÌÌ·ÙÔ˜
µÈ¤ÓÓË ™ÂÙ¤Ì‚ÚÈÔ˜ 2005
Guest Speakers
Dr. Peter Amlot
Ms. Suzie Burford
Dr. Alistair Chesser
Prof. John Cunningham
Dr. John Daugirdas
Dr. Simon Davies
Leslie Dinwiddie
Patricia Dunn
Dr. Trond Cato
Dr. Sunny Eloot
Ms. Barbara Engel
Jerry Hager
Dr. Jean Hooper
Prof. Walter Hörl
Prof. Peter Kampits
Dr. Lizzi Lindley
6
UK
Singapore
UK
UK
USA
UK
USA
USA
Norway
Belgium
UK
The Netherlands
UK
Austria
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UK
Prof. Franta Lopot
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Prof. Gert Mayer
Dr. Chris McIntyre
Dr. J. M. Morales
Dr. Fliss Murtagh
Dr. Hans-Dietrich Polaschegg
Prof. Alexander Rosenkranz
Dr. Aram Rudenski
Dr. Julian Segura
Ms. Lilli Sukula-Lindblom
Prof. Gere Sunder-Plassmann
Dr. Daniel Teta
Prof. Raymond Vanholder
Mr. Hans Vlaminck
Mr. Tony Ward
Prof. Renzo Zanotti
Czech Republic
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UK
Spain
UK
Austria
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UK
Spain
Finland
Austria
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Belgium
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European Dialysis and
Transplant Nurses Association/
European Renal Care Association
Executive Committee (EC)
Althea Mahon
Georgia Thanasa
Jitka Pancírová
Lorna Engblom
Elisheva Milo (ad interim)
María Cruz Casal García
Elisheva Milo
Iris Romach
OPEN
LINKS
President
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Publication Board
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NC
Finance Sub-Committee
Lorna Engblom
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Treasurer
Volunteer Member
Finance Director
Office Manager
Key Members
Maria Fettouhi
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OPEN
Luc Picavet
Hrvojka Mozanic
Jirí Srámek
Maria Fettouhi
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Laurent George
Hedi Lückerath
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OPEN
Veronica Francis
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Hilde Irene Langmo
Anna Mróz
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Birsen Yürügen
OPEN
Key Member Mentor
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7
Link Members
Chrystalla Despoti
OPEN
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Publications
Anna Marti i Monros
Helen Noble
Aletta Stubbs
Publication Chair
Journal Editor
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Co-Editors
Freddy Hardy
Christa Nagel
Helen Noble
Jane Macdonald
Bertrand Belot
Yolande Pirard
Kai-Uwe Schmieder
Anastasia Liossatou
Ilaria de Barbieri
Maria Jesus de la Torre Peña
Antonio Ochando Garcia
Website
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www.edtna-erca.org
Martin Gerrish
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Website Manager
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André Stragier
Public Relations Officer
Education Board (EB)
John Sedgewick
Chairperson
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Waltraud Küntzle
8
Member
Research Board (RB)
Maurice Harrington
Chairperson
Interest Groups
Anaemia Group
Lesley Bennett
Chairperson
Hypertension Group
Josep Mª Gutiérrez Vilaplana
Chairperson
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Diane Green
Chairperson
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Jacqueline Knoll
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Theodôr Vogels
Chairperson
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OPEN
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Raymond Trevitt
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Martha Girak
María Cruz Casal García
Conference President 2005 - Vienna
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Scientific Programme Committee
Cordelia Ashwanden
Scientific Programme Co-ordinator
2005 Chief Abstract Assessors
Rainer Bühler
María de la Cruz Casal García
An Demol
Maria Saraiva
Paul Van Malderen
Ronald Visser
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Denise Vijt
Luc Vonckx
United Kingdom
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The Netherlands
Belgium
Belgium
9
Vienna Conference Organising Committee
Martha Girak
Otto Feichtelbauer
Elisabeth Kahnert
Elisabeth Lehner
Claudia Mayer
Heidrun Tauschitz
Conference President
Member
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Secretariat
Anna Öhrner
Karine Desbant
Valérie Escande
Sandrine Chabert
Emmanuel Langeland
Audrey Roché
10
[email protected]
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[email protected]
Office Manager
Marketing & Communications Manager
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Finance Director
Membership Administration
Membership Administration
& Conference Registration
Saturday 10 September
18.00
Hall A
Prof. Gert Mayer
Bridging the gap between knowledge and patient care – is evidence based medicine the answer?
Sunday 11 September
09.00
Hall E2
Hall D (Translation)
Immunology
Dr. John Daugirdas
Dialysis: New schedules, new methods, and new technologies: Impact on the Patient.
Chair:
Althea Mahon
Introduction to
transplantation
Dr. Daugirdas is Clinical Professor of Medicine at the University of Illinois at Chicago.
He is editor of the Handbook of Dialysis and author of over 150 articles in the field of dialysis.
He is founding editor of HDCN (Hypertension, Dialysis, and Clinical Nephrology) - a web journal that presents latest
nephrology-related advances on a weekly basis.
Chairs:
Clare Whittaker
Mirjana Calic
What you want to know
about Immunology
Frank Van Gelder
Who should receive?
Assessment for renal
transplantation
Ray Trevitt
10.30
Break
Exhibition and Poster viewing
11.00 Hall D (Translation)
Corporate Education
Session
GAMBRO
Vascular Access –
The role of the nurse
Susanne Ljunggren
Janet Cowperthwaite
Tony Goovaerts
Chair:
Georgia Thanasa
Hall E 1
Hall I/K
Hall G
Management of fluids
Minimising the
progression of Chronic
Kidney Disease
Hall H
Hall E2
Anaemia therapy
High-tech innovations in Donation
nephrology care and
How technology can
Improving the options
psycho-social
Chairs:
help in setting target
for Donors and
perspective
Johann Schorr
weights for dialysis
How to prevent
recipients
Ronald Visser
patients
progressions to endWorkshop
Chairs:
Dr. Elizabeth Lindley
stage renal disease
345 Audit of a
Ray Trevitt
Dr. Gere Sunderprescribing algorithm for Chair:
Theodor Vogels
Annaloes Wilschut
Deuterium dilution Plassman
oral and IV iron in prethe gold standard for
dialysis patients.
Chairs:
Living a machine
Update on live
measuring body water.
Vicki Hipkiss
dependent lifestyle
donation.Techniques
Research tool or clinical Hrvojka Mozanic
266 Iron usage in
Nicola Thomas
Jean Hooper
and outcomes.
reality?
haemodialysis patients:
Prof. Ferdinand
Dr. Simon Davies
Does a formal iron
87 A Clinic to prevent
261 Increasing the
Muhlbacher
policy matter?
Chair:
the deterioration of renal
awareness of
Sue Johnson
Franta Lopot
insufficiency
community caregivers
A programme for
271 Aranesp® maintains about the needs of
Anna Brousseau
simultaneous living
haemoglobin in
8 Use of technology in
kidney donor
dialysis patients
blood volume
329 Cognitive function in peritoneal dialysis
perspective
exchanges.
patients: Extended
monitoring to improve
pre-dialysis patients
Hana Cohen
Marry de Klerk
dosing intervals
patient outcomes
Mike Kelly
Helen Boulton
Jennifer Andrews
SW Projects &
342 Kidney disease
Proceedings
273 Evaluation of
education and
Simon Wall
response to
prevention programme: erythropoiesisIdentifying a community stimulating agents using
at risk
anaemia management
Pat Simoyi
software
Marcia Waterschoot
Abstracts
272 A new
subcutaneous injection
device: SureClick™
Prefilled Pen
Jean-Pierre
van Waeleghem
11
Sunday 11 September
12.30
13.40-14.10 Hall E2
Lunch
Language Forums x 8
Leadership course (Education Board)
Hall E 1
Corporate Education
Session
Managing the obese
patient
Genzyme
Novel approaches for
the treatment of
malnutrition disorders in
dialysed patients
Dr. Daniel Teta
Bridge to better care
Fabry Disease: Not a
Rare Cause of Kidney
Failure
Dr. Frank Breunig
Middle molecule
removal in big size
patients: how to bridge
Mineral metabolism
the gap
disorders in CKD stage 5 Dr. Sunny Eloot
calcium & phosphorus
management
Fat but fit – lifestyle
Prof. Gere Sundermodification for the
Plassmann
renal patient
Barbara Engles
How to help YOUR
Chairs:
patient to a better life
Laurent George
Christa Nagel, RD
Diane Green
Chair:
Hedi Lückerath
15.45
Ethical considerations
of treatment
Autonomy and
paternalism in the
physician-patient-nurse
relationship
Prof. Peter Kampits
Chairs:
Simon Wall
Madelon Kleingeld
Surviving renal failure
Hall E 1
Hypertension
The determinants of long Cronotherapy
term survival on RRT
Dr.Julian Segura
Prof. Walter Hörl
Chairs:
Chairs:
Heather Jayasekera
Anna Marti i Monros
Anastasia Laskari
Doris Rosenkranz
317 Angiotensin
98 Potential age related converting enzyme
risk factors in a PD
inhibitors and
population
angiotensin 2 receptor
Clement Dequidt
blockers clinic: Two
advanced practitioners
246 Continuous Quality
experience
Improvement in dialysis Pat Simoyi
by using an International
Standards Organization. 253 Advantages of
Adriana Marcovici
combined profile Na/UF
in reducing side effects
189 Cognitive
during haemodialysis
Performance as a
sessions
Function of
Ronis Wagner
Haemodialysis
Ray Steenveld
158 Educational and
Psychological
intervention in patients
with hypertension on
haemodialysis
Maria Lopez
Hall G
Hall H
Hall E2
Technical advances in Advanced skills
workshop
Renal Replacement
Therapy
Taller de práctica
avanzada
Workshop
Manejo de la hipertensión
Hypertension management
Comparison of
(Lengua española)
technical practice
(Spanish language)
between European
Panel presentation
and debate
The human market
Chair:
Grainne Walsh
One centre’s experience
of patients travelling
abroad to receive renal
transplantation.
Manejo de la Hipertensión
Clare Whittaker
Dr. Julian Segura
countries
John Wright
Moderador: Josep Maria
Gutiérrez Vilaplana
105 Caring for people
who are dying on renal
wards: a retrospective
study
Helen Noble
The European Core
Curriculum in renal
technology, building
for the future
Ray James
Medida de la presión
arterialJosep María
Gutiérrez Vilaplana
The patient perspective
CEAPIR representative
150 The need for
coordinating of care in
an ageing dialysis
population
Freddy Hardy
Chairs:
Franta Lopot
Andre Stragier
Automedida de la presión
arterial (AMPA)
Josep María Gutiérrez
Vilaplana
Medida de la presión
arterial ambulatoria
(MAPA)
Luísa Fernández
The argument for
Chris Rudge, FRCS
318 Do patients who
choose conservative
management rather than
RRT receive equal care?
Pat Simoyi
Break
12
Hall I/K
ITNS Symposium
The genesis of
Diarrhoeal Disease
Dr. Bart Maes
The argument against
Prof. Ferdinand
Muhlbacher
Ejercicio práctico
Discusión
Hall I/K
Hall G
Advances in technology Bridging the gap – the patient
and technology
Water quality; stress
Oral poster presentations
factor or a helpful tool in
Chairs:
treatment?
Helen Noble
Jerry Hagen
Margaret McCann
Technical aspects of
321 BYILD - Build Your Skills in
dialysate
Peritoneal Dialysis
Dr. Hans-Dietrich
Geraldine Endall
Polaschegg
204 Switching from standard
haemodialysis to thrice weekly
Chairs:
nocturnal haemodialysis: a
Andre Stragier
single-centre experience
Peter Stockman
Ilse Claeys
16 Monitoring of dialysis
224 Index and standard of
water systems - is there
evaluation about the self-care
a need for increased
of a dialysis patient in Japan
sampling?
Chizuru Kamiya
Ray James
229 Experiencing life with a
23 Dialysis water
haemodialysis machine: a
purification: can old
phenomenological view
systems be easily
Maria Lúcia Sadala
upgraded for micro101 The effects of social support
biological safety of the
on haemodialysis patients
Dialysis water?
Birsen Yürügen
Hans Traeger
291 Anxiety, Depression and
198 Fluid quality at home Peritoneal Dialysis
Zuleyha Aydın
haemodialysis
333 Effects of exercise
installations
programme in dialysis patients
Gareth Murcutt
Deniz Karadeniz
Hall H
Nutritional
Biochemistry
Workshop
Chair:
Diane Green
Dr. Aram
Rudenski
Ione Ashurst
Hall E2
Longterm wellness
Optimising outcomes in
Transplantation
Chairs:
Meira Sternberg
Frank Van Gelder
Prevention is better
than cure.
Annaloes Wilschut
Pregnancy following
transplantation.
Clare Whittaker
More than just another
kidney- The paediatric
perspective
Grainne Walsh
Monday 12 September
09.00
Hall E 1
Transplantation
Peritoneal Dialysis
Post-Transplant
Lymphoproliferative
Disease and EpsteinBarr Virus infection in
renal transplant
patients: what can
we do?
Dr. Peter Amlott
How does membrane
function influence
patient outcome and
how does dialysis
influence the
membrane?
Dr. Simon Davies
Chairs:
Mirjana Calic
Ray Trevitt
91 Pre-emptive
immunoglobulin therapy
with plasmapheresis
enables live-donor renal
transplantation in
patients with a positive
cross-match
Meira Sternberg
120 Plasmapheresis in
the treatment of acute
vascular graft rejection.
Beverley White
Chairs:
Margherita Rivetti
Denise Vijt
Hall I/K
The patient’s view of
technology
In collaboration with
CEAPIR
The use of new
technology in patient
education
Paula Ormondy
274 Towards long-term
peritoneal dialysis
Hadassa Madar
117 CAPD vs APD:
comparison on patients'
mortality and morbidity
Glykeria Tsouka
Chairs:
Theodor Vogels
Elisheva Milo
187 Redesign and
implementation of a
model for delivery of
peritoneal dialysis
patient training
Julie Owen
81 Give priority to selfcare in haemodialysis
Rikii Dahan
181 Renal patient view a personalised on-line
patient information
system
Pamela D'Arcy
Break
Oral nutritional
supplementation – is it
effective in PD and HD
patients?
Dr. Aram Rudenski
Chairs:
Ione Ashurst
Franca Pasticci
136 High dietary sodium
intake contributes to
sodium retention in
haemodialysis patients
Paula McLaren
Hall E 1
Hall H
Chairs:
Jane Macdonald
Eva-Lena Nilsson
Hall E2
Advanced skills
workshop
Advanced skills
workshop
Hypertension
management
(English language)
ºÚÔÓÙÈÛÙ‹ÚÈÔ
∞Ó·‚·ıÌÈÛÌ¤ÓË˜
¶Ú·ÎÙÈÎ‹˜ ÁÈ· ÙËÓ
À¤ÚÙ·ÛË
Abstracts
Chair:
Heather Jayasekera
The Importance of
Hypertension
Management
178 The need for support Dr. Chris McIntyre
groups for nephrology
nurses
Renal Specific
Tami Chayu
Secondary Hypertension
Dr. Philip Kalra
244 Fatigue in
Blood Pressure
Mukadder Mollaoglu
Measurement
Blood Pressure
316 To determine the
Monitoring, Utilising
impact of a progressive Clinic BP, Self
relaxation training on
Monitoring and ABPM
anxiety levels and
Heather Jayasekera
quality of life in dialysis
patients
Discussion with Expert
Yasemin Yildirim
Panel
186 Meaning of illness
and illness
177 Ganma: The meeting representation, crucial
of modern medicine with factors in integral care
ancient culture
Esperanza Velez
Andrea Moriarty
10.30
Nutrition
Care in chronic illness
20 Improving patient
education through
How does the patient
patient-led forums
benefit from technology? Susan Heatley
Gerard Boekhoff
A questionnaire to
improve patient
satisfaction
Joan Kelley
7 Factors affecting noncompliance in renal
transplantation
Carol Bartley
Hall G
Practical Exercises
Heather Jayasekera,
Josep Ma Gutiérrez
Vilaplana,
Nurit Cohen
¢È·¯Â›ÚÈÛË À¤ÚÙ·ÛË˜
Hypertension
management
(™ÙËÓ ∂ÏÏËÓÈÎ‹ °ÏÒÛÛ·)
(Greek language)
ÀÂ‡ı˘ÓË ºÚÔÓÙÈÛÙËÚ›Ô˘
∞Ó·ÛÙ·Û›· §ÈÔÛ¿ÙÔ˘
∏ ∞ÓÙÈÌÂÙÒÈÛË ÙË˜
À¤ÚÙ·ÛË˜
¶ÚÔÛÎÂÎÏËÌ¤ÓË
√ÌÈÏ‹ÙÚÈ·:
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∞Ó·ÛÙ·Û›· §¿ÛÎ·ÚË
∏ ∞˘Ùfi-ª¤ÙÚËÛË
(ª¤ÙÚËÛË ∫·Ù’ √›ÎÔÓ)
ÙË˜ ∞ÚÙËÚÈ·Î‹˜ ¶›ÂÛË˜
∏ 24ˆÚË ∫·Ù·ÁÚ·Ê‹ ÙË˜
∞ÚÙËÚÈ·Î‹˜ ¶›ÂÛË˜
¶Ú·ÎÙÈÎ‹ ∂Í¿ÛÎËÛË
™˘˙‹ÙËÛË
Hall I/K
Hall G
Hall H
Hall E2
International health
care
Technical advances for
dialysis
The importance of
humour
Advanced skills
workshop
Research Board
workshop
Panel of international
experts
Clinical benefit of
dialysate temperature
regulation in HD
Dr. Hans-Dietrich
Polaschegg
Lost your laughter?
Call the clown doctors!
Thoughts and
experiences
Lili Sukula-Lindblom
Kirsti Linqvist
Fluid management
of the dialysis patient
European diversity
of the nurse in
renal practice
Jitka Pancirová
EDTNA/ERCA
Patricia Dunn
CANNT
Leslie Dinwiddie
ANNA
Suzie Burford
NKF - Singapore
260 Improving the quality Chairs:
Maria Cruz Casal
of life of haemodialysis
Margaret McCann
patients with a dietary
supplement
Ronit Numan-Golan
Chairs:
Elizabeth Lindley
Maria Fettouhi
Chairs:
Jacqueline Knoll
An Demol
26 The myth of the
Isolated Machine:
Blood borne viruses and
haemodialysis machines
Gareth Murcutt
86 Making heparin -free
haemodialysis work!
Yvonne Grieve
265 The technology
behind the improvement
of the Renal Anaemia
Management Service
Sue Johnson
156 A new tool: an
innovative approach to
improving patient
outcomes in a
haemodialysis setting
Amanda Raynor
Chair:
Martin Gerrish
Medical issues in fluid
control
Dr. James Tattersall
Psychological issues in
fluid control
Jean Hooper
Chair:
Maurice Harrington
Discussion on the
results of the Research
Board's
survey of the interesting
variation in renal nursing
roles and practice
across Europe
Nutritional issues in fluid
control
Prof. Monique Elseviers
Diane Green
Alessandra Zampieron
74 Psychological
reactions to patients
with ESRD
Anastasia Laskari
214 Caregivers need
support too
Hadasa Madar
13
Monday 12 September
12.30
Lunch
Leadership course (Education Board)
14.15
Hall E 1
Hall I/K
Care beyond technology Improving treatment
outcomes
When technology is
not the answer
Management of
Dr. Alistair Chesser
parathyroid and bone
disease
Treating the symptoms
of the person without
Chairs:
dialysis
Elizabeth Lindley
Dr. Fliss Murtagh
Iris Romach
Chairs:
Veronica Francis
297 To evaluate the
Joke Roelfsema
effectiveness of a
Patient Group Direction
239 A care pathway for to achieve serum
the end of life in a renal phosphate levels
setting
Dawn Yokum
Vicky Hinton
161 Deregulated
338 End of life decision
phosphate: association
making: the
with increased decline
discontinuation of
in renal function in
dialysis
predialysis patients
Yvonne White
Lynda Engelsman
Education
Technology in clinical
care - the impact of
education in enhancing
holistic practice in
nephrology nursing
Prof. Renzo Zanotti
16.15
Living with renal
disease. Sexual
dysfunction
Fertility and pregnancy
in end stage renal
disease
Prof. Gert Mayer
Chairs:
John Sedgewick
Alessandra Zampieron
An overview of sexual
problems
Althea Mahon
141 Meeting the
challenges of recruiting
and retaining an expert
renal workforce
Rosamund Tibbles
Chairs:
Cordelia Ashwanden
Maria Isabel Fernandez
Corral
221 Training of
haemodialysis nurses
for the role of vascular
coordinator
Elisheva Milo
228 Recruitment and
retention audit: Training
does make a difference
Jennie King
15.45
Hall G
Break
257 Patient's sexual
health: Do we care
enough?
Tai Mooi Ho
Hall H
Technology in Practice
Essentials of renal care
The role for advanced
dialysis technology in
liver failure
Dr. Chris McIntyre
Workshop Education
Board
Chairs:
Tina Goodridge
Tony Goovaerts
Pre-dialysis
Nutrition
Choice of treatment
Adequacy KT/V?
Access
Care of the family
Maria Saraiva
Kirsti Linqvist
126 Simultaneous
plasmapheresis and
haemodialysis as a safe
procedure in 65 patients
Thomas Dechmann
212 Lipid Apheresis:
An effective treatment
for severe
hyperlipoproteinemia
Ivana Nikolic
293 Factors that affect
the sexual problems of
dialysis patients
Handan Golgeli
335 Sexuality where
does it fit into the care
of the renal patient?
Fiona Murphy
ANNUAL GENERAL MEETING
Chair:
Althea Mahon, EDTNA/ERCA President
Welcome by the President and Appointment of Scrutineers
Approval of the 2004 AGM Minutes
Association Activities and Progress Report
Presentation of ‘EDTNA/ERCA’ Accreditation & Endorsement of Renal Education certificates
to University Nursing Schools & Renal Industry Partners
Comparison of Renal practice in European countries
Prof. Monique Elseviers
Approval of 2004 Financial report
Results of Executive Committee votes
Introduction of new Executive Committee
Association objectives 2005/2006
Motions
Future Conferences
Any Other Business
Date and Venue for next AGM
Raffle
• Attendance at the AGM will be credited with 1 point
• A top of the range digital camera will be raffled at the end of the session (for registered delegates only)
14
Hall E2
General care
Tuesday 13 September
09.00
Co-morbidities of renal
disease
Hall E 1
Vascular access
Hall I/K
Pre-dialysis care
How to monitor vascular Abstracts
access
Chairs :
Dr. Franta Lopot
Theodora Kafkia
Chairs:
Anna Marti i Monros
Jitka Pancirova
19 The introduction of a
Birsen Yürügen
nurse led pre-dialysis
11 Custom made Raster service - results of a
Method for fistula and
5 year audit
Chairs:
graft
Debra Hunt
Lorna Engblom
Cees Blokker
Veronica Francis
110 Planning and
implementing an 'Expert
25 The effect of post
97 Cardiovascular
Patient Programme' in
dilution online
mortality risk is
renal care
haemofiltration on
increased in dialysis
transonic access flow
Nicola Thomas
patients with disturbed
measurements
mineral metabolism
Ronald Visser
286 Is patient choice
Lucia Brinke
always the right choice?
124 Care management of Meagan Stobyfields
183 Blood Volume
patients with vascular
Monitoring - can we
331 Perceived health
access problems
deliver safe dialysis with Batsheva Lahav
and influential factors in
no hypotension or fluid
predialysis and dialysis
excess?
296 Multicenter initiative patients
Nurit Cohen
to improve quality of
Josep Maria Gutiérrez
vascular access care
Vilaplana
279 Cardiac output
Natasja Beukers
estimation with
346 Quality of life in
impedance
chronic renal failure
cardiography in
Karen Pugh-Clarke
Nikolaos Tzenakis
How can the
advancement of dialysis
technology improve the
cardiovascular risk of
Stage 5 renal failure
patients
Prof. Raymond
Vanholder
10.30
Break
Hall G
Hall H
Immunosuppression
Hall E2
Essentials of renal care
Advanced skills
workshop
Workshop
Education Board
Workshop
Parathyroid and bone
disease
Chair:
Ray Trevitt
Immunological
complications of
immuno suppression
Dr. Peter Amlott
Dr. Chris McIntyre
Nonnephrotoxic
immunosuppression
after renal
transplantation
Dr. Morales Cerdan
Co-morbidities of renal
failure
Chair:
Jane Macdonald
Diane Green
Cardiac
Anaemia
Diabetes
Infection control
John Sedgewick
Margaret McCann
Hall E 1
Hall I/K
Preventative
management
Advanced practices
Nutrition in practice
Patient care
Oral poster presentations
Education Board projects
New insights on
Hepatitis C virus
infection after renal
transplantation
Dr. Morales Cerdan
Does size matter? –
the dilemma when
assessing changes in a
renal patient’s weight
Barbara Engles
Chairs:
Maria Fettouhi
Alois Gorke
Workshop
Nephrotic syndrome,
diagnosis and treatment
Dr. Trond Cato Eide
Chairs:
Ione Ashurst
Joke Roelfsema
Keeping the patient from
technology (dialysis):
identifying and treating
diabetic nephropathy
Prof. Alexander
Rosenkranz
Chairs:
Hedi Lückerath
Nicola Thomas
82 Identification,
assessment and
treatment of the diabetic
foot amongst chronic
Rita Elias
324 Management of
Diabetic Retinopathy in
diabetes haemodialysis
patients
Rina Fedorowsky
Chairs:
Maria Cruz Casal
Hilde Langmo
131 Improved
effectiveness of dialysis
through online
haemodiafiltration
Susan Rogers
140 A cross-sectional
study assessing salt
intake in a low
creatinine clearance
population
Andrea Dunne
176 Novel approaches to
control serum
phosphate; intensive
coaching of the patient
by the nursing team
Angele Aarts
24 Audit of the
effectiveness of the
Dietetic Assistant on a
renal ward
Joanne Tomany
Hall G
201 Vascular access status for
haemodialysis in pre-dialysis patients
Liljana Gaber
211 Dialysis efficacy: influence of needle
gauge
Rodolfo Crespo
284 Dialysis with two arterial needles in
fistulas with inadequate flow
Emine Yildizgor
Hall H
Chair:
John Sedgewick
Update on Projects of the
Education Board
John Sedgewick
Specialist Nephrology
Education in Portugal EDTNA accreditation
Maria Saraiva
European education policy
and practice: a review of
the vision and the reality
Judith Hurst
275 Online monitoring of the dialysate during This workshop will be
haemodialysis using UV-absorbance
followed by an advice
Fredrik Uhlindu
session on the
268 Compliance and re-training in peritoneal EDTNA/ERCA
dialysis patients: multicenter study
accreditation/
Valentina Paris
endorsement programme
for post-basic Renal
6 Common problems experienced when
courses and Renal
renal patients are admitted to a general
Education provided by
hospital
Renal Industry Partners.
Belinda Dring
236 Online Monitoring of Kt/V to allow
modification of haemodialysis treatment times
Katie Fielding
15
Tuesday 13 September
12.30
13.45
Lunch
Is Technology good for the
patient?
Impact of technology on the
patient
Dr. John Daugirdas
Chairs:
Waltraud Kunzle
GeorgiaThanasa
115 Individual styles of
adjustment to chronic illness
Monique Harskamp
185 The psychological impact
of technology on patients
undergoing haemodialysis
Georgia Gerogianni
Hall E 1
Hall I/K
European Practice compared
Paediatric practice and
Access Care
Jacqueline Knoll
Hall H
Patient care
Oral posters
Managing the disruptive
patient
Anaemia therapy
Workshop
Chairs:
Martin Gerrish
Teresa Ramalhal Teixeira
Abstracts and debate
Managing Anaemia in
patients not receiving
haemodialysis.
Transplant practice in Europe:
selection of patients
289 A computer training
Theodora Kafkia
package for renal patients
Roisin McLoughlin
Infection control practice
across Europe
10 Clinical pathways
Jean Yves de Vos
Esther Pol
Chairs :
Monique Elseviers
Maurice Harrington
Hall G
An unsafe environment – the
realities of violence &
aggression in Nephrology
Nursing in the UK
John Sedgewick
Chair:
Theodor Vogels
263 Preparing the dialysis
patient for transplantation by
a renal transplant coordinator
Revital Narkis
133 A multi-pronged approach
to patient aggression in the
dialysis environment
Julie Owen
328 Continuous venovenous
haemofiltration early after
liver or kidney/pancreas
transplantation
Biserka Bokulic
288 Managing the challenging
patient
Susan Wheeler
Chair:
Leslie Bennett
Managing anaemia in
transplant patients'
Fiona Barber
Management of anaemia in
chronic kidney disease
patients not receiving
dialysis, a nursing
perspective'
Carol Anderson
The use of intravenous iron
in the community'
Belinda Dring
299 Can permeability status of
peritoneum change over
years in patients with CAPD?
Ayperi Eyupoglu
314 Why is there a variability
of malnutrition prevalence
according to anthropometry?
Juan Manuel Manzano
Angua
15.00
Closing Session
How technology has bridged the gap for the patient
Tony Ward
Tony is a person with renal failure who is also a mountaineer and will be showing a video of some of his mountaineering exploits
Presentation of manuscript and poster scholarships
16
Guest Lectures
CHALLENGES OF CARE FOR PERSONS WITH KIDNEY DISEASE IN
CANADA
WHEN TECHNOLOGY IS NOT THE ANSWER
Alistair Chesser, MD
Barts and The London Hospitals, UNITED KINGDOM.
Patricia Dunn
Clinical Associate Professor, CANADA.
atients with end stage renal failure with high levels of co-morbidity
and dependency may choose to opt for conservative management,
and not to have renal replacement therapy. The evidence for which
patients benefit most from this course of management will be
discussed, as will the process of counselling patients about a decision
not to have dialysis. The role of a renal palliative care service will be
explored. Symptom management assumes growing importance in renal
end of life care. The pharmacological and non-pharmacological
management of fluid balance, pain control, nausea and vomiting, itch
and anaemia will be considered. Psychosocial issues in the decision
not to dialyse and in the dying process for these patients will be
explored.
here are a myriad of challenges in health care today throughout the
world. I will focus on those difficulties that specifically affect our
target population, persons with chronic kidney disease (CKD)
regardless of the place they may be within the continuum of care. You
may recognize some of these problems as familiar to your own country
in greater or lesser degree, as some of these challenges are a result of
world-wide issues in health care. I will also look at some
circumstances that may be unique to Canada and I will share with you
our trials and tribulations. I will also discuss some strategies that have
been proposed to begin to address some of these concerns. Among
the challenges that we experience in Canada are the exponential
growth of kidney disease (due in no small measure to the near
epidemic status of diabetes in Canada), the world-wide nursing
shortage and the vastness of our geography. I will look at some
proposed strategies that we can use to approach these and other
challenges as opportunities for nephrology nurses. Hopefully, together
with our international colleagues we can become visionaries and
leaders in health care delivery.
P
T
MIDDLE MOLECULE REMOVAL IN BIG SIZE PATIENTS:
HOW TO BRIDGE THE GAP?
NEPHROTIC SYMDROME: DIAGNOSIS AND TREATMENT
S. Eloot1, J.Y. De Vos2, R. Hombrouckx2, P. Verdonck1
Institute Biomedical Technology, Ghent University, Belgium. 2Dialysis
Unit, AZ Werken Glorieux, Ronse, BELGIUM.
Trond Cato Eide
Sentralsykehuset, Fredrikastd, NORWAY.
1
ephrotic Syndrome (NS) consists of five main clinical observations.
Proteinuria > 3-3.5 grams/day, hypoalbuminemia, oedema,
hyperlipidemia and a hypercoaculable state. Diabetic nephropathy is
the most common cause of nephrotic proteinuria. Several primary
glomerular diseases account for a great majority of cases of the NS.
The relative frequency varies with age. In adults the most common is
membraneous GN and in children minimal change GN.
The diagnosis of the glomerulopathy is usually achieved through renal
biopsy. Specific immunological treatment is available for only few
causes of NS.
Heavy proteinuria is a predictor of the rapid progression of renal
failure. The main therapeutical goal is therefore to reduce the
proteinuria. The main treatment is ACE inhibitors, NSAIDS and lowprotein diet. Immune therapy such as prednisolone, cyclofosfamide,
cyclosporines and mycophenolat mofetil can be tried with some. Loopdiuretics and salt restriction can be useful with the most common
underfilled patients. With other diseases such as AIDS, Hep B and C,
diabetes mellitus and amyloidosis it is important to treat the cause.
These patients have a hypercoagulable state. As long as they are in the
nephrotic range of proteinuria treatment with anticoagulants is
recommended in order to prevent tromboembolic complications.
Usually heparin and/or low dose acetylic salisylic acid are
recommended.
The hyperlipidemia constitutes a risk factor for vascular disease. The
main choice of treatment is statins. Diet with fish-oils or soy-protein
has not shown any statistical difference in the LDL cholesterol.
Considerable progress has been made in understanding the
pathogenesis of the NS. This has led to some rational strategies, but
nevertheless, current therapy is far from satisfactory.
N
he removal of middle molecules has been proven in some studies to
have a long-term effect on mortality. Therefore, the present study is
aimed at investigating the impact of flow and membrane surface area
on middle molecule removal in low flux Fresenius F6HPS dialysers.
Blood and dialysate flows were varied within the clinical range 300500mL/min and 500-800mL/min, respectively, while ultrafiltration rate
was kept constant at 0.1L/h. Single pass tests were performed in vitro
in a single dialyser (3 tests), and in serially (5 tests) and parallel (3
tests) connected dialysers. The blood substitution fluid consisted of
bicarbonate dialysate into which, radioactive labelled vitamin B12
(MW1355) was dissolved. Middle molecule concentrations of samples
taken at the inlet and outlet bloodline were derived from radioactivity
measurements and were applied to calculate the dialyser clearance as
well as the reduction ratio. For the latter, the surrogate middle
molecule vitamin B12 was assumed as distributed according a two-pool
kinetic model.
Adding a second dialyser in series or parallel ameliorates significantly
overall dialyser clearance and reduction ratio, except for the highest
applied blood flow rate of 500mL/min. Better solute removal is also
obtained with higher dialysate flows, while the use of higher blood
flows seemed only advantageous when using a single dialyser. Analysis
of the ultrafiltration profiles illustrated that enhancing the internal
filtration rate ameliorates the convective transport of middle molecules.
In conclusion, adequate solute removal results from a number of
interactions: blood and dialysate flow rates, membrane surface area,
filtration profile, and concentration profiles in the blood and dialysate
compartment.
T
17
Guest Lectures
DOES SIZE MATTER? THE DILEMMA WHEN ASSESSING CHANGES
IN A RENAL PATIENT’S WEIGHT
FAT BUT FIT – LIFESTYLE MODIFICATION FOR THE RENAL PATIENT
Barbara Engel
Nutrition and Dietetic Tutor. Surrey University. Guildford,
UNITED KINGDOM.
Barbara Engel
Nutrition and Dietetic Tutor. Surrey University, Guildford,
UNITED KINGDOM.
enal disease often results in changes in the patient’s body
composition. This can include: muscle wasting, fat loss, gain or
redistribution, fluid imbalance (changes in quantity and distribution)
and decreased bone density.
The measuring tools which are presently available all have limitations.
Techniques which can be used at the patients ‘bedside’ such as
skinfold callipers and ultrasound can result in large variations when
inter and intra-observer repeated measures are compared. More
reliable tools e.g. MRI, DEXA are often not available for routine clinical
use, therefore assessments involve a degree of subjectivity.
Body composition varies according to gender, ethnicity and age
therefore baseline measurements and subsequent changes can be
interpreted with respect to the normal ranges and expected changes
which are found in the healthy population. Some studies have
indicated however that the health risks attributable to the renal
patient’s body composition profile may differ from that of a healthy
person and this may have implications for the clinical decisions made.
Once the direction, magnitude and clinical significant of any changes
have been determined using the tools at their disposal, the clinician
has to initiate an appropriate intervention. Changes in one component
of body composition may have positive or negative effects on other
components and so the need for ongoing monitoring is essential.
This presentation will summarise the current knowledge regarding the
strengths and weaknesses of the different measurement techniques,
and the interpretation of longitudinal changes in order to determine the
patient’s response to the disease and the treatment and to help make
timely clinical decisions.
ardiovascular disease (CVD) has a major influence on morbidity and
mortality in renal patients. Fluid overload and tissue calcification are
known causes of CVD and various medication and / or dialysis protocols
exist for preventing or reducing damage caused by these factors.
Diet, physical activity and behavioural strategies are also known to
influence both the onset and outcome of cardiovascular disease in the
general population, with recommendations to achieve an ideal Body
Mass Index (weight/height2) of 19 – 26 kg/m2 and to exercise for 30
minutes daily. However it is also important to note that overweight yet
fit people have a reduced relative risk of dying from CVD compared to
slim and unfit people.
Cross-sectional studies in renal patients have revealed a low tolerance to
exercise which begins prior to starting dialysis. The subsequent low
activity levels are likely to have deleterious effects and hasten the
development of CVD. With respect to body composition there is some
evidence that the ideal BMI range of 19 – 26 kg/m2 may not be
appropriate for the renal patient (lower body weight patients have
reduced survival). For many patients their medication and dialysis
treatment may actually prevent them from achieving this ideal BMI range.
There is growing evidence from small intervention studies involving
lifestyle changes in renal patients that CVD risk factors can be affected.
Improvements in quality of life, exercise tolerance, body composition
and lipid levels have been measured. Taking into consideration the fact
that the negative implications of ‘extra’ body fat can be ameliorated by
increased activity, this paper will discuss the relative importance of
aiming for positive lifestyle changes in this population rather than
aiming for the ‘perfect’ BMI.
R
A EUROPEAN CORE CURRICULUM IN RENAL TECHNOLOGY BUILDING FOR THE FUTURE
Ray James
Barts and The London Hospital NHS Trust London, UNITED KINGDOM.
he highly technological nature of renal care requires a support
structure that includes technical specialists who maintain the
equipment employed. Working within the multi-professional team, the
renal technicians play a greater part in the functioning of the units than
in other less technical areas of care and, therefore, have a vital role in
maintaining standards of care.
The role of the renal technician has been changing and, now is one that
combines technical, scientific and clinical knowledge in utilizing the
technology so that the long-term outcomes of the patient are optimized
and complications reduced. Therefore a sound knowledge base is vital
in ensuring patients' safety.
Considering the large differences in training structures and resources
available for technicians, the EDTNA/ERCA technical interest group has
undertaken to provide curriculum guidelines for an educational
framework useable throughout Europe and beyond.
The curriculum content is intended as an introduction to Renal
Replacement Therapy and is mainly for use in the training and
development of technical staff working within a renal department,
although that does not preclude its use by others. The aim of the
curriculum is to provide the foundations upon which further knowledge
and experience can be built.
Whilst centred on 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. This extension of the curriculum to include the more
clinical aspects reflects the change in the technician’s role to a more
science-based approach.
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18
C
BRIDGING THE GAP BETWEEN KNOWLEDGE AND PATIENT CARE –
IS EVIDENCE BASED MEDICINE THE ANSWER?
Gert Mayer MD
Division of Nephrology, Department of Internal Medicine, Medical
University, Innsbruck, AUSTRIA.
odern evidence based medicine (EBM), whose philosophical
origins extend back to the mid 19th century Paris and earlier, is the
conscious, explicit and judicious use of current best available external
evidence in making decisions about the care of individual patients. The
basic concept is impressive and undisputed. Nonetheless, like many
brilliant ideas, the implementation into clinical practise has been slow,
even though appropriate tools have recently been developed.
The most serious problem currently is the uncritical use and sometimes
even deliberate misquotation of the concept. Some health care
professionals hide behind the glory of the term EBM when trying to
implement and/or reinforce strict application of guidelines. Without
doubt looking for the best available external evidence is a task common
to the development of guidelines and practise of EBM. EBM also includes
the individual patient in the decision process and therefore, if practised
seriously, can never lead to “cookbook” medicine.
Furthermore EBM is not a tool to minimise health care costs. This is in
contrast to some public opinion leaders, who try to persuade us that, for
example based on EBM, only those (new and expensive) therapies can be
used, whose effectiveness have been proven in randomised, controlled
trials (one of the highest levels of evidence achievable). EBM only asks
for the best available, but not best achievable external evidence. A public
discussion about the cost/benefit ratio of treating patients might (or
might not) be desirable, but this is beyond the scope of EBM.
In summary EBM has its merits and problems. The latter mostly relate
to the difficulty to really use it on a daily basis. The greatest danger
however comes from the abuse of the term EBM by various interest
groups.
M
Guest Lectures
INTERNATIONAL CHALLENGES OF HEALTH CARE IN EUROPE
FERTILITY AND PREGNANCY IN END STAGE RENAL DISEASE
Gert Mayer MD
Division of Nephrology, Department of Internal Medicine, Medical
University Innsbruck, AUSTRIA.
Jitka Pancirova
Haemodialysis Centre Parallel 50 Prague, CZECH REPUBLIC.
he reported frequency of conception among women of child-bearing
age on dialysis ranges from 0.3 to 1.5 percent. Although foetal
wastage is markedly increased when pregnancy occurs, recent
improvements in management have resulted in an enhanced frequency
of live births (40 - 50% of all pregnancies). The outcomes in two large
surveys have been similar in patients on haemodialysis and peritoneal
dialysis. This apparent improvement in outcome is thought to reflect
more aggressive management of the uraemic state, BUN target levels
being now at least under 50 mg/dl. In clinical practise this is usually
achieved by increasing the frequency of dialysis. Aggressive treatment
of anaemia is also warranted, as well as correction of metabolic
acidosis and hypocalcaemia. Foetal heart rate during dialysis should be
monitored and dialysis hypotension should be avoided. Nutritional
counselling as well as achievement of proper weight gain are also
important factors for a successful pregnancy.
Despite optimal therapy mothers are at increased risk for severe
hypertension and prematurity still occurs in most cases (mean
gestational age 30.5 weeks). In addition it may be advantageous to
delay pregnancy until successful transplantation has been performed,
as transplant recipients have a higher incidence of successful
pregnancies and fewer complications and birth abnormalities.
T
tudies show that the incidence of chronic kidney disease leading to
end stage renal failure is increasing throughout Europe.
Diabetic and vascular nephropathies represent the most common
causes of end stage kidney disease. Demand for renal replacement
therapy is increasing at 7-10 percent per year, with higher rates in many
Eastern European countries apart from the Russian Federation and
most post-Soviet countries.
The basic cost of dialysis has not changed, but the increase in the
number and severity of co-morbid factors leads to a significant increase
of costs per treatment for each patient. The implementation of
preventive programs can help to delay or slow the progression of
chronic kidney disease. Programmes for effective prevention or delay
of onset of renal disease offer opportunities and challenges to the
Health care team.
This paper will discuss the changing needs for education required to
meet advancing technology and to maintain and improve the high level
of care necessary for the complexity of renal disease.
EDTNA/ERCA has a significant role to play in the education process.
One of the main objectives of EDTNA/ERCA is to promote quality of
care for all renal patients through education, research and audit.
EDTNA/ERCA is the only renal association offering truly multiprofessional collaboration and exchange of ideas and research findings
on a European and worldwide level.
S
AN UNSAFE ENVIRONMENT – THE REALITIES OF VIOLENCE &
AGGRESSION IN NEPHROLOGY NURSING IN THE UK
John Sedgewick,
University of Teesside, Newcastle, UNITED KINGDOM.
he extent of violence and aggression (V&A) within the National Health
Service - NHS (UK) continues to be problematic for staff delivering
care. Increasing patients numbers with increasing public expectations,
often within limited human resources, add further to the burden and
stress encountered by health care staff. Violence and aggression results
from a complex combination of personal and situational reasons, such as
fear, anxiety or frustration, medical or psychological condition, drugs or
alcohol. The situation for staff working in renal units is wholly unique.
Withdrawing treatment would mean that a patient would be consigned to
death, which is unacceptable from all moral and ethical principles that
underpin healthcare.
During the UK Annual Nephrology Nursing Conference, an anonymised
survey of delegates was conducted to establish the extent and nature
of the violence and aggression that delegates experienced in clinical
practice.
T
Results:
• 79% of nurses reported violence and aggression in the workplace,
with the majority (64%) having had an experience during the last
year. The severity of attacks ranged from fractured sternum to knife
stabbing!
• The impact of such experiences resulted in increased levels of stress
(65%) and reduced levels of confidence (23%).
• 77% of respondents reported that renal patients were involved; most
respondents reported verbal abuse. Asked to identify causative
factors in order of priority, it seemed that the major cause was
patients’ expectations of service and staff.
Recommendations: This survey identified a number of important areas
for further research. The need for effective staff education in helping
staff cope and respond to violence and aggression remains an important
goal as is the need for those experiencing aggression to have their
experience handled sensitively and compassionately. The lasting effects
of being subjected to violence and aggression must be recognised and
help given to manage the stresses such experiences entail.
19
Guest Lectures
ANTIHYPERTENSIVE CHRONOTHERAPY AND CARDIOVASCULAR
MORBIDITY AND MORTALITY
Julian Segura MD, SPAIN.
ypertension is an important worldwide challenge for public health
systems. This relevance is related to its high frequency and
associated risks of cardiovascular and kidney disease 1-3. More than a
quarter of the world’s adult population –totalling nearly one billionhad hypertension in 2000, and this proportion will increase to 29% 1.56 billion- by 2025
In clinical practice, biological rhythms are not considered as a relevant
feature in management of hypertensive patients. The development of
ambulatory blood pressure monitoring and the rapidly growing
popularity of home blood pressure measurements by patients have
now generated a series of new clinical questions that are directly linked
to the chrono-biology of the cardiovascular system, such as the clinical
interpretation of a blunted nocturnal fall in blood pressure or the
difficulty of achieving adequate blood pressure control in the morning.
Today, there is growing evidence that night-time blood pressure, and
particularly the absence of a decrease in sleep blood pressure,
contributes to the occurrence of target organ damages, and that the
early morning rise in blood pressure increases the risk of developing
cardiovascular events, including stroke, perhaps independently of
24-hour blood pressure levels. A better understanding of the
importance of the circadian variations of blood pressure could certainly
have a major impact on our view of the therapeutic management of
hypertensive patients.
H
THE USE OF NEW TECHNOLOGIES IN PATIENT EDUCATION:
PATIENT WEBSITES
HOW TO PREVENT PROGRESSION TO END-STAGE RENAL DISEASE
Gere Sunder-Plassmann
Nephrologist, Medical University, Vienna, AUSTRIA.
he incidence of end-stage renal disease is increasing worldwide and
is associated with poor outcomes and high costs. Identification of
patients with asymptomatic chronic kidney disease (CKD) and
decreasing the rate of loss of renal function in CKD patients is therefore
a major public health issue.
Factors associated with the occurrence or progression of CKD include
older age, race and ethnicity, sex, low birth weight, low socioeconomic
status, smoking, alcohol consumption, familial aggregation, lead and
other heavy metals, analgesic abuse, illicit drug use, dietary
phytoestrogens, anaemia, oxidative stress, insulin resistance,
hyperlipidemia, proteinurea, high blood pressure, and poor glycaemic
control.
Causes of renal disease should be sought and treated if found.
Randomised controlled trials established inhibition of the renin
angiotensin system, blood pressure control, and glycaemic control as
targets for intervention to halt progression of CKD. Other concepts to
slow the progression of kidney disease may include dietary protein
restriction, smoking cessation, and lowering of cholesterol levels.
T
HOW TECHNOLOGY HAS BRIDGED THE GAP FOR THE PATIENT
Hans Vlaminck, on behalf of the Research Board of EDTNA/ERCA
Tony Ward
ngoing changes in healthcare are increasing the attention placed
on patient education. Patient education is an important factor of
many health promotion and disease management programs.
Responding to increased pressure to provide more informed and
interactive information resources to patients at less cost, patient
educators are realising the benefits of using computer technology to
support the health care learning process. It is suggested that use of
technology to improve patients’ knowledge and to involve them in
health care decisions leads to better health outcomes.
Despite the growing recognition of the importance of the Internet and
information technology to patients with renal failure, poor acceptance
of information technology in nephrology remains a problem.
Speculated reasons for this slow adoption include poor technologies,
lack of beneficial clinical applications, resistance to change,
technophobia and lack of financial incentives to change. This lecture
will discuss the evolution of computer technology in healthcare
education and, in particular, to examine the application of patient
websites in the process of knowledge transfer and skill development
necessary for health promotion and disease self-management. More
specific the use of internet resources in education of patients with
chronic renal failure will be discussed. Since it is difficult for patients to
asses the content of patient websites for relevancy and accuracy, we
developed a website with links to patient websites which were
reviewed by healthcare professionals in the field of nephrology. A
grading system was developed based on the Health on Net guidelines.
It is well documented in literature that the use of computer-based
education has a positive impact on clinical outcomes, knowledge
acquisition, self-care management, and skill development. Computer
based patient education has the potential to blend with and strengthen
the established health care learning environment.
W
O
20
hen professional mountaineer Tony Ward was diagnosed with end
stage renal failure in 1997 he thought his career and a way of life
he loved was over. Since then, despite being semi paralysed in one
leg, having severely reduced function in his right lung and the fact that
he required over 10 hours dialysis a day to survive, Tony not only
returned to mountaineering, but has climbed both Mont Blanc,
Europe’s highest mountain and Mount Toubkal, North Africa’s highest
mountain.
Now following a successful transplant in March 2005 he has set his
sights somewhat higher.
Whilst Tony is by no means a technological wizard this short
presentation will highlight what can be achieved when patients and
medical professionals work together to ensure the most appropriate
treatment for the individual.
Guest Lectures
COMPARISON OF TECHNICAL PRACTICE BETWEEN EUROPEAN
COUNTRIES
John Wright
Medical Physics Department. Crosshouse Hospital, SCOTLAND.
he Research Board started collecting data for the European Practice
Database (EPD) in 2002. Since then data has been collected every
year based on the situation on 31st December. The EPD questionnaire
was in three parts. One was a centre based questionnaire, the second a
renal unit based questionnaire and the third part was country specific.
The results allowed comparisons to be made throughout Europe
regarding PD and HD prescriptions, transplantation, access, medication
and dialysis technique. The Dieticians, Social work and Pharmacist
Interest Groups were surveyed as were the technicians.
The technical questions investigated water treatment, machine
maintenance, technician duties and training. Each country has been
able to compare data collected from all the centres in their country.
Last year in Geneva the HD and PD prescriptions were compared. Now
the technical information has been collated we can compare the
differences and similarities, between technicians in Europe.
Questions have been asked about attendance at professional meetings
and technical training courses. Do technicians train clinical staff? The
questionnaire looked at the different types of disinfection used for
machines and for water distribution pipe-work as well as bacteria and
endotoxin testing and standards.
From the results we will see where countries are similar and ask if that
means we are all correct or all wrong. Where we are different we should
be asking who is doing it best.
T
Corporate Education
VASCULAR ACCESS – THE ROLE OF THE NURSE
BRIDGE TO BETTER CARE
Gambro
Genzyme
he vascular access (VA) is truly the patient’s lifeline. VA
complications are associated with poor dialysis delivery, increased
morbidity and mortality. It is therefore paramount for the patient to
have a well functioning access and for complications to be identified
early.
Nurses have a vital role in relation to the care, monitoring and
maintenance of the VA.
Currently we face several problems in regards to VA – complications are
increasing, time between placement and a procedure to restore
patency is decreasing, revision of a failing access is expensive and
often of poor outcome.
We will briefly discuss the demands placed on the VA and the outcome
associated with the different VA alternatives. The focus will be on
arterial venous access (AV fistula and AV graft) and how problems can
result in a reduced dialysis delivery.
The nurse’s role includes – minimizing the development of
complications, optimizing dialysis delivery and detecting complications
as early as possible. We will discuss how nurses can achieve this by
good access care, intra dialysis monitoring and assessment of dialysis
delivery.
Finally we will look at how the working relationship between the nurse
and patient can help to maintain the patients lifeline.
G
T
enzyme Corporate Education Symposium will be exploring the
issues of dialysis patients in your units today. There will be a
discussion on the management of renal patients and the importance of
labs, compliance and education.
By reviewing the current mortality and phosphorus risk factors along
with accumulation and calcium load issues carefully, cardiovascular risk
factors as well as bone and mineral disorders in Chronic Kidney
Disease might be prevented.
Learn more about Fabry disease; a lysosomal storage disorder that has
a prevalence of 1 in 100 in the male dialysis population. See what
symptoms you should look for as a nurse to help diagnose these
patients, and learn about the impact of enzyme replacement therapy in
these patients with Fabry disease.
For all patients, the optimum strategy relies on patient education and
involvement along with the joint efforts of the entire clinical team.
21
Education
IMPROVING PATIENT EDUCATION THROUGH
PATIENT-LED FORUMS
A CLINIC TO PREVENT THE DETERIORATION OF RENAL
INSUFFICIENCY
S. A. Heatley;
Pre-Dialysis, Manchester, UNITED KINGDOM.
A. Brousseau;
Centre hospitalier ambulatoire régional de Laval, Montréal, PQ, CANADA.
n support of the initiatives and reports from the government since
2001, encouraging patients to take control of their chronic illness, we
have developed a patient education programme for pre-dialysis
patients in the form of two annual group meetings of 40 patients. The
ethos of these bi-annual evenings is to provide pre-dialysis patients
and their families with the opportunity to meet renal multidisciplinary
team (MDT) members, patients who have experienced dialysis
treatments and to portray to patients that they are ‘not alone’ The
evenings are by invitation and pre-dialysis patients with creatinine
clearance levels ranging from 15mls/min to 25mls/min are targeted.
Established dialysis patients their family members and friends are
encouraged to attend and offer advice, support and information to
prospective patients. The first hour includes structured information
giving from the multidisciplinary team ending with an ‘ask the panel’
session followed by refreshments. This allows the invited patients to
mingle with staff and experienced patients for one-to-one informal
chats. During this session we have ‘stalls’ with written information and
dialysis treatment demonstrations taking place.
C
I
The whole evening lasts about 2-3 hours and is well attended. As a
result of the evaluations we have developed smaller group sessions,
(10 - 12) to encourage more audience participation. They have been
very well attended and well evaluated. The developments from these
sessions include increased recruitment of patient volunteers, increased
numbers of stalls, support from the Kidney Patient’s Association and
most importantly increased benefits to the patients.
anada, as other western countries, faces an alarming increase in the
prevalence of renal insufficiency. In May 2001, the Clinic to Prevent
the Deterioration of Renal Insufficiency was established in Laval to take
charge of patients at the very early stage of the disease. For persons
with diabetes, the presence of microalbuminuria is an early indication
of diabetic nephropathy. Moreover, recent studies have shown that the
presence of microalbuminuria can be observed in up to 40 % of
patients with untreated hypertension, thus signalling a possible kidney
disorder.
Within the Clinic, we developed a specialized clinical program for
arterial hypertension and microalbuminuria. The goal is to take
nephroprotection measures as soon as possible through drug therapy
and the reduction of contributing risk factors. A multivalent care
program was developed by a interdisciplinary team involving
nephrologists, nurses, nutritionists, pharmacists and social workers.
Their main clinical activities are the identification of potential patients,
teaching, treatment of underlying conditions, counselling and drug
management. Those interventions aim to help patients to modify life
habits related to hypertension like overweight, lack of exercise,
smoking, improper nutrition and alcohol consumption. The team
suggests the appropriate changes and helps the patient to adopt self
monitoring strategies to maintain the necessary changes.
The Clinic also established a secondary prevention program for
patients with advanced renal insufficiency. The goal is to slow the
decline in kidney functions and to delay dialysis by strengthening the
patient’s fidelity to medical treatment and healthy life habits.
MEETING THE CHALLENGES OF RECRUITING AND RETAINING AN
EXPERT RENAL WORKFORCE
EDUCATIONAL AND PSYCHOLOGICAL INTERVENTION IN PATIENTS
WITH HYPERTENSION ON HAEMODIALYSIS
R. Tibbles;
Barts and The London NHS Trust, London, UNITED KINGDOM.
V. Anna, M. Lopez;
Parc Tauli, Sabadell, SPAIN.
ne of the greatest challenges facing the renal world is the provision
of an expert workforce suitably equipped to meet the complex
needs of a constantly increasing patient population. A multi-faceted,
flexible approach to recruitment and retention can yield positive results
in this vital aspect of renal management. This paper will discuss how a
large city hospital is managing this issue by adopting a pro-active
approach including multi-media advertising, national and local
recruitment events, international recruitment and career progression
from novice to expert practitioner.
Team work is fundamental to renal care and an important factor in
retaining skilled staff. Individuals need to feel valued and involved in
patient and management decision making. Flexible work patterns, part
time roles and job sharing can help staff balance their work and
personal life.
Opportunities for career and personal development should be available,
supported by relevant education and training with flexibility to meet
individual needs. This should range from seminars, study days and
conferences to university based degree courses. Staff should also have
the option to experience all aspects of renal care by designing roles that
allow them to move easily from one area of the renal unit to another.
Finally, professional boundaries need to be reviewed to facilitate new
and exciting roles. Many renal health professionals are keen to acquire
new skills and establish innovative methods of care delivery to meet
patients’ needs. This has the additional benefits of enhancing job
satisfaction and retaining an enthusiastic, skilled and experienced
workforce.
ackground: Hypertension is a high prevalent chronic disease in the
general population and has been recognised as one of the most
important and modifiable cardiovascular risk factor. Patients on dialysis
are especially difficult to be properly controlled. The aim of the study
was to improve blood pressure (BP) control among our patients on
haemodialysis.
Methods: The study group comprised patients with uncontrolled BP or
patients that needed more than three drugs. A pre-post intervention
design was performed.
An educational and psychological intervention was carried out in small
groups. The topics comprised: general information about hypertension
(mechanisms, pharmacological treatment, diet) and stress fighting
strategies. After an initial evaluation, we performed the intervention
and four months later, the same assessment was repeated.
BP measurements obtained in the dialysis Unit during a full month and
automatic ambulatory home BP measurements were analysed. Anxiety,
leisure and stress tests were assessed individually.
After excluding patients with physical and mental disability, the study
group consisted of 26 patients.
Results: A slight BP decrease was observed after the intervention and
this was obtained despite a slight reduction in the amount of
hypertensive medication. Anxiety and insomnia test improved, and
relationship with friends and relatives increased.
Conclusions: Nurses have an important educational role. That activity
can have relevant impact in order to improve the quality of life of our
patients. Interaction in small groups has improved communication and
trust. That experience has been perceived as very positive and 100% of
patients would repeat the experience again.
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22
B
Education
EVALUATION OF RESPONSE TO ERYTHROPOIESIS-STIMULATING
AGENTS USING ANAEMIA MANAGEMENT SOFTWARE
PATIENT'S SEXUAL HEALTH: DO WE CARE ENOUGH?
M. Waterschoot1, M. P. Derde2, R. Daue3, B. Degrève4, E. Suetens4;
OLV, Aalst, BELGIUM, 2DICE, Brussels, BELGIUM, 3EWAPPS, Brussels,
BELGIUM, 4Amgen n.v., Brussels, BELGIUM.
T. Ho, M. Fernandez;
Hospital del Mar (IMAS), Barcelona, SPAIN.
1
ntroduction: It is well documented that sexual problems often
accompany chronic health conditions, for example: chronic renal
failure, hypertension and diabetes mellitus. One of the responsibilities
of a nurse is to provide patients with information concerning their
health and treatment to achieve optimum outcomes, thus enhancing
patients’ quality of life. However, the authors observed that the nursing
clinical pathways in their practice seldom reflect the attention given to
patient’s sexuality.
Objective: This paper aims to confirm the hypothesis that health
professionals do not give sufficient care to patient’s sexual health and
to define the causes.
Method: A descriptive study consisted of close-ended questionnaire
was employed. The medical and nursing staff of a Nephrology
Department were included in the study (92.6% response rate).
Professionals’ opinions on the importance of patient’s sexual health,
difficulty in addressing this issue and attitude were explored.
Result: Staff’s opinion on the importance of patient’s sexual health is
moderately high. However, 86% admit that they do not give sufficient
attention and 92% never initiate to address sexual issue to patients.
The results reveal the impediment being in relation to awkwardness
and deficient sex education in dealing with this subject. Some staff
have expressed other deterring factors.
Conclusion: This study confirms that professionals do not give
sufficient care to patient’s sexual health due to their conservative
attitude and lack of skill in addressing sexuality. The authors therefore
suggest some ways in helping to bridge this gap.
I
uropean Best Practice Guidelines recommend haemoglobin (Hb)
concentration > 11 g/dl in patients with end-stage renal disease
(ESRD). Hb can be increased with erythropoiesis-stimulating proteins
(ESAs); however, 5-10% of patients respond poorly (Macdougall, 2002).
The primary aim of this prospective observational study was to educate
nurses to assess Hb response to ESAs and to evaluate potential causes
of hypo-response (blood loss, iron deficiency, infection and
inflammation, inefficacious dialysis, medication, vitamin deficiency,
malnutrition, secondary hyperparathyroidism (SHPT), or pure red cell
aplasia). The secondary aims were to evaluate the frequency and
causes of hypo-response to ESAs and to determine the proportion of
patients with Hb > 11 g/dl after 6 months of observation. ESRD patients
(n=402) receiving intravenous (IV) ESA treatment at 18 centres were
included. Using anaemia management software (ARAMIS), nurses
recorded Hb, ESA dose, and potential causes for hypo-response every 4
weeks. Hypo-response was defined as Hb ≤11g/dl and high ESA dose
(> 30,000IU IV epoetin/week or >100 mcg IV darbepoetin alfa/week)
prescribed at the current and previous visits, or mean Hb >11 g/dl with
high ESA doses for the previous 4 visits. The proportion of patients
treated with darbepoetin alfa, epoetin alfa, and epoetin beta was 64%,
19%, and 17%, respectively. The patient incidence of hypo-response
during the study was 14%, and a mean 9% of patients were hyporesponsive at any given time. After 6 months, 79% of patients had Hb
>11g/dl. Iron deficiency, medication (immunodepressants, ACEI), SHPT,
and inflammation/malnutrition were the most common potential
causes of hypo-response.
E
TO DETERMINE THE IMPACT OF A PROGRESSIVE RELAXATION
TRAINING ON ANXIETY LEVELS AND QUALITY OF LIFE IN DIALYSIS
PATIENTS.
TO EVALUATE THE EFFECTIVENESS OF A PATIENT GROUP
DIRECTION (PGD) TO ACHIEVE SERUM PHOSPHATE LEVELS
(0.8 - 1.8MMOL/L)
^
D. A. Yokum, G. Glass, C. Cheung, J. Cunningham, S. Fan;
Royal London Hospital, London, UNITED KINGDOM.
Y. K. Yildirim, Ç. Fadıloglu;
Ege University High School of Nursing, Izmir, TURKEY.
Introduction: Hyperphosphataemia:
im: This study has been planned as an experimental research in
order to determine the impact of a progressive relaxation training
on anxiety levels and quality of life in dialysis patients.
Materials and methods: 46 patients (19 haemodialysis and 27
continuous ambulatory peritoneal dialysis) who had been treated with
dialysis in the Dialysis Unit Ege University Faculty of Medicine between
05 February-05 August 2001 were the study sample.
The data was collected by means of a questionnaire. Patients
Recognition Form, State-Trait Anxiety Inventory, Quality of Life Index for
dialysis patients were used to collect the necessary data. As training
material, a Hand Book written by investigations and a Relaxation
Training Cassette were used. All the forms were applied to all patients
prior to progressive relaxation training. Progressive relaxation training
sessions were given to the all patients by the investigator. After six
weeks from onset of progressive relaxation training, State-Trait Anxiety
Inventory and Quality of Life Index questionnaires were given to all
patients.
Evaluation of data: student t test, one way variance analysis, further
tuckey post hoc test and the person’s moment product correlation
analysis were used.
Results: The result of the study imposed that; progressive relaxation
training for dialysis patients decreased state-trait anxiety level and has
a positive impact on the quality of life.
.
- Frequently affects well nourished patients on HD weekly
- In conjunction with metastatic calcification of soft tissues, increases
the mortality rate in HD patients. A PGD was designed to enable renal
research dietitian / pharmacists extend their roles into phosphate
management.
Study Design: RCT - two part study with four groups
Method: Part 2 (Dec '03 - Mar'04)
34/39 stable adult patients with hyperphosphataemia originally
recruited were available to participate.
Group
(study group)
Patient Details
Individual
Advice from:
Intervention
(1 + 3)
11male:6female
Mean Age yrs:51.1+/-12.7
Research Team
Control
(2 + 4)
12male: 5female
Mean Age yrs: 47.6+/-14.4
Renal Dietitian and
doctor (standard practice)
Serum phosphate and calcium levels were measured monthly. Serum
intact parathyroid hormone (iPTH) was measured pre and post
intervention only.
Results: Post intervention (intervention and control groups respectively)
Mean serum phosphate was 1.81+/-0.54mmol/l vs 2.1+/-0.25mol/l
(p=0.09) Mean serum phosphate difference achieved was -0.22+/0.67mmol/l vs 0.19+/-0.32mmol/l (p=0.03) Mean serum calcium x
phosphate product was 4.43+/-1.2 mmol2/l2 vs 4.80+/-0.51mmol2/l2 (p=
0.10) Mean serum calcium x phosphate product difference achieved was 0.58+/-1.62mmol2/l2 vs 0.19+/- 0.32 mmol2/l2 (p=0.04)
Mean serum iPTH was 59.2+/-51.3pmol/l vs 52.2+/-49.5pmol/l (p=0.7)
Conclusion: - Despite small sample size positive changes to some relevant
parameters were achieved using a PGD to assist phosphate management.
A
23
Education
ANGIOTENSIN CONVERTING ENZYME INHIBITORS AND
ANGIOTENSIN 2 RECEPTOR BLOCKERS CLINIC. TWO ADVANCED
PRACTITIONERS’ EXPERIENCE
KIDNEY DISEASE EDUCATION AND PREVENTION PROGRAMME
(KDEPP). IDENTIFYING A COMMUNITY AT RISK
P. Simoyi;
University Hospital Birmingham NHS Trust, Worcestershire,
UNITED KINGDOM.
P. Simoyi;
University Hospital Birmingham NHS Trust, Birmingham,
UNITED KINGDOM.
his abstract will outline the work of two Advanced Nurse
Practitioners (ANPs) in jointly establishing a successful nurse-led
Angiotensin Converting Enzyme inhibitor and Angiotensin 2 Receptor
Blockers clinic. A high proportion of renal patients die from heart
disease as a complication of chronic renal failure. The cardio-protective
and reno-protective effects of the above groups of medication are cited
in much recent national and international research to include the Hope
Study, and the RENAAL studies to name a few. The need to introduce
these beneficial treatments cautiously and carefully was noted hence
the two ANPs were called upon to run the clinics.
Initially one of the Nurses was involved as the other was still finishing
her advanced training. With the assistance of one of the consultants
she developed the protocol that is currently in use. This clinic is held
once a week, 7 days after initiation of the medication by the doctors.
The patients’ biochemical results are reviewed after a systematic
history is taken and a thorough patient assessment is carried out to
exclude any adverse effects of the medication and other problems.
Those with complications are swiftly referred back to the medical
clinics for further management.
This clinic has become very successful and very popular with patients
as they feel they have time to ask a lot of questions and to learn more
about their condition and treatment.
his abstract will describe the steps taken by a group of Renal
Professionals to reach and educate the Afro-Caribbean population
about the risks of developing end-stage-kidney disease, Diabetes and
hypertension, through the Kidney Disease Education and Prevention
Programme. Most of the causes of end-stage-renal failure (ESRF) in the
Afro-Caribbean population, such as hypertension and Type 2 diabetes
are modifiable and are known to cause more end organ damage in this
community than in other communities. This population also has
difficulties in securing kidney transplants due to the complexity of their
tissue type.
Recent literature asserts the prevention of ESRF as one of the ways of
tackling this problem. Therefore a proposal was written to the Health
Providers to secure funding to support this project through a well
known programme, the “A Better Life through Education and
Empowerment” project which is run by a charitable organisation.
The education programmes were launched in a very busy shopping
mall in a big city in November 2004 with the support of a big
pharmaceutical chain , where leaflets were handed out, people had
their blood pressures checked and were advised on the risks of
developing Heart disease and kidney disease. Some of the findings on
these days were disturbing. These days are now held in the community
centres and literature is distributed in churches, Hairdressers shops
and at venues where the Afro-Caribbean people are holding functions.
The feed back has been very good. The project will be continuing for
the next three years.
T
T
Haemodialysis
THE EFFECT OF POST DILUTION ONLINE HAEMODIAFILTRATION ON
TRANSONIC ACCESS-FLOW MEASUREMENTS.
CUSTOM MADE RASTER METHOD FOR FISTULA AND GRAFT
C. Blokker;
Medical Centre Alkmaar, Alkmaar, THE NETHERLANDS.
R. Visser, M. Vette, F. Aarrass;
Dianet dialysis centres, Amsterdam, THE NETHERLANDS.
ntroduction: Unfamiliarity with fistula and graft characteristics can
lead to failed punctures, haematoma and sometimes access
occlusion. The Custom-made Raster Method provides detailed shunt
visualisation and angiographic images together by using photo editing
software. Access veins of an individual shunt and an adapted raster are
projected on a digital picture of the arm.
Method: During angiography the shunt arm is fixated and a digital
picture is taken from a fixed vertical angle and distance. Reference
points are marked on the shunt arm, which serves as a fixation to draw
a raster with coordination points. In this way a picture is created like a
roadmap with veins. There is complete integration of digitally and
radiology images by using software programs (Adobe Photoshop® +
Illustrator® en Agfa Web 1000®) under Windows XP®. All Illustrations are
made fit 1:1 by scaling up or down without distortion. Editing with
Photoshop® gives a precise projection of shunt veins on the real
coloured background of the digital photograph. In this projection the
grey angiography background is made completely transparent. The
system can contain more detailed information in combination with echo
(duplex) images of depth and diameter.
Results: This visualisation method is a useful tool for multi disciplinary
access meetings with intervention Radiologists, Access Surgeons and
Nephrologists. Access malfunction, aneurysms and stenosis can be
projected at the exact location. The system leads to clear and concrete
puncture advice. Transfer of access information and communication to
other dialysis centres is facilitated.
ransonic HD01 access flow (Qa) measurements use saline as
indicator. Substitution of fluid during post dilution HDF-online
treatment could interfere with these measurements. We researched
whether this interference is present.
27 patients with an AV-fistula or graft were dialysed on Gambro
AK200ultraS and Fresenius 4008H machines, using an effective blood
flow of 400ml/min and a substitution flow (Qs) of 83ml/min. Qa
measurements were carried out 3 times during HD mode and 3 times
during HDF mode. From these results a mean was recorded. Statistical
differences were tested with paired sample t-tests.
88 measurements were carried out; there was no significant difference
between HD and HDF Qa measurements. Means compared in Gambro
and Fresenius results also showed no significant difference. 20% of
Fresenius measurements were successful at Qs=83ml/min. In the
remaining 80% Qs needed to be lower to achieve successful
measurement. In 27% of Fresenius measurements with Qs <83ml/min,
successful measurements could only be established using minimum Qs
of 20ml/min. All Gambro measurements were successful with Qs of
83ml/min or higher. Test failure with the Fresenius could be explained
by the administration of substitution fluid in the venous bubble
catcher.
Problems with Qa measurements during HDF appear to be merely
technical. When a successful measurement is achieved, there is no
difference between HD and HDF. Fresenius 4008H doesn’t always
tolerate Qa measurements during HDF, whereas the Gambro machine
can. Therefore, to eliminate any Transonic errors, we recommend that
the Qa be measured directly after patient connection, but before
commencement of HDF.
I
24
T
Haemodialysis
THE MYTH OF THE ISOLATED MACHINE: BLOOD BORNE VIRUSES
AND HAEMODIALYSIS MACHINES
GIVE PRIORITY TO SELF-CARE IN HAEMODIALYSIS
G. Murcutt;
Royal Free Hampstead NHS Trust, London, UNITED KINGDOM.
R. Dahan, O. Ostolosh, Z. Gavish, Z. Burbea;
Rambam medical center- Dep. Nephrology, Haifa, ISRAEL.
he latest advice for UK dialysis units about managing patients with
blood borne viruses (BBV’s) came from the Department of Health
(DH) in 2002. This recommends ‘isolating’ haemodialysis machines for
certain patients/groups, however this has often led to increasing
numbers of ‘isolated’ machines.
A questionnaire was designed and sent to Renal Technologists that
asked about the management of haemodialysis machines, BBV
patients and related issues.
The survey results showed the majority of units use heat, chemical or a
combination of these to disinfect between patients. One extra
disinfection cycle is often added before isolated equipment is returned
to a common pool of spare machines. Environmental and surface
decontamination procedures varied considerably amid repeated
concerns about the balance between thorough disinfection and
equipment damage.
There is no definition of an ‘isolated’ machine and the survey results
suggest that such machines, though easily de-isolated, are often only
used for three treatments per week. The guidance views the risk of
vertical BBV transmission via the machines’ internal flowpath as
remote, yet disinfection of this flowpath is often viewed as the main
criteria for de-isolating a machine. Better protection for patients and
staff may result from a review of surface decontamination with help
from equipment manufacturers.
Haemodialysis machines are a key resource in busy renal units and
require careful management. The Department of Health guidance
suggests surface contamination is a significant risk when managing
BBV patients yet it often has a lower priority than internal disinfection
cycles in determining the status of machines.
ationale: “Self-Care” is part of the nephrology patient’s
rehabilitation, including perceptional changes and acquired behavior.
It enables patient involvement, provides feelings of responsibility,
independence and control over life (Orem, 1985). 70% of patients in the
unit can care for themselves, on different independence levels. We
believe that exposure to this subject and guidance will strengthen
feelings of self-belief.
Goal: Developing patients’ abilities for self-care, out of responsibility,
independence and control of the disease.
• Identifying patients’ abilities, learning needs.
• Raising awareness amongst patients and staff.
• Intensifying patient involvement in treatment process.
• Suiting guidance programs.
Process: Surveying literature - Training staff Setting criteria, guidance
plan-knowledge, technical skills - Identifying delaying factors - Setting
follow-up methods.
Results:
• 85% of patients found suitable for the guidance plan, 80%
expressed willingness to participate.
• Main delaying factors were fear of self-injecting and lack of technical skill.
• 80% of patients perform self-care on different independence levels,
20% reached full independence.
• Success of patients encouraged others to join the programme.
• 100% of patients expressed satisfaction.
Conclusions and Recommendations:
1) Patient involvement and independence, as well as guidance
programme and support, raise faith in self-abilities.
2) Involving staff provides support and encourages patient independence.
3) Patient exposure to self-care in Haemodialysis from the Pre-dialysis
stage.
4) Self-care programme must constitute an integral part of the
rehabilitation plan.
5) Researching the influences of self-care on the treatment results, and
the patient’s general feelings, in the wide spectrum of life.
IDENTIFICATION, ASSESSMENT AND TREATMENT OF THE DIABETIC
FOOT AMONGST CHRONIC HAEMODIALYSIS PATIENTS
Methods and Results:
• 42% of chronic Haemodialysis patients at the Medical Centre are
diabetic
• 100% of diabetic patients interviewed
• Continuous contact between treating staff and the community
• Amongst 50% of diabetic patients an increased noted in response to
treatment
• All diabetic patients are examined once a month, to identify and
treat sores on feet
• Amongst 20% of patients improvement noted in HbA1C value
• Professional cooperation intensified between hospital experts
Conclusions:
• systematic follow-up will improve results and prevent complications.
• Awareness and initiative by multi-disciplinary staff will increase
treatment success.
• Treatment management for diabetic nephrology patients will be
coordinated at the mother unit, with cooperation from hospital and
community.
• Involving and guiding patients constitute significant factors in
improving health state and identifying problems.
T
R. Elias, D. Brik, Z. Gavish, M. Levin, N. Barer-Yanai, M. Buchnik;
ntroduction: Throughout the world we witness a gradual rise in the
prevalence of diabetes. Ronald and co-workers (2003) state that 40%
of all dialysis patients are diabetic. Angeorzan and Deery (2001) state
that the chance of lower limb amputation amongst haemodialysis
patients, with diabetes, is 10 times higher. In this paper we examine
follow-up methods, assess patient situation, and compile an
intervention plan.
Goals:
• Identifying deficiencies in existing treatment methods
• Managing the diabetes treatment within the Unit
• Raising patient awareness and staff motivation
• Improving objective diabetes indexes of the disease
• Providing an intervention plan
Process:
• Literature surveyed and treatment management deficiencies
identified
• Clinical and statistic data collected
• Multi-disciplinary team established
• Guidance booklet compiled
• Conclusions and recommendations derived
I
R
25
Haemodialysis
CARE MANAGEMENT OF PATIENTS WITH VASCULAR ACCESS
PROBLEMS
MAKING HEPARIN -FREE HAEMODIALYSIS WORK!
Y. Grieve
Renal Unit, Dundee, UNITED KINGDOM.
B. Lahav, T. Chayu;
Rabin Medical Center, Petach Tikva, ISRAEL.
arious methods have been described for performing heparin-free
haemodialysis in patients with a high risk of haemorrhage but none
of these has entered widespread use.
We initiated various methods but without success, in particular, in
patients with low bloodflows.
We describe an effective method using the principle of pre-dilution
haemodiafiltration without anti-coagulation.
The protocol included:
• strong indication for potential haemorrhage
• maximum treatment time of 3 hours
• Patient bloodflow to be maintained over 250mls/min
• Pre-dilution haemodiafiltration set at 2litres/hour
Various parameters were monitored including activated clotting time
(ACT), system pressure and visual inspection of venous chamber for
clots.
The dialyser used was a standard high flux membrane.
30 treatments in 13 patients were evaluated. One patient clotted their
circuit, two required early termination of treatment due to visual
inspection indicating possible clots in venous chamber.
No correlation was noted with ultrafiltration volume, bloodflow or ACT
monitoring. All other treatments were successful and delivered target
clearance and fluid removal.
Our method is a safe and reliable way of delivering heparin-free
dialysis to patients with both acute and chronic renal failure using low
volume pre dilution haemodialfiltration.
P
V
IMPROVED EFFECTIVENESS OF DIALYSIS THROUGH ONLINE
HAEMODIAFILTRATION
atients receiving Haemodialysis (HD) require a vascular access (VA)
to provide sufficient blood volume for this treatment.
Following the placement of the VA, complications can occur such as
bleeding, infections, edema, pain and emotional stress. Our goal is to
prevent these complications and decrease the patients' suffering.
The care of the VA involves a number of medical personnel:
nephrologists, surgeons, radiologists, cardiologists, nephrology nurses,
etc. The patient can be sent from one doctor to another, without
guidance and at times, with no communication between them.
Our assumption is that if one nurse coordinates all these activities, this
will reduce the patients' suffering and reduce the number of VA
complications.
Our goal was to create a VA center in which all activities concerning VA
will be concentrated and managed by a vascular access coordinator
(VAC), who will work together with the multidisciplinary team.
We established a VAC in our unit and created specific guidelines for this
role in HD care and in the coordination of the multidisciplinary team.
For the last two years, our VAC cares for VA from the creation of the
access, to observing for complications and treating them immediately.
As a result, there was a reduction in the number of VA complications, a
great improvement in the condition of the patients' health and an
improvement in staff satisfaction.
In conclusion, we found that implementing a VAC in HD units is an
important factor in providing successful treatment for all of our
patients.
HIGH DIETARY SODIUM INTAKE CONTRIBUTES TO SODIUM
RETENTION IN HAEMODIALYSIS PATIENTS
S. R. Rogers;
Dianet, Amsterdam, THE NETHERLANDS.
P. J. McLaren, M. Suresh, J. Dowsett, G. Nevett, K. Farrington;
The Lister Hospital, Stevenage, UNITED KINGDOM.
oving to a purpose built dialysis unit in our hospital gave us the
opportunity to implement on-line haemodialfiltation techniques.
The water quality met our national and European standards of water
control.
A group of six patients were selected to monitor the effectiveness of
the technique. Two had long-term polyneuropathic symptoms, two had
high phosphate levels, and two had cardiac problems resulting in
hypotensive instability during haemodialysis and were selected for
haemofiltration. The patients were observed closely and blood results
examined to monitor all solute clearance with particular attention to
beta2microglobin. Within two months the results showed that the
patients with polyneuropathy had much reduced symptoms. All the
patients with high phosphate levels had significantly reduced the levels
to within normal values. Both the cardiac patients had marked
improvement in terms of haemodynamically stable dialysis. However
within some months we were experiencing technical problems with
both of these patients and were unable to reach sufficiently high
filtration targets to make the haemofiltration effective. Both the
patients were placed back on haemodialysis and the former problems
returned. The problems encountered were to do with either an
inadequate working fistula, or that too many alarms caused by high
system pressure and trans-membrane pressure possibly resulting from
increased haemoglobin levels made the dialysis unworkable in
practice.
Self reported quality of life has improved significantly for the remaining
4 patients who feel the benefits of broad-spectrum solute removal. As a
result more patients are now included in our HDF dialysis program.
W
M
26
e studied the relationship between sodium gain during a 48 hour
interdialytic period, sodium loss during a subsequent HD session
and their relationship to other indicators of volume change including
IDWG, change in blood pressure (BP) and change in ECF volume.
20 subjects were randomly selected. During the interdialytic period, we
estimated salt intake, IDWG, interdialytic urinary sodium. During the
subsequent HD session we studied changes in BP, relative blood
volume, ECF fluid volume and sodium mass balance.
Full data was available on 17 patients. Mean fluid and sodium intakes
were 2.54L ± 0.62 and 223.1 ± 86.8 mmol/l respectively. Mean total
sodium mass balance was -70.7 mmol ± 245.5 mmol, indicating sodium
retention. Total sodium mass balance was correlated with change in BP
in patients with residual renal function (r = -0.706, p = 0.026) but not
in anuric patients. There was a strong correlation between dietary
sodium intake and weight gain in the anuric patients (r=0.914,
p<0.001). Sodium loss during HD correlated with change in RBV
(r=0.493, p<0.05), and with change in ECF volume (r = 0.347, p =
0.086) but not with change in mean arterial pressure.
Most HD patients have high salt intakes and this has a significant
influence on fluid intake and IDWG. Sodium removal on HD is
insufficient in most cases to overcome high sodium intake and overall
sodium retention was the norm in this small study. We have ignored
losses in faeces and sweat, but including these would not significantly
alter our conclusions.
Haemodialysis
THE NEED FOR COORDINATING OF CARE IN AN AGING DIALYSIS
POPULATION
A NEW TOOL: AN INNOVATIVE APPROACH TO IMPROVING PATIENT
OUTCOMES IN A HAEMODIALYSIS SETTING.
F. Hardy, E. Vanstraelen, E. Witkowski, K. Schepers, B. Demoor;
virgajesse ziekenhuis, Hasselt, BELGIUM.
A. E. Raynor;
Loughborough Dialysis Unit /University Hospitals Leicester,
Leicestershire, UNITED KINGDOM.
ackground: Every dialysis patient who is not eligible for a kidney
transplant, is bound to die while being in renal replacement
therapy. So those patients are to be managed in a palliative
perspective.
Our aim was, within the renal multidisciplinary team, to assess the
amount of care needed and to amend the continuity of care, to have a
better detection of problems and to better cooperate with the
community nurse and the caretakers at home, in order to have a decent
Quality of Life.
We do not use the term “palliative care” but rather “care planning”,
because we want to do more than just accompany the patient when his
life comes to an end.
Method and material: We selected the patients according to an existing
DNR- code:
How extensive was the need for care, if the patient was cared for by a
community nurse or other caretakers at home, his psychological
condition and finally according to this question: ”Would you be
surprised if he dies within the year?” If NO, then he would be selected.
Every coordinator of care focuses on a few patients and fills out a
specific care plan. He is the link between our renal multidisciplinary
team, the community nurse and other caretakers at home. Every month
the team discusses the problems and possible solutions.
Conclusion: With this care plan the coordinator of care is able to assure
a more structured and continuous care, while holistically addressing
the wishes and needs of the patient.
B
ntroduction: Challenges of effective multi-disciplinary team
performance, enhanced patient outcomes and educating junior staff
in a Satellite Renal Unit have prompted the design of a new tool to
address these issues. A project plan was created and it included the
design, implementation and evaluation of a dynamic three monthly
documentation tool to be used by all Health Professionals. The tool
focuses on eight main areas of renal care, adequacy, blood pressure
control, access, anaemia, diabetes, infection control, nutrition and
bone disease. Moreover, it did include tissue viability, manual handling
and social aspects of their care so was ideal in providing an holistic
approach to the patient's care.
Objectives:
1. Excellent patient outcomes.
2. Effective Multi-disciplinary communication.
3. Increased knowledge base for junior nurses.
Evaluation: This was achieved by audits reviewing progress in the eight
areas of renal care highlighted by the tool and how effectively staff
were utilising the information from the documentation. A
comprehensive questionnaire was designed to analyse the nurses'
renal care knowledge and this highlighted training needs.
Conclusion: The tool has proven to be an invaluable document to
significantly enhance patient outcomes and has resulted in logical
comprehensible documentation for all Health professionals.
Inexperienced nurses judged it as a powerful learning tool and found it
enhanced their patient relationship.
I
NOVEL APPROACHES TO CONTROL SERUM PHOSPHATE;
INTENSIVE COACHING OF THE PATIENT BY THE NURSING TEAM.
BLOOD VOLUME MONITORING - CAN WE DELIVER SAFE DIALYSIS
WITH NO HYPOTENSION AND NO FLUID EXCESS?
A. E. Aarts, M. Custers, J. Burema;
University Hospital Maastricht, Maastricht, THE NETHERLANDS.
N. Cohen, L. Schwartz, A. Marcovici, I. Rechtman, L. Michalashvily,
D. Tovbin;
Soroka Medical Center, Beer-Sheva, ISRAEL.
ackground: There is much evidence that higher concentration of
serum phosphate and calcium is associated with an increased risk
of cardiovascular death. According to the K/DOQI guidelines for Bone
Metabolism for haemodialysis patients the adjusted calcium level
should be 2.1 -2.37 mmol/l, the serum phosphate 1.13 - 1.78 mmol/l
and the calcium phosphorous product < 4.5 mmol2/l2. Despite new
medication it is difficult to reach target values. The ability to control
adequately mineral metabolism rests on appropriate education, patient
compliance and the correct use of medication.
Methods: 61 chronic haemodialysis patients were intensively coached
by specialised nurses. On bi-weekly basis the serum calcium and
phosphate was measured and results were discussed with the patient.
When serum phosphate levels were high they tried to find out possible
reasons for this. If necessary changes to the diet or medication were
implemented. The mean serum phosphate and calcium and the
percentage of patients meeting the K/DOQI guidelines during six
months before the beginning of the coaching and six months after were
compared.
Results: Serum phosphate fell from a mean value of 1.99 ± 0.4 mmol/l
to 1.6 ±0.6 mmol/l. Mean serum calcium was not changed 2.2 ±0.4
mmol/l to 2.2 ±0.4 mmol/l. The mean calcium phosphate product
decreased from 4.5 ±2.4 mmol2/l2 to 3.6 ±1.4 mmol2/l2. The
percentage of patients meeting K/DOQI guidelines for phosphate
increased from 33 to 62%, for calcium- phosphate product from 53 to
83%. Elemental calcium dose did not change.
Conclusion: Intensive coaching of haemodialysis patients can improve
calcium-phosphate homeostasis.
B
ackground: Volume overload and hypertension due to post-dialysis
fluid-excess contribute to increased morbidity and mortality. Blood
volume (BV) monitoring (BVM) is an auto-control system with
automatic ultra-filtration that pauses to avoid hypotension at critical
relative BV (RBV) (critRBV) set-in at the beginning of haemodialysis
(HD). CritRBV is defined in a number of dialysis sessions as the highest
RBV associated with hypotension. In the absence of hypotension,
critRBV is defined by the lowest value of the minimal RBV achieved in
non-hypotensive sessions.
Hypothesis: Since each patient has variability in pre-haemodialysis
weight (pre-HDW) and BV, critRBV determined by low pre-HDW and BV
sessions may lead to incomplete fluid-removal in high pre-HDW
sessions. Thus, a variable (V) range of critRBVs determined according
to pre-HDW may be associated with less post-HD fluid-excess than
"uniform"(U) critRBV as recommended by manufacturer.
Methods: 20 chronic hospital-based HD-unit patients were screened for
a 3 phase pilot study. Baseline (B) phase assessed minimal RBV for
determining one U critRBV and a range (2-3) of V critRBVs according to
pre-HDW. 10 patients, who had pre-HDW variability, were assessed for
V and U critRBV in cross-over study.
Results: The difference in post-HD fluid-overload between the V to U
phases exceeded 600 ml {(V-B) vs. (U-B) =-290+860 vs. 319+625,
p=0.039, 1 tailed Wilcoxon signed-rank test}. Half of the patients
presented hypotension at baseline and its frequency increased in 2 of
those patients in V phase.
Conclusion: this pilot-study suggests that using of variable pre-HDW
dependent critRBV limits post-HD fluid-excess.
B
27
Haemodialysis
COGNITIVE PERFORMANCE AS A FUNCTION OF HAEMODIALYSIS
TRAINING OF HAEMODIALYSIS NURSES FOR THE ROLE OF
VASCULAR COORDINATOR
R. E. Steenveld;
North West Dialysis Service - Melbourne Health, Melbourne,
AUSTRALIA.
E. Milo1, I. Romach2, N. Shwartz3;
1
Western Galilee Hospital, Nahariya, ISRAEL, 2Sorasky Medical center,
Tel Aviv, ISRAEL, 3ISRAEL.
ackground: Although daily dialysis has consistently been shown to
have physiological benefits, little is known about its effect on
psychological or neurological function. The aim of this pilot study was
to determine whether daily dialysis improved cognitive performance
and quality of life (QOL).
Methodology: Cognitive performance was assessed using computer
based, traditional cognitive tests (TCT) on 6 well-dialysed patients by
comparing their performance on 3 sessions/week for 1 month with
their performance on 6 sessions/week for 1 month. Anxiety levels were
assessed using salivary cortisol as more frequent dialysis may have
increased anxiety levels, hence altering cognitive performance.
Patients’ perception of their QOL was assessed using the SF 36 QOL
questionnaire and Renal QOL Profile prior to and after the change to
the more frequent regime.
Results: Based on the TCT, there was a twofold improvement in local
perception (p=0.02), although other cognitive tests appeared to
change little on daily dialysis. The analyses of the SF36-QOL
questionnaire showed a 40% improvement on the physical component
after daily dialysis (p=0.02) while there appeared to be no change on
the mental component score. Salivary cortisol test results showed no
change in anxiety levels.
Conclusion: In this pilot study, daily dialysis was found to improve
physical but not mental aspects of QOL and, an improvement in local
perception on the TCT. Although this study is limited by sample size
and intervention period, it has been shown that even short term, high
frequency dialysis has the potential to improve QOL and some cognitive
indices.
ne of the biggest problems for Haemodialysis patients is Vascular
Access (VA), due mainly to severe damage to blood vessels caused
by underlying diseases. As KM of EDTNA/ERCA together with the
research board forum of Nephrology nurses, we realized the need for
training a VA coordinator in every dialysis unit. This nurse would be an
expert that would coordinate the work of the multidisciplinary team.
In order to determine the exact educational needs, we built a
questionnaire and sent it to all the units in the country. We received
answers from 75% of the units. Based on the outcome, we built a
programme of five workshops. One nurse from each unit was invited.
We had representatives from 60% of the units. The content of the
workshops included aspects related to Haemodialysis patients: types
of VA, preparation of patients for the creation of VA, the first use of the
VA, identification, prevention and treatment of complications, and care
of central vein catheters.
The instruction included lectures by VA specialists, group discussions
and presentations of standards.
Results: By using evidence based learning, we qualified a group of VA
coordinators to improve the treatment of ESRD patients. The group also
serves as a peer review group and meets periodically to update
information.
Conclusions: We found that the education of nurses on specific
problematic issues highly improved their knowledge and motivation
and improved their ability to cope with VA related problems.
B
O
CONTINUOUS QUALITY IMPROVEMENT IN DIALYSIS BY USING AN
INTERNATIONAL STANDARDS ORGANIZATION.
A. Marcovici, N. Cohen, P. Shlepher;
ackground: The rationale behind the decision to join International
Standards Organization (ISO 9002) was the belief that every patient
in our Dialysis Unit is entitled to treatment of the highest quality
available at any given time, from every aspect, namely, all the clinical,
technical, medical, nursing and other related services. In order to
achieve maximal efficacy it was necessary to identify and organize the
basic processes of care, in cooperation with all the members of the
clinical staff, fully exploiting each member's particular skills for the
benefit of the Dialysis Unit as a whole. The constant upgrading of care
administration targeted at improving the patient's welfare has become
the guiding purpose of our Unit.
Aims: Our aim was to create and adhere to a quality system of the ISO9002 type, thus improving medical care from both clinical and services
aspects with subsequent heightened customer satisfaction.
Methods: We created a structure based on ISO-9002; its implementation
and success were evaluated by the following parameters: quality of
dialysis (KT/V), breakdowns of dialysis machines, infected catheters,
problems with patients' feet, and patient satisfaction.
Results: The quality of dialysis treatment improved by 26%, there were
73% fewer breakdowns of dialysis machines, infections decreased by
47%. Problems with feet declined by only 5%, much to our dissatisfaction.
Most gratifying was the rise in patient satisfaction by 32%.
B
28
Parameter
Dialysis quality: KT/V>1.2
No. of breakdowns
of dialysis machines
Central catheters' infections
Patients with foot problems
Patient satisfaction
Before
After
ISO-9002 ISO-9002
62%
83%
Expected
Results
improvement% improvement%
25%
26%
37
59%
34%
70%
50%
30%
25%
25%
10
20%
31%
97%
73%
47%
5%
32%
Conclusions
Our data show that the introduction of ISO procedures enabled us to
achieve our aims and to improve the quality of dialysis.
Haemodialysis
ADVANTAGES OF COMBINED PROFILE NA/UF IN REDUCING SIDE
EFFECTS DURING HAEMODIALYSIS SESSIONS
CARDIAC OUTPUT ESTIMATION WITH IMPEDANCE CARDIOGRAPHY
IN HAEMODIALYSIS PATIENTS
R. Wagner, A. Salamanka;
Rabin Medical Center-Beilinson Campus, Petah-Tikva, Israel., Petach Tikva,
ISRAEL.
N. G. Tzenakis, M. M. Kelesidou, K. Maraki, V. Vlahos, G. Sioka,
D. Ntzani, D. A. Kalogeraki, P. Papadaki, E. Vardaki, E. Dafnis;
Univ.Hospital of Heraklion, Heraklion, GREECE.
ajor side effects of Haemodialysis - blood pressure drops, nausea
and headaches - are mainly caused by imbalance between intracellular and extra-cellular sodium levels. From the 60% total watercontaining body-weight, 65% is intracellular water (ICW) and 35% is
extracellular (ECW). The dissolution of NaCl indicates the plasma
osmolarity and by that the intracellular concentrations and cell volume.
Throughout dialysis procedures UF values are between 1000 - 3000 cm?,
and blood pressure in most patients is within norm. Nevertheless, 15% 50% of the patients have blood pressure drops during dialysis sessions.
With no further medical complications (i.e. heart failures), blood pressure
drops tend to stabilize spontaneously by intra-cell refilling.
Sodium profiling is a method for temporarily increasing sodium
concentration levels in the dialysis liquids in order to transfer liquids from
ICV to ECV, thus improving its availability for ultrafiltration. This in turn
improves cardiovascular stability without increasing ICV sodium levels.
UF profiling (gradual UF reduction), is performed in order to prevent
sudden falls in Blood Pressure which results in rapid weight loss during
the dialysis process.
We developed a combination of both profiling methods: Combined Profile,
in order to achieve the benefits of both. With high sodium levels
improving ICV to ECV liquids transfer, while preventing hypovolemia due
to high ultra filtration.
Following 6 months of Combined Profile experience, compared to previous
non-profiling methods, we made the following observations –
Reduction of sudden falls in B.P.
Less complains of Headaches, Muscle Cramps and Thirst.
Improvement of subjective general feeling,
No evidence of increased UF values.
I
M
ntroduction: The present study, assessed the cardiac output (CO)
derived by Impedance Cardiography (ICG) with simultaneous
measurements of CO obtained by echocardiography (ECG), in 109 HD
patients.
Patients and methods: ICG was measured with a BioZ system, on two
consecutive non-HD days (baseline: ICG1 and after 48 hours: ICG2), at the
same time for the individual patient. ICG, on all occasions, was derived as
the average of all CO determinations taken over a 20-minute period. At
baseline, simultaneously measurements of cardiac output were obtained
by echocardiography. Blood pressure was controlled only by adjustment
of dry weight. Reproducibility between the ICG measurements, as well as
the agreement between ICG1 and ECG measurements, were assessed by
the agreement analysis method of Bland and Altman. Bias and 95%
confidence interval were calculated.
Results: Bias between repeated ICG1 and ICG2 measurements was -0.013
(95% CI= -0.045-0.019) and 95% limits of agreement of measurements
variation were (-0.344) - 0.318 (95% CI= -0.398 to -0.290 and 0.264 to
0.372). Bias between ICG1 and ECG measurements was -0.030, (95% CI=0.083 - 0.023) and 95% limits of agreement of measurements variation
were (-0.577) - 0.517 (95% CI= -0.667 to - 0.488 and 0.427 to
0.606).Moreover, the linear regression analysis between ICG1 and ECG
with the 109 cases: ICG1= 1.204(ECG) -1.112 indicates the close
relationship (R2= 0.79, p<0.0001) between the impedance cardiography
and echocardiographic measurements at baseline.
Conclusions: ICG is a simple, non invasive tool for haemodynamic
monitoring in HD patients with high repeatability and close relationship
with echocardiography.
MULTICENTER INITIATIVE TO IMPROVE QUALITY OF VASCULAR
ACCESS CARE
N. Beukers1, M. van Loon2, W. van der Mark3, C. de Bruin1,
R. Huisman1, F. van der Sande2, J. Tordoir2, J. Zijlstra4, P. Blankestijn3;
1
Academisch Ziekenhuis en NSN, Groningen, THE NETHERLANDS,
2
Academisch Ziekenhuis en NSN, Maastricht, THE NETHERLANDS,
3
Universitair Medisch Centrum en NSN, Utrecht, THE NETHERLANDS,
4
ZGT Twenthe en NSN, Almelo/Hengelo, THE NETHERLANDS.
ackground: Of the haemodialysis population of our country
approximately 60% has a native AV fistula and 25% a synthetic
graft, European average is 80% AV fistula.
Aims of the project: a] increase the percentage AV fistulas, b] decrease the
number of complications, especially thrombosis, in patients with grafts.
Methods: A national multidisciplinary taskforce defined a program to be
followed by participating centres. Three vascular access coordinators (all renal
nurses) guided the centres. The total duration of the project was 3 years.
1 Diagnosis: assessment of existing access care, baseline period.
2 Advisory rapport: including suggestions to improve care.
3 Implementation of advice.
4 Re-evaluation of care and assessment of improvements, follow up period.
End points were: formal institution of vascular access care on the dialysis,
type of new access created, number of thromboses, type of temporary
catheters, number of PTA.
Results: 27 Centres (approximately 2200 patients, half of the dialysis
population) participated. Vascular access care was instituted in all
centres.
B
Baseline period - 69% of patients received an AF fistula and 29% a graft.
Follow up period - 77% and 22% response (p<0.001).
Interventions because of graft thrombosis baseline 0.34 events/patientyear and did not change.
The use of subclavian catheter decreased from 34% to 11% and of jugular
catheter increased from 34% to 56% (p<0.001) of total number of
catheters used, number of PTA increased from 0.36 to 0.48 /patient-year
(p<0.001).
Conclusion: This large multi-centre initiative shows that institution of
vascular access coordinators can result in improvement of patient care.
29
Haemodialysis
MANAGEMENT OF DIABETIC RETINOPATHY IN DIABETES
HAEMODIALYSIS PATIENTS
I. Schnitzer, R. Fedorowsky, S. Naaman, L. Israeli, D. Zevin;
Golda-Campus Rabin Medical Center, Givat-Hashlosha, ISRAEL.
10% - 21% of all people with diabetes develop kidney disease and 20-39%
of them develop diabetic retinopathy.
Retinopathy is a leading cause of blindness in American adults. Although
diabetic retinopathy cannot be prevented, the risk of developing it can be
reduced by: having an eye examination once a year, treating high blood
glucose and high blood pressure, reducing fluid overload and cessation of
smoking. Diabetic retinopathy is often treated with laser surgery to shrink
the abnormal blood vessels or to seal the leaking ones.
Diabetic Retinopathy Study showed that loss of vision was found in 16%
of untreated eyes compared to 6.4% of treated eyes.
In our haemodialysis unit, 40% (N-43) of all patients are diabetic, only
27% of them have normal vision, 16% are blind, 19%-38% have moderate
to high vision impairment and only 60% of them had routine eye
examination.
Mean years with diabetes 16, years in dialysis 2.7.
Our diabetes care program concerning diabetic retinopathy includes
mainly, Routine eye examination by referring the diabetic-patients to
ophthalmic service in our hospital.
Blind patients care management includes: Involvement of the family and a
community nurse, monitoring glucose blood level during haemodialysis
and caring for their psycho-economic and social rights by social worker.
Results: All patients have annual eyes examination and 27% of patients
with normal vision did not develop vision impairment. Through education
and cooperation with renal and eye care professionals, the diabetic
patient can remain optimistic about successfully managing the disease
and its ocular complications.
Peritoneal Dialysis
CAPD VS APD: COMPARISON ON PATIENTS' MORTALITY AND
MORBIDITY
POTENTIAL AGE RELATED RISK FACTORS IN A PD POPULATION
G. Tsouka, F. Bourboula, I. Dimakakou, M. Xatzipanagiotou,
A. Vourloumis, G. Bougatsos;
Ippocratio General Hospital, Athens, GREECE.
C. Dequidt, D. Vijt, W. Van Biesen;
University Hospital Gent, Gent, BELGIUM.
n view of the increasing age of the PD population, it is important to
assess potential age related risk (RR) factors in PD. As infectious
complications are still a major cause of technique failure and even
death, we evaluated potential age related risk factors.
Method: Between 1998-2004 122 (male = 67; female = 55) incident PD
patients (mean age: 59.5) were included. Diabetes was present in 32.8%
of the patients. 72.1 % were self-caring patients. 41.8 % were late
referrals.
Peritonitis free time (PFT), non-infectious complications free time (nCFT),
exit-site infection free time (EIFT) and therapy failure (TF) were evaluated
using Cox regression.
Results:
I
Riskfactor
Gender
Late referral
Diabetes
Age at start PD
Selfcare
PFT
p value
0.598
0.675
0.990
0.030
0.869
RR
1.02
-
nCFT
p value
0.149
0.798
0.100
0.077
0.111
EIFT
RR
-
0.559
0.625
0.831
0.769
0.698
Mean time on PD (mths)(x±SD)
Peritonitis (1 episode/mth/pts)
Hospitalizations(1 admission/mth/pts)
CAPD
54±19.8
28.5
9.7
APD
40.8±17.3
42.3
10.3
ns
<0.05
ns
Shift to HD (pts)
Deaths (pts)
CAPD
3
4
APD
0
2
ns
ns
TF
-
0.113
0.012
0.907
0.684
0.808
2.73
-
Conclusion: Age per se is a significant risk factor for developing
peritonitis sooner. As ‘selfcare’ did not influence PFT, it should be
accepted that specific age related problems (e.g. immuno-deficiency),
play a more important role than technique related factors.
30
he aim of this study is to compare retrospectively CAPD and APD on
patients’ (pts) mortality, morbidity and technique survival, as well
as to elucidate the role of each method on these parameters in the
elderly (>65 yrs) pts. We studied 34 pts, 24 were undergoing CAPD
(mean age:61.8±5.5 yrs, M:F=10:14) and 14 APD (mean age:59±7.3 yrs,
M:F=10:4). Our results are shown in the table:
T
Concerning with the influence of each mode on the morbidity of the
elderly, the elderly CAPD pts (10/24) had significantly higher peritonitis
and hospitalization rates compared with either the younger CAPD pts
(14/24) or with the elderly APD pts (4/14) [Peritonitis:1 episode/mth/
pts 14.9 vs 36.7, P<0.01 and 14.9 vs 64, P <0.05 respectively.
Hospitalization:1 admission/mth/pts 6.3 vs 11.7, P<0.01 and 6.3 vs 24,
P<0.05 respectively].
Our findings suggest that the two chronic peritoneal dialysis modes are
comparable concerning the mortality, hospitalization rate and
technique survival. APD apparently surpasses CAPD in the incidence of
peritonitis, because of the smaller number of daily catheter-to-transfer
set connections that is needed. It is noteworthy that the superiority of
APD in the morbidity of the elderly PD pts makes it a more appropriate
treatment for them.
Peritoneal Dialysis
ARANESP® MAINTAINS HAEMOGLOBIN IN PERITONEAL DIALYSIS
PATIENTS: EXTENDED DOSING INTERVALS
REDESIGN AND IMPLEMENTATION OF A MODEL FOR DELIVERY OF
PERITONEAL DIALYSIS (PD) PATIENT TRAINING
J. E. Owen, C. Reed, A. McOrmond, N. Barker, J. Goller;
North West Dialysis Service, Victoria, AUSTRALIA.
raditionally our PD program provided education in a hospital
ambulatory care environment and on completion of training a home
visit was undertaken to establish PD at home. Home visits are a
recognised part of a PD home training programme. They provide a
means of assessing home situation and environment, implementation
of training objectives and continuation of care between the dialysis unit
and home. A review, incorporating patient focus groups, led to the
revision of the training model. Staff roles were redirected to deliver the
majority of training in the patient’s home. The aim of this change was
to improve the transition of PD therapy from the hospital training
environment into the patient’s home.
The changes were evaluated by comparing specific training data
12mths post-change to the 12mths prior to implementation. Patient
focus groups were used to qualitatively identify issues arising.
Quantitative analysis indicated that training took 3-8 days (median 5)
with the new training program compared to 3-15 days (median 8) prior
to the changes (p<0.005). Under the new training method, 0/31
patients failed to reach competency compared to 5/39 with the old
program (p=0.07). In both cases, the length of training required is
related to the patient age (older patients require longer training) but is
not related to CrCl at commencement of training. Patient feedback
indicated overall satisfaction with common themes of confidence and
decreased anxiety.
In conclusion, through reorganisation of patient training we have
improved the transition to the home environment.
T
H. Boulton1, B. Szablyar2, F. Marques3, D. Borniche4;
1
Manchester Royal Infirmary, Manchester, UNITED KINGDOM,
2
Pflegedienstleitung, KfH Kuratorium für Dialyse and
Nierentransplantation, Nürnberg, GERMANY, 3Hospital Santa Cruz,
Lisbon, PORTUGAL, 4Hemodialysis Centre, Bois Guillaume, FRANCE.
he ease of anaemia management in dialysis patients using
erythropoiesis-stimulating agents (ESAs) may improve with reduced
injection frequency (Mahon and Docherty EDTNA/ERCA Journal, 2004).
Aranesp® (DARBEPOETIN ALFA) is an ESA that can be administered less
frequently than recombinant human erythropoietin (rHuEPO). This
analysis assessed the efficacy and safety of subcutaneous, weekly
(QW) or every-2-week (Q2W) Aranesp® in peritoneal dialysis (PD)
patients. This is a pooled analysis of 8, 24-week European studies.
Selected inclusion criteria required patients to be ? 18 years, receiving
dialysis, and receiving rHuEPO, with haemoglobin 10-13 g/dL. Patients
on 2 or 3-times weekly rHuEPO were assigned to QW Aranesp® and
those on QW rHuEPO were assigned to Q2W Aranesp®; the same route
of administration was maintained. The starting dose of Aranesp® was
calculated using a 200 IU rHuEPO: 1 µg Aranesp® ratio; dose was then
titrated to maintain haemoglobin levels (10-13 g/dL). This is a cohort
analysis of PD patients receiving subcutaneous Aranesp®. Of the 128
PD patients, 71 were converted to Aranesp® QW and 57 were converted
to Aranesp® Q2W. During the evaluation period (weeks 21-24), 98%
(65/66; QW) and 96% (45/47; Q2W) of patients had maintained their
dosing frequency. Haemoglobin levels and Aranesp® doses did not
change significantly over the study period, and Aranesp® was well
tolerated. Subcutaneous QW or Q2W Aranesp® is efficacious and well
tolerated for the maintenance of haemoglobin levels in PD patients.
The reduced number of injections allowed by Aranesp® may improve
the ease of anaemia management in the PD population.
T
FACTORS THAT AFFECT THE SEXUAL PROBLEMS OF DIALYSIS
PATIENTS
TOWARDS LONG-TERM PERITONIAL DIALYSIS
H. Madar, R. Fedorowsky, L. Dori, S. Naaman, A. Chagnac;
Rabin Medical Center, Petah Tikva, ISRAEL.
H. Golgeli;
RTS YASAM, Bursa, TURKEY.
echnological advances in peritoneal dialysis (PD), which enable
adequate dialysis and minimize damage to the peritoneum, have
improved the outcome for PD patients. However, method-related
complications remain the weak point of PD, resulting in a low rate of
long-term PD compared to haemodialysis (HD).
The aim of this study was to estimate catheter, method and patient
survival during a period of 8 years of PD (1996-2003).
Sixty-five incident patients were surveyed, of whom 37% had diabetes
mellitus and 45% - cardiovascular disease. At 3 years: Catheter survival
was 69%, Method survival - 72% and Patient survival - 71%. 63% of the
patients maintained residual renal function (RRF) after 3 years, 45% after 4 years. Among patients who had previously undergone renal
transplantation, only 13% maintained RRF after 1 year versus 86%
among other patients (p<0.001). Peritonitis was the single most
common cause of transfer to HD (30%), followed by mechanical
complications (25%) and ultrafiltration failure (UFF) (15%). The overall
rate of peritonitis declined from 0.63 to 0.33 per patient-year during
the 8-year period. This decline was not a result of the increased use of
automated PD (APD). Thirty-three patients were transferred to APD for
the following reasons: quality of life - 39.4%, need for higher PD dose 27.3%, mechanical complications - 24%, high transport and UFF - 9%.
These results compare favourably with published series. This gives
hope that further advances in technology may lead to a greater
improvement in technique and patient survival.
im of this study is to define the sexual problems of the dialysis
patients and to determine the factors that affect those problems.
A total of 63 dialysis patients, out of 243 dialysis patients from various
dialysis centres participated in the study between the dates of
03.05.2004 and 14.05.2004.
“Beck Depression Criterion” and “Golombok & Rust Intensiviy Sexual
Satisfactory Criterion” (GRISS) are used to gather the data. In analysing
the data SPSS 10.0 computer program, in statistical evaluation t-test,
ANOVA and Pearson correlation analysis are used.
The results demonstrate that the sexual problems among dialysis
patients are seen as 57.1%. There is a significant difference in gender,
age, marriage year, education, depression level when compared to
sexual problems (P<0.01). It was determined that the sexual problems
are more widespread among the women dialysis patients 92%. It was
seen that there is no significance difference between sexual problems
and the number of children, income, family type, having private
bedroom, daily needs, dialysis year, frequency of dialysis, being
transferred, having second or third health problems (P>0.05). It was
also determined that the most common sexual problems among
women are avoiding from men’s company and touching while the
common sexual problems among men are frequency and premature
ejaculation 76% and 10.5% respectively.
T
A
31
Psychosocial Care
PLANNING AND IMPLEMENTING AN 'EXPERT PATIENT
PROGRAMME' IN RENAL CARE
PSYCHOLOGICAL REACTIONS TO PATIENTS WITH ESRD
A. Laskari, M. Kourakos;
General Hospital of Nikea Pireaus, Athens, GREECE.
S. Woodcock, C. Eggeling, K. Sandhu, N. M. Thomas;
SW Thames Renal and Transplantation Unit, Surrey, UNITED KINGDOM.
he diagnosis of End Stage Renal Disease (ESRD) and the
implementation of dialysis is a painful and stressful progress. A
patient in dialysis becomes dependent. He undergoes a series of losses
and continuous restrictions, such as the loss of bodily function and
social relations, as well as restrictions in diet and reduced sexual
activity.
All the above are the reasons for the psychological reactions and
problems.
The elements that interact with the above reactions are related to
patient age, gender personality, past experiences of other illnesses, to
the nature of the disease and the patient’s environment (family,
hospital, society).
In this paper we will analyse the reactions of a patient with ESRD, such
as depression, fear of death, shock at the event, sexual losses, dialysis
discontinuation, culture reaction and problems, etc.
Also we will present ways of how the team can help the patients to
solve their problems and face the disease.
he Expert Patients Programme (EPP) is a national health service
training programme that provides opportunities to people who live
with long-term chronic conditions to develop new skills to manage their
condition better on a day-to-day basis. Expert patient programmes take
place over two hours per week for six weeks and are led by people
who, themselves, live with a long-term health condition.
An EPP programme for those with renal disease has been developed by
a tertiary renal unit, in liaison with local and national kidney patient
associations. Two working groups were formed: one to develop the
timing and content of the programme, the other to develop staff
awareness.
The programme will commence in April 2005. There will be twelve
participants on the first programme, who are either receiving
haemodialysis or peritoneal dialysis, or have had a transplant. The first
programme will be facilitated by outside instructors, but in the future it
is hoped that patients with renal disease will themselves become
facilitators. The content of the programme will be adapted slightly from
an original Chronic Disease Self-Management Course. Evaluation will
be ongoing.
The aim is for patients to feel confident and in control of their lives, and
to effectively manage their condition in partnership with health care
professionals. By implementing this programme, patients will be
provided with the necessary 'self-management' skills, so they can
make a tangible impact on their disease and quality of life.
T
T
GANMA: THE MEETING OF MODERN MEDICINE WITH ANCIENT
CULTURE
INDIVIDUAL STYLES OF ADJUSTMENT TO CHRONIC ILLNESS
M. Harskamp;
Dianet Dialysis Centres, Utrecht, THE NETHERLANDS.
A. E. Moriarty, M. J. Warbrooke, S. J. Signal;
Royal Darwin Hospital, Darwin, AUSTRALIA.
urses who are familiar with different types of coping processes are
more able to help patients to develop their coping skills. Rational
understanding and emotional empathy can help them to help patients
to adjust to a chronic illness.
R. Moos (1982) has proposed the crisis theory which describes factors
that influence the way patients adjust during a crisis. These
adjustments depend on the coping process, which is influenced by
three factors: (1) illness-related factors, (2) background and personal
factors, and (3) social environmental factors.
Patients need to address two types of adaptive tasks in the coping
process: (1) tasks related to the illness or treatment, and (2) tasks
related to a general psychosocial functioning.
What coping skills do patients and their families employ when they
deal with these adaptive tasks?
(1) Appraisal-focused coping: logical analysis, cognitive redefinition,
avoidance or denial.
(2) Problem-focused coping: seeking information and support, practical
problem-solving.
(3) Emotion-focused coping: emotional discharge, affective regulation,
resigned acceptance.
Some coping skills may be more appropriate for dealing with some
tasks than others. Patients use these skills selectively, often in
combination.
Undergoing renal placement therapy entails more than just
impositions: it is also a chance of personal growth. The crisis theory is
very useful for understanding how patients adjust, and can help nurses
to learn how to deal with patient’s coping tasks and skills and to be
sensitive to their emotional reactions and needs.
G
N
32
anma is a word from an indigenous language of this region. It
describes the interface of different knowledge systems and beliefs.
It signifies the respect that stems from appreciation of difference. This
results in enhanced understanding between two groups.
Traditionally, health professionals expect patients to conform to the
medical paradigm. There is little acknowledgement for non-medical
issues.
This has not resulted in quality care. Our team realised the need for
change in approach. The patient, not the disease ideally is the focus.
Over 70% of people currently receiving Renal Replacement Therapies
(RRT) must relocate from remote Indigenous communities to the
capital. The catchment area is geographically large, yet sparsely
populated (800,000 sq km). Vast distances and poor infrastructure limit
access. For most, English is not the first or second language.
The price paid for accessing treatment includes poverty, homelessness,
loneliness, isolation, racism and discrimination. Most of these
problems were not experienced in their home communities.
Our challenge is to develop treatment plans that acknowledge the
above problems and allows the patient to receive RRT in a culturally
appropriate manner.
To achieve this, our team engages in consultation with patients,
families and communities. This has lead to patient driven initiatives
such as the expansion of RRT in remote areas, increased training and
use of interpreters, local research, extended liaison with remote
communities, culturally appropriate resources and staff training in
culturally appropriate behaviours.
By practicing “Ganma” patients and staff have developed greater
mutual respect, which in turn has lead to improved patient outcomes.
Psychosocial Care
THE PSYCHOLOGICAL IMPACT OF TECHNOLOGY ON PATIENTS
UNDERGOING HAEMODIALYSIS
THE NEED FOR SUPPORT GROUPS FOR NEPHROLOGY NURSES
T. Chayu1, S. Kreitler2, F. Zur3;
1
Rabin Medical Center, Beilinson Campus, Petach Tickva, ISRAEL,
2
Tel Aviv University, Tel Aviv, ISRAEL, 3Meir Hospital, Kfar Saba, ISRAEL.
nd Stage Renal Disease is a progressive disease. It may damage
other body systems to varying degrees. Treatment consists in
changing life style including dialysis which is the default treatment and
only means of survival for many patients who cannot get a kidney
transplant.
Nephrology Nurses (NN) play a crucial role in treating patients in the
different contexts ranging from the pre-dialysis clinic, through
haemodialysis or peritoneal dialysis to transplant ward. NN team is
under constant stress due to the need to integrate complex technology
with the no less complex needs of patients and their families.
We assumed that wellbeing of nurses would be necessary for
improving the nurses' ability to tackle the difficult problems of
instrumentation without disregarding the individual patient.
We examined the need for support groups in the population of
Nephrology Nurses. Questionnaires including various demographic
details and 10 questions concerning support groups were administered
anonymously to 300 nephrology nurses in over 30 wards.
The results showed that 88% of NN felt the need for support groups,
77% would participate in them.
Statistical analysis showed that the need and interest were greater in
women, especially those with higher education, married with more
children, regular nurses more than those in supervising positions.
Nurses working for many years more than the novices wanted groups
to be available continuously.
The findings support the conclusion that in order to increase the
benefit of patients from advanced technology in nephrology it is
necessary to invest in improving the well-being of the NN.
E
G. Gerogianni1, S. Gerogianni2;
Haemodialysis Unit, 'Tzaneio' Hospital, Athens, GREECE,
2
Haemodialysis Unit, 'Attiko Therapeutirio', Athens, GREECE.
1
t is generally accepted that the modern technology in dialysis units
has contributed to the achievement of the desirable therapeutic
outcomes in the dialysis setting and to the improvement of patients’
care. However, the highly technological settings in dialysis units often
prevent nurses from providing effective psychological support to these
patients. This happens because nurses have to deal effectively with the
modern technology of dialysis machines in order to achieve the
desirable therapeutic outcomes in clinical practice. This makes patients
feel devaluated as individuals, since nurses spend little time with them.
Thus, it is essential for dialysis nurses to maintain a balance between
the technical aspects of dialysis treatment and patients’ care.
So, apart from the technical expertise and the supervision of dialysis
treatment, dialysis nurses need to teach patients how to cope
effectively with the difficulties of their disease and provide them with
effective psychological support during their treatment. Additionally,
they need to use empathy and other effective communication skills
during their interaction with their patients, and create a friendly,
educative, and therapeutic relationship with them. This will help
patients feel better during their dialysis treatment and overcome any
psychological problems caused by the high technology in
haemodialysis.
I
MEANING OF ILLNESS AND ILLNESS REPRESENTATION, CRUCIAL
FACTORS IN INTEGRAL CARE
CAREGIVERS NEED SUPPORT TOO
E. Velez;
FJD, Madrid, SPAIN.
ntroduction: A comprehensive study of End-Stage-Renal-Disease
(ESRD) and Haemodialysis (HD) must include the socio-cultural
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 is able to
improve nursing staff/ patient interaction. The meaning of their
experience is also an influential factor on the caring methods to be
displayed by the patient
Objective: To identify and characterize the meaning attributed to the
ESRD and HD by patients as a first approach to the representational
world of this event.
Framework: Theory of Representations and Explanatory Model of
Illness
Methodology: A narrative qualitative methodology, grounded in a
constructivist paradigm was used. Using a non-probabilistic and
convenient sampling, twelve HD patients were approached using a
face-to-face in depth interview technique. 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 arisen
at the outset of illness are not related to renal failure, instead these
symptoms are coherently accommodated with previous experiences of
the patient. The inevitability of haemodialysis treatment convinces of
the presence of illness and it opens a wide range of metaphors and
symbolic representations.
Conclusions: Representations of ESRD and HD conform a
multidimensional corpus where different elements of scientific order
and common sense converge and interact. All of these contribute to
construct the meaning of this specific illness and its treatment.
I
H. Madar1, M. Shorer2, F. Raz2, S. Khadija2, E. Elenhoren3, S. Isaac1,
A. Livne1;
1
Rabin Medical Center, Petah Tikva, ISRAEL, 2Nephromor, Ramat Gan,
ISRAEL, 3Haemek Hospital, Afula, ISRAEL.
he advancement of technology has brought about major
improvements to medicine, but the human touch is still one of the
essentials to successful medical treatment. Having recognized the
patients' need for psychosocial support, we established a team in
order to assess the stress factors affecting patients and attempt to
alleviate them.
A questionnaire, which was distributed among 30 patients, revealed
that there was a discrepancy between the patients’ expectations for
psychosocial support and the actual state of affairs. The patients
suggested a greater involvement of the nursing staff in the support of
their spouses.
To that effect, we established a closed group of 10 dialysis patients’
wives, who had 2-hour-long weekly meetings with a team of nurses. At
the first meeting, the members of the group answered a questionnaire
in order to determine the stress factors affecting them. 80% of the
attendees remarked that they felt anxious and fatigued, and 50% depressed and exhausted. Their expected benefit from the group
meetings was an improvement in their ability to cope with their
spouses' disease and its ramifications.
The issues which were discussed in the meetings covered the cognitive,
emotional and behaviourist aspects of coping with the spouses'
disease.
The effectiveness of the nursing team’s involvement will be assessed
from the feedback questionnaires and presented at the 2005 EDTNA
congress.
In conclusion, the group enabled its members to express themselves
without feelings of guilt or failure and may also contribute to an
improvement in their coping abilities.
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33
Psychosocial Care
INCREASING THE AWARENESS OF COMMUNITY CAREGIVERS
ABOUT THE NEEDS OF DIALYSIS PATIENTS
FATIGUE IN HAEMODIALYSIS PATIENTS.
M. Mollaoglu1, B. Yürügen2;
1
Cumhuriyet University, Sivas, TURKEY, 2Istanbul University, Istanbul,
TURKEY.
atigue is a common complaint in long-term dialysis patients that
may influence their quality of life. There is little information relating
to the fatigue experience of persons with end-stage renal disease
receiving haemodialysis treatments. The purpose of this study was to
describe the fatigue experience of people with renal failure who require
maintenance haemodialysis and to examine factors that could be
associated with fatigue in renal patients. The sample consisted of 78
(56.5%) male and 14 (43.5%) female patients. Ages ranged from 18 to
67 with a mean of 48.3 years. The data were collected using a
questionnaire determining the socio-demographic features, clinical
characteristics and Fatigue Visual Analogue Scale. No significant
associations were noted between the biochemical variables measured
and fatigue. The presence of anaemia was linked to fatigue
experienced in the patients sampled. It appeared from the data that a
complex relationship between fatigue, anaemia and symptom
presentation requires further clarification. Marital status, employment
status, length of time on haemodialysis were significantly related to the
presence of fatigue. This study has demonstrated the importance of the
relationship between fatigue and clinical characteristics in end-stage
renal failure and indicates the importance of focusing on these aspects
of care.
F
H. Cohen, E. Milo;
Western Galillee Hospital, Nahariya, ISRAEL.
nd stage renal disease (ESRD) and its implications are fairly
unknown among the public in general, but also among
professionals in the community.
Consequently, the patient must deal with obstacles and misunderstandings when he seeks help or support from community agencies. This
situation makes coping with the disease more difficult.
This project was a joint workshop, organized by our hospital and aimed
at increasing awareness among social workers in different community
agencies - welfare, health funds, old age homes and home care agencies.
The response was high and participants arrived with motivation to
develop better collaborative work.
The workshop consisted of four sessions, each containing a
presentation and debate.
The first and second sessions dealt with haemodialysis and peritoneal
dialysis respectively and were presented by the head nurses of those
departments. The third session dealt with the psychosocial aspects of
the dialysis patient. This was presented by the social worker of the
nephrology department. The fourth session was presented by a dialysis
patient, whose personal story enlightened the whole workshop.
During the workshop the participants asked many questions. Great
interest was shown and dynamics among the participants was fruitful.
Methods of strengthening the communication between the hospital
and the community were discussed and participants agreed to help
patients and their families cope with their illness as much as possible.
The workshop succeeded in increasing awareness and contributed to
the knowledge about ESRD.
It should be noted that consequently the quality of service to patients
in the community was improved.
E
SEXUALITY: WHERE DOES IT FIT INTO THE CARE OF THE RENAL
PATIENT?
MANAGING THE CHALLENGING PATIENT
S. Wheeler, S. Horwell;
F. M. Murphy;
Trinity College, Dublin, IRELAND.
eports of physical and verbal abuse against staff in dialysis units
within the UK are unfortunately becoming commonplace. The
extent of the problem in dialysis units has not been fully explored and
neither have the long-term effects on staff and other patients. Because
of the nature of the patients we treat there are many barriers affecting
managers who try to respond to this threat to staff. Unlike other clinical
areas, such as accident and emergency departments, where patients
can be removed and banned from re-attending, there are both legal and
ethical issues associated with refusing to treat haemodialysis patients
because it is a life-sustaining treatment.
This paper will explore the care and management of a haemodialysis
patient whose behaviour is not only challenging for the staff, but has
become violent and aggressive in nature. This case has had a catalyst
effect within our renal unit, whereby strategies have been put in place
to protect the staff and patients and to prevent such situations
occurring again in the future. Such measures as employing a mental
health nurse to work in the haemodialysis unit have been implemented
and action taken through the legal system. We have also been able to
explore the perceptions of the staff to the current situation.
I
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34
ncreasing demands have required the dialysis nurse to become
technologically skilled often to the detriment of caring. Dialysis can
allow nursing to be evaluated as a series of techniques that anyone can
learn (Bevan, 1998). However to ensure a holistic nursing approach
there must be an integration of technology and patient care.
There are opportunities for dialysis nursing to bridge this gap by
demonstrating explicitly the art and core of nursing through
psychosocial well-being (Bevan, 1998).
Sexuality is one such crucial area of patients’ psychosocial well-being
and should be an integral part of caring for patients with chronic kidney
disease.
Sexual dysfunction remains common in patients with renal disease
(Palmer, 1999) with the majority of the literature addressing physical
causes. However sexuality is a multidimensional concept. It is not
entirely about sexual function but includes the way we feel about
ourselves, our self-esteem, body image and how we are perceived by
others. How we interpret sexuality reflects our own attitudes which
must be set aside when dealing with the sexual and sexuality issues of
our patients (Sheils, 2003). Research indicates that patients prefer
health care professionals to initiate a discussion about sexual
concerns, but many nurses expect patients to do this. When no one
introduces the topic of sexuality, the patient is often left to resolve
sexual concerns alone.
This presentation will draw upon relevant literature pertaining to the
nurses’ role in the assessment and management of appropriate
strategies which facilitate the integration of sexuality within renal
nursing practice.
Psychosocial Care
END OF LIFE DECISION MAKING: THE DISCONTINUATION OF
DIALYSIS
Y. White;
University of Wollongong, New South Wales, AUSTRALIA.
ackground: This discontinuation of dialysis is the second most
frequent cause of death in dialysis patients in Australia. 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 and the alleviation
of suffering.
Purpose of Review: This paper will present a review of the literature
and information gained from experienced clinicians in relation to
ethical and lawful end of life decisions in those with ESRD. The review
incorporated legal, professional and ethical issues inherent in the
discontinuation of dialysis for patients, nurses and doctors.
Conclusions: This review has enabled the identification of issues in
decision making in regard to the discontinuation of dialysis for the
patient and their health care team. At the same time it also enabled the
identification of practical tips to assist individuals and colleagues in
ethical and lawful decision making, and the facilitation of a ‘good
death’ following the discontinuation of dialysis.
B
THE INTRODUCTION OF A NURSE LED PRE-DIALYSIS SERVICE RESULTS OF A 5 YEAR AUDIT.
CARING FOR PEOPLE WHO ARE DYING ON RENAL WARDS:
A RETROSPECTIVE STUDY.
K. Rees, H. Noble;
D. J. Hunt;
Hammersmith Hospitals NHS trust, Charing Cross Hospital, London,
UNITED KINGDOM.
ver a 5 year period the flow of patients on to our dialysis
programme has been analysed, looking at patient choice of
modality, acute access starts, late referrals and pre-dialysis education.
Between 1999-2004, 418 patients commenced either haemodialysis
(HD) or peritoneal dialysis (PD). Of these 225 (54%) patients were able
to make their own modality choice (no contraindications to either HD or
PD). 165 (73%) patients chose PD and 60 (27%) chose HD.
187 (45%) had a planned start, 126(30%) were unknown acute starts
and 103 (25%) were known but had an acute start.
In 2000 a pre-dialysis nursing service was introduced to help patients
and their families prepare for dialysis treatment.
Comparison of data from 1999 to 2004 shows a decrease in numbers of
known patients starting HD acutely, from 37% in 1999 to 13% in 2004,
and subsequently an increase in numbers of patients starting HD with
permanent access (functioning arterio-venous fistula), from 7% in 1999
to 38% in 2004.
In summary from our data. Patients who have choice tend to opt for PD.
Patients who have acute starts tend to stay on HD. There has been an
increase in numbers of patients on HD as a permanent treatment. The
introduction of the pre-dialysis nursing service has led to the
development of a conservative treatment pathway for some of our
patients.
O
ne of the challenges for renal staff is caring for people with renal
failure who are dying because they have either chosen not to start
dialysis or, after a period on dialysis, have chosen to stop. Statistics
will be shown to support this.
A steering group was set up to look at how these patients died and
whether all the available resources were used appropriately to ensure
that they were cared for with respect and dignity.
The following aspects of care were audited to measure current practice
against best practice; spiritual support, patient / carer involvement,
symptom control; involvement of specialist palliative care staff and the
management of the withdrawal of dialysis. Data were collected
retrospectively from May 2003 to May 2004.
Within this period 60 patients requiring palliative care died on the renal
wards. Analysis of the data showed that although the care was
generally satisfactory there was a need for more staff education on
caring for dying patients. This needs to focus on supporting patients to
withdraw from dialysis, medication management and referral to
specialist palliative care staff.
A renal, multi professional supportive care team is being developed to
enhance and support the care of people with renal failure who are
dying. Audit continues alongside the development of a care package
and standard for caring for these patients.
O
35
A MULTI-PRONGED APPROACH TO PATIENT AGGRESSION IN THE
DIALYSIS ENVIRONMENT
LIPID APHERESIS: AN EFFECTIVE TREATMENT FOR SEVERE
HYPERLIPOPROTEINEMIA
J. E. Owen, J. Spiteri, M. Malandra;
North West Dialysis Service, Victoria, AUSTRALIA.
I. Nikolic, M. Koscak, M. Maretic Dumic, N. Basic Jukic, P. Kes;
University Hospital Centre Zagreb, Zagreb, CROATIA.
he NWDS is the largest provider of dialysis services within Australia.
It has a strong commitment to providing a safe work and health care
environment for both staff and patients. Over the last few years an
increasing number of angry and aggressive episodes were noted within
the NWDS dialysis satellites.
In recognising this NWDS adopted a multi-pronged approach to
address these issues:
1) Patients were given a specific dialysis rights and responsibility
brochure
2) In-house Anger and Aggression management workshops were
designed and implemented. These bi-annual two part workshops
provide staff with training and skills to manage difficult patient
behaviour in the dialysis environment.
3) Annual patient satisfaction surveys were implemented providing an
avenue for patients to raise issues or concerns.
4) A “Difficult Clinical Interactions” workshop (Cognitive Institute1) was
introduced for all staff. This examined basic communication needs for
staff to provide for more effective communication with patients
5) Pilot staff patient forums were introduced into our Sunshine satellite
attended by patient and staff representatives. This provides a forum for
patients and staff to present concerns and suggestions.
Results: During the period there was a 41% decrease in documented
patient incidents. Of these, patient aggressive incidents constituted
49% (19/39) of documented incidences in 2002 compared to 17%
(4/23) in 2004 (p=.03).
Conclusion: By providing mechanisms for patients and staff to manage
difficult clinical situations NWDS has reduced the number of aggressive
incidents and improved staff morale.
ntil recently, 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA)
reductase inhibitors have been the most effective treatment option
for patients with severe hyper-lipoproteinemia. Continuous apheresis
removes lipoproteins that contain apo-lipoproteins from plasma.
Regularly performed, LDL apheresis decrease LDL cholesterol levels
much lower than can ever be achieved with drug therapy alone.
Therefore, apheresis may prevent development of severe
atherosclerosis and all other diseases and complications associated
with hyper-lipoproteinemia.
The first apheresis procedure in Department for Dialysis, University
Hospital Centre Zagreb, was performed in April 2004. Since that time,
we have performed 54 procedures on 4 patients. Patients were treated
with 4, 32, 20 and 18 procedures. Vascular access has been achieved
by punctuation of two large antecubital veins. Average treated blood
volume was 9 litres per session, and the process took up to 3 hours.
Before treatment, average cholesterol level was 15,25 mmol/L and
triglycerides 13,89 mmol/L. Patients have achieved and maintained
average level of cholesterol 5,3 mmol/L and triglycerides 2,13 mmol/L.
There were no complications associated with the lipid apheresis
procedure. None of the patients had received angiotensin-convertase
enzyme inhibitors. Atherosclerotic complications have not been
recorded from the beginning of the treatment.
Our results confirm the usefulness of extracorporeal therapy in
achieving and maintaining low LDL cholesterol levels. Longer follow-up
is necessary to determine the clinical benefit of lipid apheresis in our
patients.
T
U
RECRUITMENT AND RETENTION AUDIT: TRAINING DOES MAKE A
DIFFERENCE
A CARE PATHWAY FOR THE END OF LIFE IN A RENAL SETTING
J. A. King;
Royal Berkshire Hospital, Reading, UNITED KINGDOM.
V. C. Hinton, M. S. Fish;
Nottingham City Hospital, Nottingham, UNITED KINGDOM.
he aim of this study was to find out if offering specialist renal
training courses to practitioners enhanced staff recruitment and
retention. An audit of staff specialist renal skills acquired through
training was assessed. Analysis of the records available since 2003 in
this Trust, of staff retention and increased nursing satisfaction
following renal course attendance, was undertaken.
Method. The research used semi-structured interviews gaining
qualitative data. The participants were all staff who had undertaken
renal courses available in this Trust.
Results. When the interviews were thematically analysed, key themes
emerged, which displayed enhanced insight, confidence and increased
skill base. We also looked at quantitative data concerning staff
retention, staff movement and staff sickness, which helped us to
identify that not only do staff actually stay longer but also appear to
contribute significant changes in advanced skills and knowledge but
also more positive attitudes.
In conclusion, we found that by offering specialist training we now
have a choice of skilled renal nurses offering themselves for
recruitment. They in return benefit from our advanced renal programme
and help deliver enhanced quality care to our patients. This also leads
to enhanced job satisfaction promoting increased retention of these
skilled nurses.
D
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36
emand on renal services doubled in the last 10 years, the greatest
increase being the elderly population. Dialysis is not suitable for
some patients, whilst others will choose withdrawal from treatment. To
meet the needs of these patients a palliative care program was
developed.
The Renal Care Pathway for the dying was based on the Liverpool Care
Pathway. End of life issues include the availability of a multi-skilled
team enabling a holistic approach to care and the integration of
palliative medicine into renal services. The team included a renal
pharmacist, nephrologist, and nurse specialist.
Documentation was ratified, and an education program developed .A
renal nurse was employed for 2 days a week to deliver this program,
supported by the Renal Clinical Nurse Specialist and Palliative Care
Link Nurses.
An audit will compare and contrast the care of 10 patients, before and
after implementing the care pathway. Initial findings indicate improved
standards of care, and communication. Further educational
opportunities to support staff include: communication, religion and
peri-death cultures. Induction programs for all new renal staff now
include an overview of the pathway.
The development of the care pathway needed time, enthusiasm and
teamwork. However, the renal unit now provides end of life care which
facilitates patient’s wishes, death with dignity and appropriate support
for families, partners and staff.
IRON USAGE IN HAEMODIALYSIS PATIENTS: DOES A FORMAL IRON
POLICY MATTER?
S. Johnson1, A. Lee2;
1
Illawarra Health Service, Wollongong, AUSTRALIA, 2Prince of Wales
Hospital, Randwick, AUSTRALIA.
IS PATIENT CHOICE ALWAYS THE RIGHT CHOICE?
M. Stobyfields, M. Yaqoob;
he aim of this study is to compare patient populations treated in
renal centres with formal iron policy to determine iron dosage
against hospitals that do not have a formal iron policy.
From April to September 2003, validated data were extracted from the
Renal Anaemia Management (RAM) database from 16 hospitals.
Comparison of patient population (n=3098) was assessed using
haemoglobin, serum ferritin, transferrin saturation (TSat), epoetin
dosage and iron dosage. This study also investigated the patient
population through age, gender and aboriginality.
The number of haemodialysis patients in centres that do not have
formal iron dosage policy was 842 (27.1%). Patients from these centres
have a lower serum ferritin (509.8 versus 569.7, p<0.0001) and TSat
(27.9% versus 28.6%; p=0.025) than the patients dialysed in centres
with formal iron policies. Mean haemoglobin concentrations (11.4 g/dL
versus 11.7 g/dL; p=0.0003) were also lower for the patients in nonformal policy centres. Patients were administered a significantly lower
single iron dose and regular iron dose in formal iron policy centres
(p<0.0001). However the patients receiving several iron doses received
lower doses in non-formal policy centres.
The RAM data revealed significant differences in mean Ferritin, TSat
and Hb between the iron policy groups. These differences however,
would have minimal clinical impact as both groups’ means met the
current clinical practice guidelines for our country. Timely data
collection and feedback to the clinicians regarding formal iron
management policy may influence patient care, although achieving
Anaemia Management guidelines does not necessarily require a formal
iron dosing policy.
T
he evidence suggests that timely referral of chronic renal failure
patients for assessment, education and evaluation for renal
replacement therapy and conservative management leads to better
patient outcomes. Patient choice is an essential component of the
decision making process which can only occur with effective and
appropriate education and psychological support. This paper explores
whether the patient’s choice is always the right choice when compared
to the physician and nurse’s choice.
A prospective audit was undertaken over a six month period of 60 predialysis patients. We developed a pre-dialysis assessment tool,
including reasons for patient, nurse and physician choice of treatment.
The criteria for choice by the physician and nurse are multifactorial and
include medical, physical, psychological and social factors.
The results showed that 72% (n=43) chose the same treatment as the
physician and nurse, of those, 14 chose APD, 16 CAPD and 13
haemodialysis. However, 28% (n= 17), PD suitable, disagreed with the
physician and nurse. After additional support, education and advice,
which included home visits, 53% (n=9) changed their choice to that of
the physician and nurse. Of the remaining 7 patients, 4 opted for no
treatment. One patient from the no treatment group changed his mind
when he became symptomatic and required dialysis.
This audit highlights the benefits of pre-dialysis education and
assessment to assist patients to make the right decision, particularly
those suitable for PD/APD. We have also developed a supportive
management programme for those opting for no dialysis.
T
DO PATIENTS WHO CHOOSE CONSERVATIVE MANAGEMENT
RATHER THAN RRT RECEIVE EQUAL CARE?
COGNITIVE FUNCTION IN PRE-DIALYSIS PATIENTS
M. Kelly, M. Stobyfields, M. Yaqoob, A. Mahon;
P. Simoyi;
University Hospital Birmingham NHS Trust, Birmingham,
UNITED KINGDOM.
his study was done to investigate whether those patients who
opted for conservative management were making informed choices
and enjoyed the same quality of life and care as those patients of
similar age and with similar co-morbidities who opted for
haemodialysis in the researcher’s unit. It is noted that conservative
management is now becoming an acceptable and common treatment
option for renal failure in the world. The number of those opting for
conservative management was rising in an environment where the unit
was experiencing shortages in haemodialysis provision. There was
need to review the service to ensure that patients' autonomy and
choices were upheld. This was also an opportunity to use the findings
in launching a user friendly conservative management programme.
All patients who opted for conservative management were identified.
After ensuring that the ethical requirements for research were fulfilled,
structured interviews were carried out on both groups of patients and
the results were analysed using SPSS for Windows statistical package.
Patients of above 65 years who were given adequate information about
their treatment chose to be conservatively managed and enjoyed a
better quality of life than the control group. Most of the patients’ blood
results were well controlled except for a few in the conservatively
managed group. Therefore current good practice such as strict monthly
audit of blood results to include blood pressure, social work provision,
dietetic provision and safe staffing levels that currently happens in the
dialysis unit needs to be extended to the conservatively managed
group too.
T
ognitive impairment may compromise a patient’s quality of life and
decision-making ability. The level of cognitive function of predialysis patients has not been fully explored, although a recognised
complication of chronic renal failure. There is evidence that correction
of some factors such as haematocrit, result in improved cognitive
function and preliminary findings suggest that cognitive function
improves after transplantation.
Within the pre-dialysis service we have developed an assessment tool
to aid in the decision-making process which includes using the MiniMental State Examination (MMSE) to assess cognitive function. The
MMSE is a brief, standardised method to assess cognitive function and
assesses orientation, attention, intermediate and short-term recall,
language, and the ability to follow simple verbal and written
commands. A normal cognitive function is a MMSE score of 25-30, with
cognitive impairment present if ≤ 24.
Over the last 6 months we have collected scores on 32 pre-dialysis
patients. The MMSE score in diabetics (n=11) was significantly lower
than in non-diabetics (p<0.05). There was also a significant correlation
(p < 0.05) between GFR and MMSE score. However, there was no
significant difference in MMSE scores found between age, sex,
haemoglobin and ethnicity.
This paper will discuss the impact of cognitive impairment on the predialysis education and the patient’s ability to make informed decisions.
Although the numbers are small, it highlights the need to adapt our
current pre-dialysis education.
C
37
PERCEIVED HEALTH AND INFLUENTIAL FACTORS IN PRE-DIALYSIS
AND DIALYSIS PATIENTS
L. Hernández Santamaría, J. Gutiérrez Vilaplana;
Hospital Universitari Arnau de Vilanova de LLeida, LLeida, SPAIN.
ntroduction: The knowledge of the quality of life related with
perceived health, is becoming an important factor to keep in mind in
our units.
Patients start pre-dialysis and renal replacement therapies programs at
older ages. The quality of life related to perceived health monitoring,
will allow us a better adaptation and to individualise patient cares, as
well as nursing care adjustment along the time.
Objectives:
• To quantify the quality of life related with the perceived health
(QLRH) in pre-dialysis and dialysis patients.
• To value different factors that influence in the quality of life related
with perceived health.
Methods: By means of a descriptive and traverse study, pre-dialysis
and dialysis patients of our geographical influence area were
studied. 70% of the population that could be studied completed all
inclusion criteria (n=261), the instrument used in the study, was the
EuroQol-5D (European origin questionnaire, adapted to our culture).
The period of study was from 12/02/2004 to 15/05/2004.
Analyzed variables: sex, age, group (pre-dialysis, haemodialysis,
peritoneal dialysis), diabetes.
Results: EuroQol-5D questionnaire results were:
• All Patients: 0.65(±0.016), haemodialysis patients: 0.63(±0.020),
Peritoneal dialysis: 0.65(±0.064), pre-dialysis 0.72(±0.024).
• Women: 0.54 men: 0.72
• <59 years old:0.76, 59-78 years:0.62,›78 years:0.59
• Diabetic patients: 0.59, non diabetic patients: 0.67
Discussion: Factors that influenced in the perceived health of our
patients were; age, sex, diabetes mellitus and the dialysis technique.
There were differences in the quality of life related to perceived health
among the study groups.
I
AUDIT OF A PRESCRIBING ALGORITHM FOR ORAL AND IV IRON IN
PRE-DIALYSIS PATIENTS
V. Hipkiss, E. J. Lindley, S. Ashmore, C. Bartlett, P. Harte-Armitage, A. F.
Mooney, E. J. Will;
St James's University Hospital, Leeds, UNITED KINGDOM.
uring 2004, patients attending our multidisciplinary pre-dialysis
clinic were included in a computerised iron management algorithm
if they had haemoglobin<12g/dl and/or were receiving an
erythropoesis simulating agent (ESA). Patients classified as iron
deficient by our local definition (either ferritin<150Ìg/l, or ferritin 150500Ìg/l with red cell hypochromia RCH?5%) were initially prescribed
oral ferrous sulphate. Iron status was reviewed each month. Patients
who were iron deficient after receiving three months of oral
supplementation, or declared as unable to tolerate oral iron, were
prescribed a 200mg iron sucrose infusion at their next clinic visit.
This audit showed that, in 2004, 108 of 133 iron deficient patients were
first treated with oral iron. Only 6 were declared as intolerant. Of 71
patients who completed 3 months of oral supplementation, 10 became
iron replete and 6 achieved a haemoglobin>12g/dl. Use of oral iron
resulted in a modest, but significant, improvement in iron stores
(median increase in ferritin 19Ìg/l, interquartile range 75Ìg/l).
Functional iron availability improved in non-ESA-treated patients
(median decrease in RCH 1%, IQR 2%), but deteriorated significantly in
ESA-treated patients (median increase in RCH 3%, IQR 7%). Of the 50
patients treated with IV iron in 2004, 20 completed the course and
became iron replete after 1 to 11 infusions. Patients with RCH>10%
required significantly more infusions (median of 5 compared to 2).
Our audit suggests that oral iron supplementation should be restricted
to patients who are maintaining an adequate haemoglobin without
ESAs and that patients with RCH>10% may need more frequent
infusions.
D
QUALITY OF LIFE IN CHRONIC RENAL FAILURE
K. Pugh-Clarke;
Royal Infirmary, Staffordshire, UNITED KINGDOM.
roblem: Compared to general population norms, quality of life
(QOL) is suboptimal in end-stage renal disease. Recent studies
indicate that QOL is impaired prior to initiation of renal replacement
therapy, implying that initial decline in QOL originates in the chronic
renal insufficiency (CRI) phase of renal disease. Given the significance
of QOL as a clinical outcome, there is little QOL research in CRI.
Purpose: To measure QOL at three distinct phases (based on creatinine
clearance - Ccr) of the disease trajectory: normal renal function with
underlying renal disease (Ccr ? 75 ml/minute), moderate CRI (Ccr 40 60 ml/minute), and advanced CRI (Ccr ≤ 30 ml/minute); to establish if
QOL differs between these groups.
Design: Data were collected from 25 patients from each of the Ccr
bands, -total patient population, 75. We measured self-reported QOL
(Schedule for the Evaluation of Individual Quality of Life - SEIQOL),
uraemic symptoms and several laboratory variables.
Findings: SEIQOL was significantly lower, symptom number, frequency,
and intrusiveness, significantly higher in the advanced CRI group
compared to normal renal function group. SEIQOL and symptom
intrusiveness did not differ between advanced CRI and moderate CRI
groups, SEIQOL was significantly lower (p<0.05) and symptom
intrusiveness significantly higher (p<0.05) in moderate CRI group
compared to normal renal function group.
Conclusion: Self-reported QOL is already impaired in moderate CRI.
Significant difference in QOL and symptom intrusiveness between
moderate CRI and normal renal function groups may denote a causal
relationship between perceived symptom intrusiveness and QOL early
in renal disease trajectory.
P
38
Renal Nutrition
AUDIT OF THE EFFECTIVENESS OF THE DIETETIC ASSISTANT ON A
RENAL WARD.
J. O. Tomany;
Manchester Royal Infirmary, Manchester, UNITED KINGDOM.
roblem: Many renal patients are at risk of malnutrition. The Dietetic
Assistant (DA) works with the renal dietitian to ensure nutritional
needs of patients are met.
Purpose: To audit the role of the DA on the renal ward and evaluate how
effective the DA is at promoting good nutrition and improved dietary
intake.
Design: The study was in two parts: Observational study- completed on
2 days when the DA was on the ward and 2 days when the DA was off and
a Patient Satisfaction Questionnaire-completed for 1 day on 2 alternate
weeks. All the information was collected and analysed.
Findings: Observational Study-sample size was 48 patients on both DA
days and non DA days (exclusions included patients off the ward on
overnight leave/dialysis/at theatre and patients who were nil by
mouth/on clear fluids). Aspects of food service monitored showed that
on days when the DA was on the ward 88-100% of targets were achieved
compared to 0-94% when the DA was not present.
Patient Satisfaction Questionnaire-46% response rate. 91% of patients
were offered snacks, 82% thought that the availability of snacks was
acceptable. 53% of patients reported that food was served at the correct
temperature, 79% of patients reported receiving the correct amount of
food, 92% of patients prescribed nutritional supplements were offered a
range of flavours by the DA. 53% of patients rated the food as satisfactory, 21% rated the food as good.
Conclusion: The audit highlights the importance of the role of the DA on
a renal ward.
P
CARDIOVASCULAR MORTALITY RISK IS INCREASED IN DIALYSIS
PATIENTS WITH DISTURBED MINERAL METABOLISM
L. T. Brinke1, M. Noordzij2, J. Korevaar2, E. Boeschoten1, F. Dekker3,
R. Krediet4, W. Bos5;
1
Hans Mak Instituut, Naarden, THE NETHERLANDS, 2Department of
Clinical Epidemiology and Biostatistics, Academic Medical Center,
University of Amsterdam, Amsterdam, THE NETHERLANDS, 3Department
of Clinical Epidemiology and Biostatistics, Leiden University Medical
Center, University of Leiden, Leiden, THE NETHERLANDS, 4Department of
Nephrology, Academic Medical Center, University of Amsterdam,
Amsterdam, THE NETHERLANDS, 5Department of Internal Medicine, St.
Antonius Hospital, Nieuwegein, THE NETHERLANDS.
n 2003, NKF-K/DOQI published guidelines recommending tight control
of plasma calcium (Ca), phosphorus (P), calcium-phosphorus product
(Ca x P) and intact parathyroid hormone (iPTH) levels. Within the context
of these guidelines, we examined effects of plasma concentrations on
cardiovascular mortality in haemodialysis (HD) and peritoneal dialysis
(PD) patients in the Netherlands.
As part of a large multi-centre cohort study (NECOSAD), we included 1565
patients new on dialysis between 1997-2003. Two-year average plasma levels were calculated per patient. Cox regression analysis was used to calculate
Hazard Ratios (HRs) for cardiovascular mortality risk. Mean (SD) age was 60
years (15), 61% male, and 64% HD. In total, 577 patients died during the
study period. 42% of deaths in HD and 51% in PD patients had a cardiovascular cause. Survival analysis for patients having plasma Ca levels above the
K/DOQI target yielded HRs of 0.6 (95% Confidence Interval: 0.4-1.9) for HD
and 0.5 (0.3-1.0) for PD. For patients with elevated plasma P concentrations
we found HRs of 1.6 (1.1-2.3) for HD and 2.6 (1.4-4.7) for PD patients. Having
plasma Ca x P levels above target yielded a HR of 2.0 (1.2-3.5) for PD patients.
No significant effect was found for HD patients. Finally, we observed a HR of
1.6 (1.0-2.7) for HD patients with suppressed plasma iPTH levels. In PD
patients no effect was found for iPTH. These findings demonstrate that the
presence of plasma Ca, P, Ca x P and iPTH concentrations beyond the targets
advised by K/DOQI increased cardiovascular mortality risk.
I
A CROSS-SECTIONAL STUDY ASSESSING SALT INTAKE IN A LOW
CREATININE CLEARANCE POPULATION
DEREGULATED PHOSPHATE: ASSOCIATION WITH INCREASED
DECLINE IN RENAL FUNCTION IN PRE-DIALYSIS PATIENTS
A. Dunne, I. Ashurst;
Barts and the Royal London Hospital Trust, London, UNITED KINGDOM.
L. Engelsman1, E. M. Voormolen2, D. C. Grootendorst2, I. Beetz2,
Y. W. Sijpkens2, E. W. Boeschoten1, J. G. van Manen2, R. M. Huisman3,
F. W. Dekker2;
1
HansMakInstituut, Naarden, THE NETHERLANDS, 2LUMC, Leiden,
THE NETHERLANDS, 3AZG-DCG, Groningen, THE NETHERLANDS.
ackground: Evidence is overwhelming of the relationship between
salt intake and raised blood pressure (BP) (Intersalt Study). The
British diet contains around 150-190mmol sodium/24h (RDA <100mmol
sodium/24h). The MDRD trials showed hypertension was a major factor
in the progression of renal disease. This study aims to assess salt
intake, utilising food record charts (FRC) against 24h urinary sodium
excretion with low creatinine clearance (LCP).
Method: Cross-sectional survey of 23 LCP (n=13 male; n=10 female),
mean age 57.3yrs(+/-15). FRCs were analysed using CompEatPro (version 5), a computer-based nutritional analysis programme. Sodium
intake was compared to 24h urinary excretion to establish the accuracy
of the FRC. BP reading, anti hypertensive medication and BMI were also
recorded. The majority of subjects received no dietary restriction advice.
Results: Mean sodium intake was 117.6mmol/24h(+/-41.4); mean sodium excretion (132.7mmol/24h(+/-40.1) There was no significant difference between mean sodium intake and excretion (p=>0.10), however, no
correlation was found (r=>0.10). Mean BP was 125/73mmHg(+/-14/9),
mean arterial pressure (MAP) 90mmHg(+/-9) indicating good control
within the British Renal Association recommendations. Participants were
taking up to 6 different anti-hypertensive medications. BMI ranged from
23-27kg/m2 (normal 20-25kg/m2).
Conclusion: The findings agree with the Intersalt study highlighting the
unreliability of the FRC as a dietary assessment tool. Participants’ weights
were clinically normal therefore no effect would be expected on BP. The
anti-hypertensive medication and urinary sodium excretion indicates a
high salt intake. This study has limited power due to small sample size,
but highlights the need for a reliable and accurate salt assessment tool.
B
any pre-dialysis patients have a disturbed calcium phosphate
balance. The aim of this study was to evaluate the K/DOQI
guidelines with regard to the decline in renal function in pre-dialysis
patients. Patients were divided into groups according to values above
or below the upper thresholds from the K/DOQI guidelines; serum
calcium corrected for albumin (2.21-2.37 mmol/l), phosphate (<1.49
mmol/l) and their product (<4.2 mmol2/l2). A total of 360 patients (age
59±15 y, clearance 16.9±6.6 ml/min, decline in renal function of
0.65±1.7 ml/min/month) participated. Phosphate was <1.49 mmol/l in
54% of patients, calcium <2.37 mmol/l in 69% and calcium-phosphate
product <4.2 mmol2/l2 in 82%. Adjusted statistical analyses showed
that patients with phosphate levels above the upper threshold had a
0.39 ml/min/month faster decline in renal function compared to those
who had a level below that threshold (p=0.051). The decline in renal
function was 0.43 ml/min/month faster in those with high calciumphosphate product (p=0.12). Calcium level above or below the upper
threshold was not associated with a faster decline (0.31 ml/min/month,
p=0.14), nor was calcium below the lower threshold
(0.21 ml/min/month, p=0.5). In conclusion, a large proportion of predialysis patients do not meet the K/DOQI guidelines, especially those
for phosphate. High levels of phosphate and calcium-phosphate
product seem to be associated with a faster decline in renal function in
these patients. Prevention of hyperphosphatemia should be part of the
multifactorial approach to preserve renal function.
M
39
Renal Nutrition
IMPROVING THE QUALITY OF LIFE OF HAEMODIALYSIS PATIENTS
WITH A DIETARY SUPPLEMENT
R. Numan-Golan, D. Mashiach, R. Fudin;
Haemek Hospital, Afula, ISRAEL.
an nutrition which is enriched with a dietary supplement prevent
and treat malnutrition in haemodialysis patients? Literature states
that 30-49% of Haemodialysis patients suffer from mild to severe
malnutrition which increases morbidity and mortality. Malnutrition is
evaluated mainly by laboratory findings, the primary value being Prealbumin. Other values are Albumin, lipids, ferritin and transferin. These
patients need guidance for correct dietary intake of proteins, energy
and limitation of electrolytes, minerals and fluids. For this purpose the
dietician uses liquid food supplements that are specifically suited to
the dialysis patient. The dietary supplement that we used in this study
has a nutritional formula with vitamins and minerals suited especially
for patients suffering from acute or chronic renal failure.
We wished to test whether by giving this supplement 3 times a week it is
possible to improve the patients' quality of life, and prevent morbidity
and mortality.
40 haemodialysis patients were chosen with similar degrees of illness
and with albumin levels below 3.5 mg/dl. The study group included 20
patients who received the supplement, 10 were diabetic and 10 non diabetic. The control group included 20 patients who did not receive the
supplement.
The study was done over a period of 6 months. Blood samples and urine
collections were taken and ADL functions were monitored. Other parameters were checked such as hospitalizations and patient compliance to
drinking the supplement.
Conclusions: there was a remarkable objective and subjective improvement in the ADL functions of the patients, however, no laboratory
changes of significant statistic importance were found.
C
Technology
USE OF TECHNOLOGY IN BLOOD VOLUME MONITORING TO
IMPROVE PATIENT OUTCOMES
MONITORING OF DIALYSIS WATER SYSTEMS - IS THERE A NEED
FOR INCREASED SAMPLING?
J. Andrews, K. Turner;
Manchester Royal Infirmary, Stockport, UNITED KINGDOM.
R. James;
The Royal London Hospital, London, UNITED KINGDOM.
aemodialysis treatment-related hypotension is one of the most
frequent complications encountered in hospital based dialysis
units. This can be caused by rapid fluid removal from the blood
compartment which is in excess of refilling of fluids from the interstitial
space. It is exacerbated by the patient’s inability to support their blood
pressure by vasoconstriction. On our dialysis unit, these hypotensive
episodes are controlled by an infusion of saline. However, this does not
give a full picture of the patient’s haemodynamic status. What is
necessary is a blood volume monitoring system that gives a clear
picture of the patient’s volume situation.
The newer dialysis machines have now incorporated a blood volume
monitoring system which will graphically demonstrate the viscosity of
the blood and therefore reveal impending hypovolemia. This technical
development is able to reduce hypovolemic episodes and consequently
reduce the volume of replacement fluid during dialysis. Blood volume
monitoring, (BVM) is easy to perform, although there is some
uncertainty among the dialysis personnel about how and when the use
of this is helpful. In order for the healthcare team to use technology for
the benefit of patients, what is needed is a concerted effort in training
the dialysis staff in the use and necessary interventions of the BVM
monitoring system. The outcomes of the use of the BVM system will be
discussed using case histories.
ssurance of adequate 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 failed to
detect.
Current guidelines suggest that samples 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 lowest. Points of connection to machines
should be tested in ‘several month’ rotation. The survey extended
sampling to include all machine connection points.
Four systems were investigated. The bacterial culture method used was
R2A media for 7 days at 22°C and endotoxin levels monitored using the
Limulus Amoebocyte Lysate (LAL) assay. The samples from routine test
points generally returned results within our operational limits (<10
CFU/ml and <0.06 EU/ml). However, results from several machine
connection points on two sites 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 reached was 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 allowing for
remedial action at an earlier stage.
H
40
A
Technology
DIALYSIS WATER PURIFICATION: CAN ALSO OLD SYSTEMS BE
EASILY UPGRADED FOR MICROBIOLOGICAL SAFETY OF THE
DIALYSIS WATER?
SIMULTANEOUSLY PLASMAPHERESIS AND HAEMODIALYSIS AS A
SAFE PROCEDURE IN 65 PATIENTS
H. Traeger;
Werner GmbH, Leverkusen, GERMANY.
T. Dechmann, R. Linkechova, A. Voiculescu;
Department of Nephrology, H.-Heine University Düsseldorf, Düsseldorf,
GERMANY.
he Reverse Osmosis membrane removes safely all bacteria from the
feed-water. The produced water is bacteria- and pyrogen-free.
Older systems are not equipped with inline UV radiation for sterilizing
the product water. They have also no product water recycling during
the dialysis down time. During the down time hourly refreshing of the
product water in the pipeline is necessary.
This abstract describes how a system can be checked, or whether a
Biofilm contamination is present. If this has been determined, which
methods are recommended to remove this Biofilm in the whole system.
Finally, the abstract recommends which additive components can be
added to older systems to make this nearly as safe as a new and
modern water purification which is equipped with hot water sanitation
etc.
T
ackground: Some diseases such as systemic vasculitis and
haemolytic uremic syndrome/ thrombotic thrombocytopenic
purpura (HUS/TTP) require both plasmapheresis (PE) and
haemodialysis (HD) successive, due to concomitant acute renal failure.
We have developed a combination of both procedures in order to
reduce the treatment time and save resources.
Method: The components of a dialyzer (polysulfon membrane) and
plasmafilter are serially connected by a continous arterio-venous
haemofiltration (CAVH) system. In an extracorporeal circulation, using a
blood pump the patient’s blood is first led to the plasma filter and then
into the dialyser. The total procedure does not take longer then a
routine haemodialysis (3- 4 h).
Results: In 65 patients we performed 460 tandem treatments in the last
15 years. 20 patients suffered from c-ANCA positive vasculitis, 33 from
HUS/TTP and 12 from other diseases. In the mean 8 treatments per
patient and therapy cycle (range 1 to 16) were performed.
None of the patients had volume disturbances caused by plasma shifts
and derangement of electrolyte and acid-base balance was
immediately equalized. There were no episodes of hypotension or
bleeding.
Summary: Tandem plasmapheresis and haemodialysis treatment under
special conditions are very feasible. There were no technical
complications. The procedure saves considerable time and resources.
B
RENAL PATIENTVIEW - A PERSONALISED ON-LINE PATIENT
INFORMATION SYSTEM
FLUID QUALITY AT HOME HAEMODIALYSIS INSTALLATIONS
G. Murcutt;
Royal Free Hampstead NHS Trust, London, UNITED KINGDOM.
P. D'Arcy, S. Barnes;
Birmingham Heartlands and Solihull NHS Trust, Birmingham,
UNITED KINGDOM.
n 2003, national renal associations, including patient representative
groups, voluntarily banded together to review opportunities to
capitalise on advances in Information Technology to improve renal
services to patients.
A key objective of the voluntary group was to meet one of the national
standards - to provide a patient-centred service by 2014. The group
proposed to build an internet site for access by renal patients. The site
would be populated with up to date test results and internet links to
pertinent information based on the patients’ diagnosis and treatment
mode. Patient data, with patients’ permissions, would be equally
accessible to carers, general practitioners, and staff in other healthcare
locations that the patient might attend.
Renal PatientView was born.
Funding was acquired and a secure internet site with secure data
transfer protocols was created. Dialysis unit pilot site testing
commenced September 2004.
• Patients moving between dialysis centres can ‘register’ for Renal
PatientView at each centre.
• Accumulated test results from several centres creates a truly
composite, shared electronic patient care record, accessible with
patients’ permissions to anyone anywhere in the world where there
is internet access
• Internet links are customised to the patient’s diagnosis and
treatment mode, with context specific links for patient and medical
practitioner perspectives
We are the second dialysis unit invited to be a pilot site. In April 2005,
we will review our experience of implementing the internet service
Renal PatientView and assess whether it meets the standard in
providing a patient centred service.
I
he purity of dialysis fluid has been established as an important
parameter in patient care. Fluid quality is checked regularly in
clinics but little data is available from home haemodialysis (HHD)
installations.
Samples of RO water and dialysis fluid from each HHD site were
analysed for chemical and microbiological (TVC/Eu) purity and the
carbon filters were tested.
Over three years, 126 samples were sent for chemical analysis; 114
passed on all parameters including chlorine/chloramines. 6 failures
passed when retested and in the rest the RO output conductivity had
risen above 25ÌS. After each RO membrane was replaced the water was
retested and confirmed as being within specification.
Of 61 microbiological samples taken, most showed breaches of TVC/Eu
limits - only machines fitted with ultrafilters passed. Sections of tubing
between the RO and the machine were examined and found to contain
biofilm deposits.
The carbon block filter and single-patient RO appear capable of
providing water of an appropriate chemical purity. A confirmed 25 ÌS
output conductivity reading was found to be a useful cut off point. It
can be speculated that the infrequent use of HHD equipment, and
difficulty of disinfection, leaves sections of tubing liable to biofilm
formation.
Home patients are often on dialysis for many years and so are
susceptible to the long-term effects of chemical and microbiological
impurities. The technology to deliver fluid of an appropriate standard is
readily available and should be used when planning for the future.
T
41
Technology
THE TECHNOLOGY BEHIND THE IMPROVEMENT OF RENAL
ANAEMIA MANAGEMENT SERVICE
A NEW SUBCUTANEOUS INJECTION DEVICE:
SURECLICK™ PREFILLED PEN
S. Johnson, P. Byrne;
Illawarra Health Service, Wollongong, AUSTRALIA.
J. van Waeleghem;
University Hospital Antwerp, Antwerp, BELGIUM.
he Renal Anaemia Management Programme is an incomparable
service available in 18 major renal centres. Since its conception 5
years ago, the software package has been modified to accommodate
the needs of the renal team and the renal patient population. In
addition, with the support of nephrologist, the RAM software has
created a specialised role of Renal Anaemia Co-ordinator (RAC).
The RAM software collects clinical data and patient characteristics from
patients with anaemia associated with renal disease. This is an integral
part of a National exchange of information for the optimal management
of the overall health of the renal patient population.
The RAM database is an invaluable tool that has changed the practice
of anaemia management and improved the outcomes for patients with
renal insufficiency. RAM provides a rapid method for reviewing
haematological and biological parameters on a regular basis with a
multidiscipline approach. At a glance, RACs can now detect trends in
determining vascular access programming, dietetic review, and patient
education and support services.
The positive approach from a collaborative team framework has
allowed for the Renal Anaemia service to reach common goals and
improve outcomes, in a diverse and flexible approach. RAC provides a
point of contact and education for patients, family members and their
GP’s regarding erythropoietin therapy. This advancement in technology
has revolutionised the collection of information about individual
patients, their presenting history of renal failure, earlier recognition
and treatment of renal disease.
rythropoietic treatments for anaemia can be administered to
patients via the subcutaneous route. Injecting systems exist, but
advances in the ease of use of these systems would benefit both
patients and healthcare providers by improving convenience. The new
Aranesp® SureClick™ PFP is fully automated once triggered, and is
easy to use with only 3 handling steps: 1) place SureClick™ at a right
angle to the skin and push down to unlock; 2) press and then release
the red button to activate the injection, listening for a click; and 3) after
the 2nd click (or a count of 15), lift the pen from the injection site. The
needle safety cover will lock into place to help prevent needle injuries.
This study assessed nurse and physician satisfaction with the
SureClick™ PFP when administering Aranesp® (darbepoetin alfa) for
the treatment of anaemia in patients with chronic kidney disease
(CKD). A total of 40 nurses and physicians in the UK, France, Italy, and
Spain were surveyed. Overall, nurses and physicians agreed that the
SureClick™ PFP is an improvement over current injection methods, the
key attributes being ease of use (automation, single dose) and safety
(reduced risk of needle injuries, reduced risk of infection with single
dose). The development of the SureClick™ PFP is a new approach to
improving anaemia management in patients with CKD. The ease of use
and safety of the SureClick™ PFP may benefit both patients and care
givers by improving patient quality of life and treatment adherence
while reducing nursing workload.
T
E
Transplantation
PREEMPTIVE IMMUNOGLOBULIN THERAPY WITH
PLASMAPHERESIS ENABLES LIVE-DONOR RENAL
TRANSPLANTATION IN PATIENTS WITH A POSITIVE CROSS-MATCH.
FACTORS AFFECTING NON-COMPLIANCE IN RENAL
TRANSPLANTATION
C. Bartley, K. Turner;
Manchester Royal Infirmary, Manchester, UNITED KINGDOM.
M. Sternberg, T. Klein, Y. Orlin, E. Mor, A. Yussim;
Rabin Medical Center, Beilinson Campus, Petah Tikva, ISRAEL.
on-compliance or non-concordance has been discussed in nursing,
psychology, and medical journals, yet many health care
professionals are still faced with problems surrounding patient noncompliance with medical recommendations. In order to reduce
rejection of the transplanted graft, infection, morbidity, mortality and
re-hospitalisation, compliance with therapeutic regimes is a
fundamental element of renal transplantation. Cultural factors can have
a significant effect on compliance and these can be influenced by both
the patient and the health care professionals and this may have an
impact on how patients comply with medical regimes. Cultural health
beliefs are poorly explored or understood, and possibly not easily
tolerated which may in return lead to patients labelled as non
compliant. Western medicine often ignores the importance and
influence of culture, but in a multicultural and pluralistic society it is
vital that health care professionals understand and adopt culturally
sensitive approaches to clinical practice in order to help foster
compliance. A literature review of factors influencing compliance has
been undertaken as a consequence of personal experience in hearing
patients voice their regrets of not complying with treatment post
transplant. Understanding compliance issues from a cultural
perspective may provide a framework on which to base both pre and
post transplant nursing care, enhancing concordance with medication,
improving patient outcome and graft longevity.
ackground: The presence of antibodies against the donor's cells,
resulting in a positive crossmatch, precludes transplantation in
patients who have an otherwise acceptable living-kidney donor.
Method: Four patients, aged 21-65 years, with PRA of 40%-100% and a
positive cytotoxic crossmatch against their living donor, were treated
pre-emptively with 4-6 cycles of intravenous immunoglobulin (IVIG) and
plasmapheresis (PP), until obtaining negative crossmatch. All four were
subsequently transplanted, immunosuppressed with FK (target levels
10-15 ng/ml), MMF 1.5 gr/day and prednisone tapered to 30 and 10
mg/day at months 3 and 6, respectively. Follow-up: 11- 96 months
(median 37.5 m).
Results: Following IVIG/PP treatment the cross match converted to
negative in all patients, allowing transplantation from their prospective
donors. Two patients developed 3 episodes of acute rejection, and
were successfully rescued by re-initiation of IVIG with or without PP
and a cycle of pulse corticosteroids and antithymocytic globulin. One
patient died of myocardial infarction 8 yrs after transplantation, with a
well functioning graft (serum creatinine of 1.6 mg%). At a mean followup of 31.3 months, the remaining 3 grafts are functioning (average
serum creatinine: 1.8 mg%). There were no complications directly
related to IVIG/PP treatment, however 3 of the 4 patients had posttransplantation infectious complications: CMV, osteomyelitis and
infection of a penile prosthesis.
Conclusion: IVIG/PP treatment is a feasible means for eliminating a
positive cross-match, thus enabling successful live-donor kidney
transplantation.
N
42
B
Transplantation
PLASMAPHERESIS IN THE TREATMENT OF ACUTE VASCULAR
GRAFT REJECTION.
B. White, R. Visser;
Dianet dialysis centres, Amsterdam, THE NETHERLANDS.
espite numerous advances made in transplantation, acute rejection
still remains a major complication. Recent studies have shown that
use of plasmapheresis in the treatment of acute vascular rejection
improves the chances of graft survival.
In 1997 the plasmapheresis was transferred to be under the
management of the renal unit, because we could offer a 24 hour
service for all acute cases in our hospital. The number of cases has
steadily increased, incorporating not only plasmaphersis, but also
stem-cell-pheresis and red-blood cell exchanges. Since July 2003, we
started using plasmaphersis in the treatment of acute vascular
rejection in renal transplants.
When a biopsy shows acute vascular rejection, combined with a
decreased urine production, the patient commences therapy. Treatment
consists of consecutive sessions, alternating between two sessions
using saline/albumin followed by one session using fresh frozen
plasma. Depending on the lymphocyte count, therapy is carried out in
conjunction with a course of A.T.G.
Between July 2003 and October 2004, 124 transplants were carried out,
15 suffered a case of acute rejection. 6 were diagnosed with acute
vascular rejection, of these 6, 5 were successfully treated with
plasmapheresis and A.T.G. One patient only needed plasmapheresis to
ensure a reversal of acute vascular rejection.
We encountered no problems with the technique itself and although
plasmapheresis seems to improve the outcome of graft survival, we
need to ask ourselves, as demand increases: "Do we have the capacity
to treat these patients on our unit in the future and is it our domain?"
D
Education Posters
VASCULAR ACCESS STATUS FOR HAEMODIALYSIS IN PRE-DIALYSIS
PATIENTS
CLINICAL PATHWAYS
E. E. Pol;
Twenteborg Hospital, Almelo, THE NETHERLANDS.
L. Gaber;
Clinical Center Ljubljana, Ljubljana, SLOVENIA.
n the dialysis ward it was previously unclear as to who was
responsible for what and when, not only among the nursing staff, but
also within other disciplines. There was too little structure and fine
tuning in the care provided. There was a lack of clear, unambiguous
communication with the patients. A great deal of time was wasted in
reporting.
We wanted to introduce improvements in all of the above points.
As a result, we developed digital Clinical Pathways (C.P.) for
haemodialysis, peritoneal dialysis, pre-dialysis and transplantation.
A C.P. is a multidisciplinary, result-orientated care plan. The emphasis
when developing a C.P. is on multidisciplinary, geared cooperation and
teamwork, on the planning and following up of the care and on a
patient-orientated approach.
C.P. are developed and realized with the help of the PDCA method. By
following the Plan-Do-Check- and Act phase the care is improved, both
in content and at the organisational level.
The C.P. on the dialysis ward offers advantages for the:
Patients
• More satisfaction concerning information and education;
• Less complications, less anxious and more knowledge.
Care workers
• C.P. are accessible to everyone involved via the intranet;
• Employees are better informed about task agreements made;
• Time is gained when documenting the care;
• Structure is created both for new and experienced colleagues.
Organisation
• Better cooperation is achieved between the care provided by the
different disciplines;
• The existing protocols for all disciplines can be linked via C.P.
P
I
atients with chronic renal failure begin dialysis with little
understanding of their disease and treatment options. Majority of
patients avoid this with proper education. To educate patients and
relatives, a pre-dialysis education and counselling have been provided
since 1997. Our goal was also to create a vascular access in pre-dialysis
patients before the need for chronic dialysis. We wanted to minimize
the need for catheters as a bridge to a mature arteriovenous fistula
which is superior for chronic use of other vascular accesses.
Methods and Results. 254 patients (137 male, 117 female, mean age of
62 years) with chronic renal failure from four dialysis centres were
enrolled in the study when their creatinine concentrations were
exceeding 400 mmol/L.
55 patients out of 254 patients received a proper education. In 103
chronic renal patients a new native arteriovenous fistula was
constructed before initiating haemodialysis, three patients had
inadequate own vessels and Gore-Tex graft was used. All of them
except 9 patients underwent early access evaluation. 24 patients lost
effective use of their arteriovenous fistula and required
reestablishment of vascular access.
Internal dialysis catheters were placed in 148 patients with end stage
renal disease at the onset of chronic haemodialysis. To provide vascular
access in 60 patients, mean hospitalization was 15.8 days.
Data illustrates the need for intensification of pre-dialysis education in
order to provide larger proportion of patients entering haemodialysis
with arteriovenous fistula. Thus we can minimize the use of venous
catheter access and the risk of catheter related complications.
43
Education Posters
A COMPUTER TRAINING PACKAGE FOR RENAL PATIENTS.
EFFECTS OF EXERCISE PROGRAMME IN DIALYSIS PATIENTS.
^
M. Kavannagh, U. Maguire, A. Mulhern;
Renal dialysis, Letterkenny General Hospital, Ireland, Letterkenny,
IRELAND.
n conjunction with the local branch of the National Kidney
Association, it was decided to develop a computer training package
for renal patients. Distance learning was the type of education selected
as it suited the needs of most patients. The National Training and
Development Institute was approached and an instructor was assigned
to develop and implement an education course.
The course involves thirty hours study a week for the patient. A tutor
provides weekly one to one teaching and telephone support is also
available. A computer, printer and software are provided at home for
the patient's use. Three laptop computers were purchased for patient
use while on dialysis, by the national kidney association. At present,
four patients have enrolled on the programme. Two have been
transplanted and have been able to continue their studies at home
when ready. The patients learn use of a computer and can work toward
their European Computer Driving Licence (ECDL) and other awards. The
National Kidney Association provides the patient with a 300 euro
training allowance and a small increase is available for those patients
receiving social welfare benefits.
This programme has provided educational opportunities to patients
while receiving dialysis treatment. It also has promoted the holistic
care of the renal patient which is a cornerstone of the renal unit
philosophy.
I
A. D. Akyol1, Y. K. Yıldırım1, Ç. Fadıloglu1, F. Akçiçek2, D. Karadeniz3,
N. Ergin3, N. Bakkal3, B. Ünal3, A. Mertbilek3;
1
Agean University-Nursing High School, Izmir, TURKEY, 2Agean
University-Internal Medicine, Izmir, TURKEY, 3Agean University-Dialysis
Units, Izmir, TURKEY.
ims: This study was to evaluate the effects of an exercise
programme on laboratory findings, functional status, and daily
living of activities in haemodialysis and peritoneal dialysis.
Material-methods: This experimental study included 33 patients
receiving chronic haemodialysis and peritoneal dialysis in the Dialysis
Unit Ege University Faculty of Medicine between January-November
2004 for 12-weeks. The exercise programme involved a warm-up,
stretching, strengthening, and cardiovascular training. Patients were
excluded if they were <18 years or >70 years of age, had been on
haemodialysis for < 6 months, had diabetes mellitus, symptomatic
cardiovascular disease, musculoskeletal limitations, dementia or other
mental disorders, and were not competent to give informed consent.
The study was approved by the local ethical committee.
The data was collected by means of a questionnaire. Patients
Recognition Form, Laboratory Finding Form, Karnofski Performance
Index, and Barthel Index were used to collect the necessary data.
Exercise booklets were given to all patients. The analysis was carried
out using statistical software SPSS 11.00. In evaluation of data, student
t test, one way variance analysis, further post hoc test and the person’s
moment product correlation analysis were used.
Results: Twenty-four patients completed the exercise programme. The
result of the study imposed that: exercise performed in dialysis
patients increased the plasma haemoglobin (Hb), haematocrit (Htc),
and white blood cell count (WBC) levels; decreased the level of
cholesterol, urea, and creatinine. Contrary to this, there was not any
influence of exercise on the performance status, and daily living of
activities of participants.
A
THE EFFECTS OF THE EDUCATIONAL PROGRAMMES ON THE
DISCHARGING OF PERITONEAL DIALYSIS WASTES IN HYGIENIC
MANNERS
IMPROVEMENT OF DATA RECORDING PROCEDURES ACCORDING
TO SIX SIGMA
N. Vitri;
Renal Medical Services. Adler Clinic, Jerusalem, ISRAEL.
his project was implemented to improve data recording procedures
and quality control, by examining nursing data records under the
supervision of a team trained in Six Sigma methodology.
Six Sigma is a statistical term referring to six standard deviations lying
between the mean and nearest specification limit. It is a highly
disciplined process, focusing on developing and delivering near perfect
products producing no more than 3.4 defects per million functions.
Globalization, instant information accessibility and competitive
environment leave no room for error and new ways to satisfy customers
must be created.
Our project is based on a 4-phased cycle devised by Dr. Deming: plan,
do, check and act.
During March 2003 patient files were checked and defects in data
recording were identified and graded by severity for the purpose of
mapping problems and for staff performance evaluation.
A repeat check of random files was conducted in September 2003, the
goal being a decrease of 25% in the number of recording errors
compared to the previous check. Main causes of errors were unclear
written medical orders, tiredness and copying of multiple data in short
time spans.
Results: The repeat check showed a significant decrease in the number
of errors.
Conclusion: Errors in recording nursing parameters are one of the main
causes of patient mortality and morbidity. Creative solutions must be
found to increase performance and eliminate variation through
introducing behavioural change. This is problematic particularly in
cases where recording is routine.
T
44
M. Albaz1, A. Karakoc2, G. Kirikci3, R. Dolgun4;
1
Medicine Faculty of University of Marmara, Istanbul, TURKEY, 2SSK
Nisantasi Dialysis Center, Istanbul, TURKEY, 3Istanbul Medicine Faculty
of University of Istanbul, Istanbul, TURKEY, 4SSK Istanbul Training
Hospital, Istanbul, TURKEY.
im of the study: It is well known that some viral infections can be
transmitted through peritoneal effluents in peritoneal dialysis (PD)
patients. Prevention of this condition which could be an important risk
factor for public health was attempted by educational programmes and
control of the discharges of these medical wastes. The aim of this study
is the impact of educational programmes on behaviour of patients for
removing of wastes in hygienic manners.
Material and method: We performed educational programmes for 25
nurses from different CAPD units between May 2004 and November
2004. 556 CAPD patients living in Istanbul were educated by the
nurses working in their CAPD units between 01 November 2004 and
December 2004. Patient education programmes included self and
others’ protection and medical waste contamination as well as
management. Posters and brochures were used for these education
programmes. We also collaborated with local municipalities for the
organization of proper methods for collecting the medical waste.
Results: After the education programmes, patients were controlled at
randomized times at their homes or at work to determine the patient
compliance. We observed that approximately 81% of PD patients were
discharging the drainage fluids to the toilet and collecting the other
medical wastes into the red labelled medical waste bags. These bags
were collected by the local municipalities.
Conclusion: Our results suggest that the educational programmes for
PD nurses and patients improved the PD patients’ behaviour for the
discharge of peritoneal dialysis waste products.
A
Education Posters
A BREATH-LESS STRESS
G. Bonar, J. A. Williams;
Dept of Nephrology Morriton Hospital, Swansea, UNITED KINGDOM.
This paper explains how a renal unit introduced meditation classes as a
form of stress management and relaxation for members of a
multidisciplinary team within a renal setting. It is well documented that
health care professionals experience stress when caring for patients,
and the renal department is no exception when it comes to a stressful
environment.
The methodology of the study was the provision of lunchtime breathing
meditation classes under the kind instruction of a member of staff who
is a practicing Buddhist. The breathing meditation sessions were held
on weekdays and from a practical point of view were around twenty
minutes in order that staff did not leave the clinical area for any great
length of time.
The findings from the study were positive in that participants felt they
had benefited greatly from the breathing meditation sessions. They
agreed unanimously that the classes helped to relieve stress both on a
personal and professional level.
To conclude, the meditation sessions provided an opportunity for staff
to experience breathing meditation first hand, offering "time out" and
invaluable shared experience away from the clinical area.
Recommendation would be that the sessions should continue for
members of the multidisciplinary team as a means of managing and
alleviating stress in their daily lives. It would appear that breathing
meditation is a suitable practice for healthcare professionals.
SWITCHING FROM STANDARD HAEMODIALYSIS TO THRICE WEEKLY
NOCTURNAL HAEMODIALYSIS: A SINGLE-CENTRE EXPERIENCE
F. Rivero, A. Martínez,, M. Contreras, E. López, I. Alguacil, R. Crespo;
Hospital Reina Sofía, Cordoba, SPAIN.
I. C. Claeys, L. Stevens, A. S. Devriese, J. R. Boelaert, E. Matthys, M.
Schurgers, S. Vandecasteele;
AZ St Jan, Brugge, BELGIUM.
ackground/Aims: Nocturnal haemodialysis offers superior dialysis
efficiency and better haemodynamic stability without interference
with daily activities. Thrice weekly nocturnal haemodialysis was recently
introduced in our centre. We evaluated changes in objective and
subjective parameters of patient well-being caused by the switch.
Methods: Clinical and laboratory data were collected in 16 patients
switching from standard haemodialysis (4 h) to thrice weekly nocturnal
haemodialysis (8 h). Dialyser, blood flow and dialysate flow rate remained
unaltered. Patients completed a questionnaire on quality of life (KDQOLSF™) before and 7 weeks after the switch.
Results: Dialysis efficiency, as evaluated by Kt/v, increased significantly
(1.3±0.1 to 2.1±0.1, P<0.001). The number of phosphate binders decreased
from 6.8±1.3 pills/d to 4.7±1.4 pills/d (P<0.01), while serum phosphate
levels decreased from 5.1±0.3 meq/L to 4.4±0.3 meq/L (P<0.05).
Interdialytic weight gain increased from 2.3±0.3 to 2.9 ±0.3 kg (P<0.01).
The KDQOL questionnaire revealed significantly better scores on
questions pertaining to emotional and physical limitations as a
consequence of dialysis treatment. When specifically asked to evaluate
their general condition, 8 patients reported to feel much better, 4 patients
to feel better, 3 patients to feel unaltered and 1 patient to feel worse after
the switch. The latter patient attributed his appreciation to sleep
deprivation. Seven patients have a full-time professional activity.
Conclusion: Nocturnal haemodialysis improves quality of life and allows
patients to continue their professional activities. However, as
haemodynamic tolerance improves, adherence to dietary measures and
fluid restriction decreases substantially.
B
DIALYSIS EFFICACY: INFLUENCE OF NEEDLE GAUGE
he purpose of this study was to evaluate the effect of needle gauge
on the dialysis efficacy in haemodialysis patients (HD).
Five stable patients on regular HD therapy were studied. Each patient
was studied in six consecutive weeks: one week with 16G needle
gauge, one different week with needle gauge 15G and other week with
14G, leaving a week of “wash out” between each studied needle gauge.
All sessions were performed with the same blood flow rate, HD
monitor, membrane, time of HD and ultrafiltration according to the
needs of the patients. The efficacy of HD was performed with a urea
monitor (Biostat 1000). It permits us to calculate, by internal
algorithms, urea clearance, Kt/V, SRI and urea distribution volume.
Effective blood flow rate (Qbe), venous pressure and blood
recirculation, were determined for all needle gauge
T
Needle gauge
16G
15G
14G
Kt/V
1.35±0.1
1.41±0.4
1.34±0.2
Urea Clearance
180±18
203±9
179±19
SRI
70±4
85±36
71±3
Qbe
314±2
328±21
335±2
%REC
8.8±2.2
8±1.9
8.6±2.5
No statistical differences were found (N.S.) between three needles
gauge.
In conclusion, the dose of dialysis was not modified by needle gauge.
It appears not to influence the delivered dialysis efficacy.
45
INDEX AND STANDARD OF EVALUATION ABOUT THE SELF-CARE OF
A DIALYSIS PATIENT IN JAPAN.
C. Kamiya1, I. Honda2, T. Egawa3;
1
Akita University,School of Health Scienses, Akita, JAPAN, 2School of
Nusing Faculty of Medicine Mie University, Tsu, JAPAN, 3School of
Health Scienses Faculty of Medicine Kyoto University, Kyoto, JAPAN.
urpose: To obtain index and standard of evaluation about the selfcare of the dialysis patients in Japan.
Methods: Subject of study: 1000 dialysis units across Japan.
Method: postal questionnaire
Period: July - September 2002.
Content: Evaluation on water intake; Food restriction; and shunt
management in a dialysis patient. Multiple choice 3 to 4 choices for
each item was offered. Also “personal feelings” was added to the reply
column.
Results: Eligible replies were obtained from 556 units (56.6%).
Water intake: 461 (81.4%) units evaluated by the amount of increases
in weight. 225 (39.8%) units evaluated by rate of weight which
decreased to dry weight. 425 (75.1%) units evaluated by CTR and
clinical data. 348 (61.5%) units evaluated by the speech and behaviour
of the patient.
Food restriction: 436 (77.0%) units evaluated by clinical data, such as
potassium and Lynn. 371 (65.5%) units evaluated by contents of a
meal. 365 (64.5%) units evaluated by the speech and behaviour of the
patient. 45 (8.0%) units evaluated by Food Self-care Index.
Management of shunt: 432 (76.3%) units evaluated by checking the
thrill by the teacher or blood vessel pulsation. 319 (56.4%) units
evaluated by the speech and behaviour of the patient.
Conclusion: Index which can be evaluated from the Nursing viewpoint
will need to be developed also evaluation of water intake and shunt
management from now on.
P
EXPERIENCING LIFE WITH A HAEMODIALYSIS MACHINE:
A PHENOMENOLOGICAL VIEW
M. A. Sadala, M. Lorençon;
Universidade Estadual Paulista (UNESP), Botucatu SP, BRAZIL.
he aim of present study is to describe the experience of patients
undergoing haemodialysis starting from their own perception. A
qualitative perspective using Merleau Ponty’s Existential
Phenomenology was considered to be the most appropriate
methodology for this study. 15 patients were interviewed in a
Haemodialysis unit at a Brazilian teaching hospital. Interviews were
based on the question “What does it mean the experience of living with
a haemodialysis machine?” Convergences in speeches were grouped
into three categories: the machine, improvement in quality of life,
reflection on patients’ experience. These findings show the existential
reality patients experience. A haemodialysis machine dictates their
lives: they have to accept strict rules controlled by a team of healthcare
providers. They realize it has to be so and there is no way out. It is the
only way to get some relief from the disease’s symptoms. The feeling is
mostly acceptance of the condition. Healthcare providers’ dedication is
recognized. Some participants complain about painful procedures,
others deny them, others fantasize the reality. An essential piece of
information is the lack of future perspectives: few patients mentioned
the possibility of transplant or some possibility of acting on their own
care. Those findings have led us to reflect on the performance of
healthcare providers in a haemodialysis situation. The study may
contribute to outline new perspectives for nurses to understand the
needs of patients undergoing haemodialysis. An approach allowing for
patients’ views will probably bring awareness to patients as to
possibilities of helping with their own treatment.
T
ONLINE MONITORING OF KT/V TO ALLOW MODIFICATION OF
HAEMODIALYSIS TREATMENT TIMES
K. Fielding;
Renal Unit, Derby, UNITED KINGDOM.
roblem The Renal Association Standards recommend that all
patients receive thrice-weekly haemodialysis and aim for a Kt/V of
1.2 or more. However, the dialysis dose received from each session can
vary and despite an adequate monthly Kt/V, patients still may not be
consistently receiving an adequate dialysis dose.
Purpose To discover if utilising the online monitoring of ionic dialysance
and altering the patient’s dialysis time for that same treatment can
ensure that an adequate dialysis dose is delivered.
Design 12 chronic haemodialysis patients were monitored for a total of
54 haemodialysis sessions.
The ionic dialysance was measured at 60 minutes and 120 minutes
during the haemodialysis treatment. Ionic dialysance is monitored
using the Integra haemodialysis machines. At 120 minutes, the dialysis
time was altered by a maximum of ±10%, to attempt to achieve the
target Kt/V(ID) of 1.1 The alteration in time and end Kt/V were
measured
Findings: 51/54 sessions required the dialysis time to be altered to
achieve the desired Kt/V. 37/54 sessions were increased by a mean
time of 19 minutes. 4/54 were decreased by a mean time of 18 minutes.
44/54 sessions reached the target Kt/V of 1.1.
Conclusion The use of online monitoring to alter the patient’s
haemodialysis time and thus the delivered dialysis dose, leads to a
treatment time that is responsive to the individual needs and more
consistently provides an adequate haemodialysis dose.
P
46
ONLINE MONITORING OF THE SPENT DIALYSATE DURING
HAEMODIALYSIS USING UV-ABSORBANCE
F. Uhlin1, I. Fridolin2, L. Lindberg3, M. Magnusson1;
1
Department of Nephrology, University Hospital, Linköping, SWEDEN,
2
University of Technology, Biomedical Engineering Centre,Tallinn,
ESTONIA, 3Department of Biomedical Engineering, University Hospital,
Linköping, SWEDEN.
ackground: Monthly control of dialysis dose has been
recommended by NKF-DOQI guidelines using blood samples.
However, the use of an on-line monitoring system makes it possible to
achieve an adequate dialysis dose consistently given to the
haemodialysis patient.
We have earlier presented the possibility to estimate dialysis dose
(Kt/V) and protein catabolic rate (PCR) from ultra violet (UV) light
absorbance measurement of the spent dialysate.
The aim of this study was to present some clinical alarm situations and
manipulations that affects clearance and which are recorded by UVabsorbance.
Methods: 128 treatments distributed among 15 patients receiving
chronic haemodialysis were included in the study. The patients were
monitored on-line with UV-absorbance at the wavelengths of 280, 285
and 297 nm respectively, using an UV-spectrophotometer. The
treatments were analysed concerning the occurrence of deviations in
clearance during dialysis. Manipulations with blood- and dialysateflow were performed in three sessions.
Results: The high sampling rate using the UV-absorbance allowed an
immediate picture of the clearance process during dialysis treatments.
Alarm situations, changes in blood- or dialysateflow can be visualised
and evaluated directly on the screen.
Conclusion: Besides estimating Kt/V and PCR, continuous monitoring
of UV-absorbance gives the opportunity to verify reductions in
clearance e.g. due to poor blood flow as well as give the nursing staff
feedback after interventions to improve clearance e.g. after needle
corrections.
B
DIALYSIS WITH TWO ARTERIAL NEEDLES IN FISTULAS WITH
INADEQUATE FLOW
CONTINUOUS VENOVENOUS HAEMOFILTRATION EARLY AFTER
LIVER OR KIDNEY/PANCREAS TRANSPLANTATION
E. Yildizgordu1, A. Demirbas2;
1
RTS Guneydogu Dialysis Center, Gaziantep, TURKEY, 2RTS Turkey,
Istanbul, TURKEY.
B. Bokulic, N. Bednjanec, L. Peter, S. Spicek, S. Stublic;
University Hospital Merkur, Dept. of Medicine, Zagreb, CROATIA.
im: Obtaining adequate blood flow through two arterial needle
entries in fistulas in patients with inadequate flow.
Method: This is a method that was tried in patients under dialysis
treatment with inadequate blood flow (n:3). There were problems with
the fistulas during the first dialysis treatment. In the first patient,
dialysis was tried through a catheter; however, adequate flow was not
obtained by the catheter either. Two arterial and one venous needle
punctures were planned. Blood was drawn using arterial needles in two
different sites and dialysis was completed without any problems. Blood
was returned through the venous needle (Pic.1). Arterial needles
entering in two different sites were connected with a three-way
stopcock, and arterial tubing was connected to the other end of the
stopcock to constitute an arterial line (Pic.2). Venous needle and line
were connected normally and the treatment was completed. The
treatment of the patient was continued with this method until the
maturation of the fistula. The same method was applied in the other
two patients with fistula problems; they were dialyzed with this method
until one patient was converted to peritoneal dialysis, and the other
had his fistula maturated.
Findings: Mean Kt/V before/after the application were measured as
0.90 (+0.15/-0.26) and 2.03 (+1.55/-1.02) respectively.
Discussion-result: Adequate blood flow for HD was obtained by
combining the blood flow through two arterial needles and dialysis
sufficiency was achieved. Laboratory values and clinical parameters
rapidly improved. Currently, in necessity, dialysis procedures are
successfully being performed with the method described.
A
VVH is frequently performed in organ transplant recipients for renal
failure in early phase following transplantation. Due to coagulation
impairment and recent surgery, these patients are at increased risk of
bleeding and different strategies are developed to perform CVVH under
minimal systemic, or no anticoagulation. In the present study we
assessed filter survival in simultaneous kidney and pancreas transplant
(SPKT) and liver transplant (OLT) recipients in whom CVVH (Braun
Diapact CRRT) was performed within two weeks following the
transplantation. 8 patients were included (4 SPKT and 4 OLT). There
were total of 27 procedures (10 SPKT and 17 OLT) in whom duration of a
single CVVH treatment was not pre-prescribed. Anticoagulation was
maintained by arterial line low-dose heparin infusion (goal APTT 1-1,5x
upper limit of reference range). Filter was flushed by 100 ml saline
hourly. Mean filter survival was 19,82 ± 2,98 hrs, heparin dose 590,4 ±
85,3 U/hr, and APTT 50,96 ± 5,5 s. There was no statistically significant
difference between SPKT and OLT filter survival (20,06 ± 5,9 vs. 19,59 ±
2,6 hrs), heparin dose (703,1 ± 46,88 vs. 440,0 ± 163,5 U/h) and APTT
(46,9 ± 2,7 vs. 56,39 ± 13,14 s). There was only one major bleeding
episode in these patients (1 OLT recipient). In conclusion, CVVH can be
successfully performed with an acceptable filter survival in organ
transplant recipients using low-dose heparin infusion, in combination
with filter flushing, without an increased risk for bleeding
complications. It is associated with a high work-load for a nurse.
C
THE ROLE OF PATIENTS COMPLIANCE IN CONTROL OF PHOSPHATE
LEVELS IN HAEMODIALYSIS PATIENTS
SUCCESSFUL PREGNANCY AND DELIVERY IN A PATIENT ON
HAEMODIALYSIS
M. Prsa, S. Balon, G. Novakovic, Z. Truhan, D. Pavlovic;
University Hospital "Sestre milosrdnice", Zagreb, CROATIA.
E. Melero-Rubio, C. Terry-Osset;
Hospital Arrixaca, Murcia, SPAIN.
revention and treatment of hyperphosphatemia is very important in
haemodialysis patients.
The aim of this study was to evaluate the patients’ compliance in
treatment of hyperphosphatemia
The values of calcium, phosphate and parathyroid hormone (PTH)
levels were recorded in 73 patients, mean age 59.7 (24-81), on
haemodialysis 4.7 (1-18) years. All patients were interviewed by one of
the authors regarding when and how many of phosphate binders are
used.
The mean Ca level was 2.2 (range 1.83-2.8) mmol/l; 11 of 73 (15%) had
Ca level higher than 2.4 mmol/, mean P level was 1.74 (range 0.8-3.07)
mmol/l and 30 of 73 (41.2%) patients had P level higher than 1.8
mmol/l. The mean PTH level was 37.8 (range 0.7-158.4) mmol/l, in 28
of 73 patients (38.5%) the level of PTH was higher of 31.4 mmol/l. Five
of all patients (7%) did not take any phosphate binders. All others used
calcium carbonate, mean 2.7 g (1 to 12). 16 of patients (22%) take
phosphate binders only with main meals, 8 patients (11%) take them
between meals and 2 (3%) after meals. All the others take phosphate
binders before or during all meals. During a week, 8 patients (11 %)
missed once or twice taking phosphate binder, and 6 (8.2%) more than
twice missed taking phosphate binders. Poor compliance of our
patients is a big problem and poor education could be one of the
reasons. Therefore, greater effort from renal nurses into patient
education could be of great value.
P
P
regnancy in patients with nephropathy implies a risk for the mother
as well for the foetus. The number of maternal morbidity and foetal
loss probability for this kind of patients increases, although during the
last years, the percentage of successful deliveries stands on 50%.
We describe a case of successful delivery happening in our unit. A
woman aged 35, undergoing pre-dialysis and 14 weeks pregnant. The
first measure adopted was the establishment of an immediate internal
arteriovenous fistula and the consequent admission to the hospital, in
the gynaecology department, all along the gestation period. The
treatment began with the patient undergoing 9 hours of haemodialysis
per week. At the end of the pregnancy, the treatment consisted on 12
hours per week. This dose was low according to the references found in
the bibliography, although it could not be increased since the AV fistula
was not sufficiently developed to be punctured daily. Blood pressure
was monitored during the sessions in order to avoid hypotensive
episodes. Loss of volume was also eliminated aiming to maintain the
patient’s residual diuresis. Blood volume restoration was carried out
by the administration of normal saline. Creatinine maintained a normal
level and the anaemia was controlled by the administration of iron and
erythropoietin. After 34 weeks, a caesarean section was performed.
The baby’s weight was 2 kg, it had normal Apgar scores and no
congenital anomaly was detected. The patient is currently on
haemodialysis. The baby was discharged and is in good health.
47
THE EFFECT OF BETA GLUCAN ON ANTIBODY RESPONSE TO
HEPATITIS B VACCINATION IN PATIENTS WITH CHRONIC RENAL
FAILURE
J. Erturk, E. N. Aran, D. Dag;
Süleyman Demirel University School of Medicine, Dialysis Unit, Isparta,
TURKEY.
ialysis patients have suboptimal immune-response in spite of
double doses hepatitis B vaccination. Beta glucan is an immunostimulating agent and thought to have an effect on antigen presenting
cells activation. In this study, we aimed to investigate the effect of beta
glucan on antibody response to hepatitis B vaccination in patients with
chronic renal failure.
The patients were divided to three groups. Group I: non-immune
patients not receiving beta glucan (n=28; 17M, 11F). Group II: nonimmune patients receiving beta glucan (n=14; 8M, 6F). Group III:
before vaccinated, but non-immune patients receiving beta glucan
(n=24; 15M, 9F). All patients were vaccinated with double doses of
hepatitis B vaccine as defined elsewhere. Beta glucan was given 10 mg
a day, orally, for two months. Measurement of antiHBs antibody titrates
was planned after six and twelve months.
In 54% of group I patients (6/11), in 78% of group II patients (11/14)
and in 83% of group III patients (20/24), antiHBs antibodies had
become positive. In Beta glucan taken groups (II, III), antiHBs antibody
positivity ratio was higher than in group I, but not statistically
significant. In addition in antiHBs antibody titrates, there was a
significant difference between groups I and III (Mean antiHBs antibody
titrates were 189±400 mIU/mL in group I, 133±152 mIU/mL in group II
and 387±391 mIU/mL in group III) (p=0.035).
In conclusion, beta glucan seems to be a beneficial adjunct to
treatment in patients with chronic renal failure who are vaccinated
against hepatitis B virus but more especially in those before
vaccination, who are non-immune.
D
VASCULAR ACCESSES. AN INVESTMENT!
PERSONAL TREATMENT FOR EACH PATIENT - MOTTO OR REALITY?
G. Rovner, M. Buchnik, Z. Gavish, G. Maister, M. Levin;
ntroduction: Haemodialysis treatment management relates to many
physiologic aspects. Recent technological advancement has enabled
individual monitoring of patients’ haemodynamic state, by blood
volume monitoring, blood sodium level and KT/V testing during
treatment, in an aim to compile personalized dialysis program.
Goal: Improving patients’ haemodynamic state and raising KT/V values.
Aims: Decreasing cases of hypotension - Setting “dry weight” - Suiting
personal weight and sodium profiling - Setting optimal dialysate
temperature - Improving KT/V values - Improving patients’ general
feeling during dialysis.
Process: Surveying literature - Choosing patients - Compiling work plan:
observation, suiting personal program, evaluation - Processing data
Equipment: Gambro AK 200 S dialysis machines with KT/V modules BVM sets.
Results: New “dry weight” determined for 50% of patients.
Personal weight profiling determined for 100% of patients.
Sodium profiling established for 67% of patients.
Optimal dialysate temperature set for 100% of patients.
Decrease noted in number of hypotensive cases..
Following intervention, for 50% of patients KT/V level reached 1.2; 50%
of patients KT/V increased by 15%.
100% of patients reported improved general feeling.
Conclusions: Continuous monitoring of blood sodium is necessary, for
sodium profiling.
Personal weight profiling contributes to haemodynamic stability.
Decreasing dialysate temperatures under 37 degrees, contributes
significantly to patients’ haemodynamic stability.
KT/V measuring during treatment, enables immediate intervention and
treatment quality improvement.
Recommendations: Blood volume monitoring and KT/V measuring is to
be performed continuously, to enable compiling patient program.
I
BONE METABOLISM AND DISEASE IN CHRONIC KIDNEY DISEASE.
STILL A CHALLENGE FOR ALL RENAL NURSES
I. P. Silva;
Dialave-diálise de aveiro,lda, Aveiro, PORTUGAL.
I. P. Silva;
Dialave-diálise de aveiro,lda, Aveiro, PORTUGAL.
e choose the type of access as a variable, then studied the comorbidity and mortality of 200 patients with end-stage renal
disease (ESRN) receiving haemodialysis through a year. With this study
we want to show how important is to invest all knowledge in the
prevention of problems. The study shows once again that the AV fistula
must be elected as the best.
W
W
48
e follow-up 200 patients with ESRD in Haemodialysis during a
year and observed the PTHi values. As renal nurses we must be
alert to this measures. The study associates PTHi values with comorbidity and mortality.
A NEW METHOD TO REDUCE THE INTRADIALYTIC PROBLEMS:
PROFILED HAEMODIALYSIS
SATISFACTION WITH HEALTH CARE OF HAEMODIALYSIS PATIENTS
M. A. Mollaoglu;
Cumhuriyet University, Sivas, TURKEY.
D. Tosi, S. Passarini, P. Fiorito, G. Ruggeri, M. Saragoni, D. Mattucci,
E. Marchese, F. Buonpadre;
S.ORSOLA-MALPIGHI, Bologna, ITALY.
he purpose of this study was to assess haemodialysis patients’
satisfaction with care, and to explore the relationships between
satisfaction and socio-demographic variables.
The study was carried on 138 patients in 3 haemodialysis units in Sivas
between the dates September 2004 and January 2005. Participants
ranged in age from 18 to 67 years with a mean age of 48.3 years. The
data were collected using a questionnaire determining the sociodemographic features and Satisfaction with Health Care of
Haemodialysis Patient Scale. Overall, patients were satisfied with their
care . An ANOVA demonstrated that patients were most satisfied with
nursing/dialysis treatment aspects, followed by physician related
aspects of care, and least satisfied with financial/transportation
aspects (p<0.05). Overall satisfaction with care was most highly
correlated with satisfaction with nursing care (r = .74) and. medical
(r = .68). Patients who had been on dialysis for a shorter length of time
or who had less education were more satisfied with care. Findings in
this study, although preliminary, may provide renal unit staff with
appropriate health care information about ESRD patients, in an effort
to understand better their psychosocial needs and satisfaction with
health care.
T
urpose: A new method of Profiled Dialysis(PHD) has been set up
from many years in the Department of Nephrology (University of
Bologna).
This Profiled Dialysis is based on the use of a new kinetic mathematical
model.
The aims of this Profiled Dialysis are: 1) stabilize the intradialytic blood
volume boosting the refilling of plasma water from the intracellular and
the extravascular to the extracellular /intravascular compartments, in
order to balance the ultrafiltration; 2) counteract the disequilibrium
syndrome reducing the shift of water from the extra to the intracellular
compartment.
Methods: In the present prospective and multicentre study this Profiled
Dialysis, has been applied continuously, for a period of 8 months, in a
group of 13 haemodialysis patients with clinical intolerance to previous
dialysis treatment. During the study, comparisons with patient’s basal
treatment, were evaluated the following parameters: a) the sodium and
water balance, b) the % incidence of intradialytic complications such as
hypotensive events, cramps, headache, vomiting, and c) the metabolic
and nutritional status.
Conclusions: In all patients treated with Profiled Dialysis a higher
stability of intradialytic blood pressure and a decrease of the incidence
of disequilibrium syndrome symptoms have been achieved, in
comparison with previous treatment. These clinical intradialytic
improvements are not correlated to clinical, instrumental or
biochemical indexes of sodium-water overload nor to a worst dialysis
adequacy and nutritional state.
P
PAIN CONTROL IN DIALYSIS PATIENTS
PLASMAPHERESIS
R. Morgenstern, L. Schwartz, N. Cohen, A. Marcovici, D. Tovbin;
N. M. Moreira, P. J. Pinto, L. J. Gaspar, H. B. Lima;
H. S. JOÃO, Maia porto portugal, PORTUGAL.
ackground: Life expectancy of dialysis patients has risen due to
advanced technology and treatment. To improve quality of life
parallel to life-span, supportive care is required including the treatment
for chronic pain.
Pain, in itself, is a stressful condition leading to poor compliance,
function, quality of life (QOL) and perceived control. Multi-factorial pain
depletes the sufferer's physical and moral energy, and depresses the
immune system.
Hypothesis: Since haemodialysis (HD) patients compose a unique
hybrid of hospital and community patients who respond differently to
pain medication, their pain management deserves specific program and
guidelines.
Methods: Pain-control program was started for our 55 chronic HD
patients. The nursing staff received instructions for pain assessment,
and a pain-coordinator was chosen. Follow-up included pain-intensity,
location and pain-treatment. Pain-intensity was assessed by Visual
Analogue Scale (VAS 0-10) at every session, even without complaints of
pain. Detailed assessment was performed at VAS>3.
Results: For the last year we have conducted pain-assessment and
treatment according to the protocol. A decrease (35to22%) of
moderate-severe pain (VAS 4-10) has been shown, since pain-control
and treatments were started. Although pain sites varied, lower
extremities were 1/3 of all sites at the same magnitude of pain. Use of
analgesics subsequently rose (24to75%) due perhaps to the clinical
staff's growing awareness of patients' pain.
Conclusions: Pain-program in HD patients was associated with
increased analgesic use, pain relief and patients' confidence in staff. To
further improve pain-management and QOL in these patients, our staff
is currently establishing guidelines for analgesics use in HD patients.
P
B
lasmapheresis (PLF) is a procedure in which blood is separated into
cells and plasma. The plasma is removed and replaced with plasma
or albumin, often referred to as plasma exchange. This treatment is
used to remove antibodies from the bloodstream, thereby preventing
them from attacking their targets. It does not directly affect the
immune system's ability to make more antibodies, and may only offer
temporary benefit. In an autoimmune disease, the immune system
attacks the body's own tissues. In many autoimmune diseases, the
chief weapons of attack are antibodies, proteins that circulate in the
bloodstream until they meet and bind with the target tissue. Once
bound, they impair the functions of the target, and signal other
immune components to respond as well. PLF is a relative safe
procedure, but there are some risks associated with the treatment.
Constant monitoring during the treatments allows the measurable
benefits of PLF to outweigh its risks in our Unit we mainly use this
procedure in self-limited disorders such as Lupus, Focal and Segmentar
Glomeruloesclerosis (SG) and other diseases like Myasthenia Gravis. In
2004 we performed a total of 35 sessions of PLF in 4 patients.
Diagnosis: 3 Females: focal and SG; 1 man: PRA. The mean age was
27.5 years old; 3 females and 1 man.
Conclusion: Other conditions may respond to PLF as well. Beneficial
effects are usually seen within several days. Effects commonly last up
to several months, although longer-lasting changes are possible,
presumably by inducing shifts in immune response.
49
THE TREATMENT OF ACUTE RENAL FAILURE IN THE INTENSIVE
CARE UNIT WITH CONTINUOUS RENAL REPLACEMENT
MODALITIES
HAEMODIALYSIS CATHETER DYSFUNCTION IS REDUCED BY
CATHETER RESTRICTED FILLING WITH GENTAMICIN AND HEPARIN.
B. Devcic, S. Racki, I. Maleta, A. Sustic, Z. Zupan, B. Krstulovic;
Clinical Hospital Center Rijeka, Rijeka, CROATIA.
H. Pitt;
Renal Unit, Derby, UNITED KINGDOM.
ntroduction: Acute renal failure (ARF) is a sudden decline of renal
function in the previously healthy individuals. ARF in the intensive
care units (ICU) is usually associated with multiple organ failure (MOF)
and varies between 7% and 23% of admissions. Various treatments can
be used, but mortality remains high (50-60%).
Methods: we have analysed 23 ARF patients (14 males, 9 females) in
the ICU in the Clinical Hospital Center Rijeka, Croatia, during the 2003.
All the patients were treated by Intensive Care Specialists and
nephrology teams. The patients were treated with continuous renal
replacement modalities: continuous venovenous haemofiltration
(CVVH), continuous venovenous haemodialysis (CVVHD) and
continuous venovenous haemodiafiltration (CVVHDF). We used an
adequate technical procedure and dialysis membrane according to
clinical standards.
Results: the mean age was 60,1±14,6 years. Medium single treatment
time was 34,7±40,6 hours, range between 3 and 240 hours without
interruption. In the all patients a biocompatible polysulphone
haemodialysis membrane was used and three different substitute
haemofiltration solutions. We presented treatment characteristics
(ultrafiltration and substitution rate, dialysate and blood flow rate,
anticoagulation profile), standard laboratory and haemodynamic
parameters. The clinical outcome: 12 (52%) patients died, 9 (39%)
patients recovered completely and 2 (9%) patients developed chronic
renal failure requiring dialysis.
Conclusion: the treatment of ARF complicating MOF in the ICU can be
successful using continuous renal replacement modalities. High
mortality rate depends on the clinical conditions of the patients. The
most important is to begin renal replacement treatment as soon as
possible in the critically ill patients developing ARF.
roblem: Vascular access using tunnelled catheters for
haemodialysis (HD) is commonly limited by catheter related
infection (CRI) and catheter dysfunction.
Purpose: To study the outcome of catheter restricted filling with
gentamicin and heparin on haemodialysis catheter dysfunction.
Design: We have completed a randomized controlled trial of gentamicin
locking newly inserted catheters and have demonstrated 90%
reduction in CRI.
We studied catheter dysfunction over 30 months. The initial period had
lines locked with heparin alone. The second segment was during the
randomised control trial (RCT) on newly inserted catheters only, the
third 10 months was after full adoption of antibiotic locking. Catheter
malfunction was defined as a blood flow rate <200 ml/min, with a
delivered Kt/V of <1.0.
Findings: CRI rates fell from 4/1000 (pre RCT) to 0.3/1000 catheter
days for patients within the RCT and 0.76/1000 catheter days for all
patients post RCT. This was associated with a significant lowering of
CRP levels following the introduction of gentamicin locking (31.6 cf 20.4
mg/l p<0.05).
Catheter malfunction was halved by introduction of antibiotic locking
pre RCT 0.06± 0.02 (0-0.18), during RCT 0.02± 0.007 (0-0.065) and post
RCT 0.03± 0.008 (0-0.07) urokinase infusions per catheter per month
(48 infusions in total), p=0.05.
Conclusion: This study shows that gentamicin and heparin locking of
haemodialysis catheters reduces CRI and may help prolong the lifespan
of tunnelled dialysis catheters by reducing catheter malfunction,
thereby improving patient outcome on haemodialysis.
UP-TO-DATE KINDS OF HAEMODIALYSIS - A BETTER CHOICE FOR
PATIENTS ON HAEMODIALYSIS
ANAEMIA MANAGEMENT IN DIALYSIS PATIENTS WITH EVERY-2WEEK ARANESP® (DARBEPOETIN ALFA)
I
C. V. Bucevac, M. V. Milic;
Zavod za endemsku nefropatiju, Lazarevac, SERBIA AND
MONTENEGRO.
3 groups of 20 patients included in the chronic haemodialysis
programme in our centre were examined during the year 2004.
The groups had similar characteristics sex, age and the duration of the
medical treatment comprising haemodialysis.
Patients of the first group were those on the programme receiving
acetate haemodialysis. Patients of the second were those receiving
bicarbonate haemodialysis. Patients of the third group were on
haemodiafiltration.
All the patients` corresponding parameters were controlled during the
period of one year - (haematocrit, the parathyroid hormone, blood
pressure and the index Kt/V).
All the examined parameters were statistically better (p < than 0.5)
with the patients on haemodiafiltration in relation to those on the
bicarbonate dialysis and far better in relation to the patients on the
acetate haemodialysis (p < than 0.01).
All the patients on the haemodiafiltration had a well-regulated blood
pressure through better achievement of dry body weight and all had a
much better blood picture than the patients from the other two groups,
through better elimination of the uremic inhibitors of erythropoesis.
Conclusion: more up-to-date technology (machines, membranes), more
up-to-date haemodialysis and well trained nurses are a significant step
towards achieving a better dialysis and better general health of these
patients.
50
P
B. Szablyar1, D. Borniche2, R. Canteiro3, W. Thallner4, L. Edwards5;
1
Pflegedienstleitung, KfH Kuratorium für Dialyse and
Nierentransplantation, Nürnberg, GERMANY, 2Hemodialysis Centre,
Bois Guillaume, FRANCE, 3Fresenius Medical Care, Venda Nova,
PORTUGAL, 4A.ö. LKH Klagenfurt, Klagenfurt, AUSTRIA, 5Northern
General Hospital, Sheffield, UNITED KINGDOM.
ranesp®, an effective anaemia treatment in patients with end-stage
renal disease, can be administered at extended dosing intervals
relative to recombinant human erythropoietin (rHuEPO). This analysis
assessed the efficacy of anaemia treatment with Q2W Aranesp® in
patients receiving dialysis. Eight 24-week European studies with the
same design were pooled (evaluation: weeks 21-24). Selected inclusion
criteria required patients to be ≥ 18 years, be receiving haemodialysis
or peritoneal dialysis, be receiving rHuEPO, and have haemoglobin
levels 10-13 g/dL. Patients initiated Aranesp® based on previous
rHuEPO therapy (1 µg Aranesp®: 200 IU rHuEPO): once weekly (QW) if
converting from 2 or 3-times weekly rHuEPO or Q2W if converting from
QW rHuEPO. The route of administration was maintained, and the dose
of Aranesp® was titrated to maintain haemoglobin levels (10-13 g/dL).
This is a cohort analysis of dialysis patients receiving Q2W Aranesp®. A
total of 1101 patients were included in this analysis (intravenous, 196;
subcutaneous, 905). Ninety-seven percent of patients maintained their
Q2W Aranesp® dosing interval, and 85% of these patients (intravenous,
82%; subcutaneous, 86%) maintained their haemoglobin in the target
range. Regardless of administration route, there was no change in dose
between baseline and evaluation. Aranesp® was well tolerated. Q2W
Aranesp® effectively maintains haemoglobin levels in dialysis patients.
Less-frequent dosing regimens may offer the advantage of allowing
more time for patient care.
A
CONDUCTIVITY-BASED VASCULAR ACCESS FLOW EVALUATION
INTEGRATED IN HAEMODIALYSIS MACHINE
HDF AS A CHRONIC THERAPY - EXTRAORDINARY OR ORDINARY?
P. M. Sinclair, A. Dunlop, N. Velasco;
Crosshouse Renal Unit, Ayrshire, UNITED KINGDOM.
ntroduction: Some of the morbidity associated with chronic
haemodialysis is thought to result from the retention of large
molecular solutes that are poorly removed by diffusion in conventional
haemodialysis.
Haemodiafiltration (HDF) combines convective and diffusive solute
removal in a single therapy.
Time for Change: Due to the increasing need for dialysis and our aim of
improving middle molecule clearance, our unit commenced HDF as a
Chronic Therapy 2 years ago.
We used Post Dilution HDF on all patients. Benefits we have found in
this therapy are better patient stability and dialysis efficiency, as
measured by blood chemistry, blood pressure and patient acceptance.
The limitation of this mode is that haemo-concentration of the blood
limits the rate of filtration to approx 25-30% of the incoming blood flow.
It has been claimed that Mid Dilution technology offers very good urea
clearance and offers unsurpassed clearance in toxins in the middle
molecule range.
Aim: The aim of this abstract is to present our experiences with Mid
Dilution technology for HDF and the reality of the benefits claimed.
Measures being assessed and presented are: Staff Acceptance, Patient
Questionnaires, Procedural Changes, Blood Chemistry, Beta 2
Measurements.
Relevance: This is an exciting therapy. With the combination of on line
substitution technology and clinically advanced membranes we aim to
continually improve middle molecule toxins, as measured by Beta 2
Microglobulin.
I
M. Portova1, A. Kesziova1, M. Chobotova1, M. Kutova1, Z. Mihalova1, G.
Novotna1, J. Sebesova1, R. Svensson2, J. Sternby2, F. Lopot1;
1
General University Hospital, Prague 6, CZECH REPUBLIC, 2Gambro AB,
Lund, SWEDEN.
ascular access blood flow (QVA) has to be usually measured by an
external device. Gambro has now developed an algorithm enabling QVA
evaluation by the Diascan module, an integral part of AK200S haemodialysis
(HD) machines. It is based on conductivity change induced by switching
between normal and inverted needles position. Accuracy and reliability of the
method was tested in frame of a research and feasibility study.
Procedure: QVA was measured concurrently by the Diascan module and by
the HD01 ultrasonic dilution device (Transonic Systems) in 20 patients
dialysed on Gambro AK200S machine. Reproducibility of Diascan QVA
measurement was evaluated from duplicate measurements performed at the
same extracorporeal blood flow (QB=300 ml/min). Influence of
measurement conditions was assessed by paired measurement immediately
following each other, performed at QB=300 and at QB=200 ml/min.
Accuracy of the new method was assessed by correlating Diascan QVA
measurement result with that obtained by the Transonic HD01, both
performed at QB=300 ml/min.
Results: Reproducibility of Diascan measurement at QB=300 ml/min was very
good (r=0,905; n=20). Correlation of the Diacsan-based and Transonic-based
QVA values was also satisfactory (QVADias=0,91*QVATrans-46; r=0,85).
Diascan measurement with QB=200 tended to give slightly lower results than
measurement with QB=300 ml/min. One QVA measurement with Diascan
typically takes 26-28 minutes with one operator´s intervention in between.
Conclusions: Accuracy and reproducibility of the new measurement appears
sufficient for routine clinical use. No additional material costs are incurred
with this method. Drawback of the new method is its rather long time needed
for one measurement.
V
Paediatrics Posters
THE RELATIONSHIP BETWEEN HOME CARE AND PERITONITIS OR
DIALYSIS ADEQUACY IN CHILDREN ON CHRONIC PERITOENAL
DIALYSIS
ALLERGIC DERMATITIS CAUSED BY POVIDONE-IODINE: AN
OMITTED COMPLICATION OF CHRONIC PERITONEAL DIALYSIS
TREATMENT
S. Senturk, N. Akcan, S. Unturk, H. Aslan, E. Kiryatan, S. Baldemir,
O. Yavascan, N. Aksu;
SSK Tepecik Teaching Hospital, Department of pediatric nephrology,
Izmir, TURKEY.
N. Akcan, S. Senturk, S. Unturk, H. Aslan, O. Goker, O. Yavascan,
G. Sozen, N. Aksu;
SSK Tepecik Teaching Hospital, Department of pediatric nephrology,
Izmir, TURKEY.
hronic peritoneal dialysis (CPD) in children is an important modality of
renal replacement therapy. Parents whose children are undergoing
CPD have to make important changes in home conditions in accordance to
information which is given about CPD. This study was performed in order
to evaluate the potential relationship between the incidence of peritonitis,
adequacy of dialysis and the home conditions in children on CPD.
This study was carried out on 21 patients (12 boys, 9 girls), aged 4 to 24
years old (mean age: 5.66 ± 13.76 years). The mean duration of CPD
treatment was 27.62 ± 41.42 months (range: 7-111 months, follow-up
period: 870 pt-mos). Between these 21 patients 17 (80.9 %) there were
48 peritonitis episodes. The incidence of peritonitis was one
episode/18.12 pt-months. The living and home conditions were
evaluated for every patient during the home visits performed by CPD
nurses. Statistical analysis was made using Mann-Whitney U test. A P
value of less than 0.05 was considered to be significant.
Among these 21 patients the exchange-room, the hygienic conditions,
the ventilation and light was inappropriate for 36.4 %, 13.6 % and
13.6 % patients, respectively. The incidence of peritonitis was
significantly correlated with the frequency of exit-site care and the
quality of oral care (p<0.05).The adequacy of dialysis was not
correlated with home conditions.
In conclusion, it is necessary to give regular updated education and
make home visits for this specific group of patients. This policy might
help to reduce the incidence of peritonitis and hospital admissions in
children on CPD.
llergic dermatitis around the catheter exit-site caused by the topical
antiseptics such as povidone-iodine, chlorhexidine gluconate is an
uncommon complication in patients on chronic peritoneal dialysis
(CPD). As yet, limited reports have been published concerning this rare
noncatheter-related complication. The frequency of this type of
dermatitis is not known, as reports of isolated cases constitute the only
source of information.
We report on our clinical experience of two paediatric patients among
the 86 children with end-stage renal disease who underwent CPD
treatment during the period between November 1995 and December
2004. Two patients (2.3 %) developed allergic contact dermatitis with
the appearance of extensive patchy and linear erythema on around the
exit-site area owing to administration of povidone-iodine solution. The
symptoms subsided within a week after daily topical application of
normal saline solution in both of patients.
In conclusion, allergic dermatitis caused by povidone-iodine at the site
of the catheter exit should be kept in mind as a complication in
patients on CPD. Therefore, antiseptic solutions should be used
cautiously in these patients.
C
A
51
COMPLIANCE AND RE-TRAINING IN PERITONEAL DIALYSIS
PATIENTS: MULTICENTER STUDY
S. Quadri1, V. Paris2, G. Gruppo Italiano Studio Re-Training PD3;
1
Ospedali Riuniti, Bergamo, ITALY, 2Baxter, Milano, ITALY, 3Brescia Civili,
Brescia, ITALY.
Objectives:
• To evaluate the theoretical knowledge that the patient retained from
his/her initial PD training
• To evaluate the patient’s compliance at home
• To identify the necessary areas of re-training for the patient and/or
partner
In this abstract we will describe the first phase of this study.
Material and methods: All PD patients from 12 centres that had been
treated for at least 4 months were included in a cognitive investigation.
Between November and December 2004, 420 questionnaires were
delivered. By January 2005, 360 fully completed forms were returned
(response rate 85%). The questionnaire contained 30 queries
regarding: peritoneal dialysis, diet, drugs, infections (peritonitis and
exit-site) and physical activity.
Results: Sample data: mean age 63 years; mean dialysis age 35
months/patient; gender 210M/140F. Of the questionnaires returned,
74% were completed by the patient and 26% by the partner.
The initial results show that 62% of the answers were correct, 25%
were incomplete and 13% were wrong regarding diet and fluid intake.
All data is currently being analyzed and final results will be available in
April.
Discussion: Although the preliminary results are quite satisfactory,
there was a substantial percentage of patients who forgot some of the
information that they received during their initial training at hospital.
Conclusion: Over time, due to the chronic nature of kidney failure and
dialysis therapy, the patient forgets or alters the information received
at the beginning of dialysis treatment.
CAN PERMEABILITY STATUS OF PERITONEUM CHANGE OVER
YEARS IN PATIENTS WITH CAPD?
A. Eyupoglu1, D. Unal2, H. Cakmak1, T. Sav1, B. Tokgoz1;
1
Erciyes University Semiha Kibar Transplantation and Dialysis Hospital
CAPD Unit, Kayseri, TURKEY, 2Erciyes University Semiha Kibar
Transplantation and Dialysis Hospital CAPD Unit, Kayseri, TURKEY.
nformation: Performing a PET (Peritoneum Equality Test) which
determines the permeability of peritoneum to urea, creatinine, and
glucose is the most important step in the treatment of patients with
CAPD.
Aim: To determine whether the permeability of peritoneum changes
over years and to evaluate the importance of changes on the disease
progression.
Material and Method: 45 patients who were treated in our CAPD unit
during 2000-2004 were included in the study. Membrane permeability
in the PET tests performed in five-year period was evaluated based on
the permeability of urea, creatinine, and glucose. Tests were performed
using 2000 ml 2, 27% glucose solutions. Peritoneal fluid samples were
taken at 0.2 and 4 hours and blood serum samples were drawn at the
end of 2 hours. Results were calculated using PD sufficiency test
formulas.
28 of patients (57%) were male, 21 (43%) were female. Age range was
between 27 and 74. There was no statistical difference in the ages of
the patients between sexes (p>0, 05). BSA indexes were in normal
ranges in all patients. There were no infections related to PD in any
patient. 0, 05 was accepted for significance.
Discussion: No significant change in peritoneal membrane permeability
of our patients over years was found in this retrospective study. Result
demonstrates that even dialysis solutions are changed, there will be no
change in the peritoneal membrane permeability. It should be noted
that changes in membrane permeability can take place in the future
years and can affect the course of disease.
I
BYILD - BUILD YOUR SKILLS IN PERITONEAL DIALYSIS
G. A. Endall;
Portsmouth Hospital Trust UK, Portsmouth, UNITED KINGDOM.
YILD came from a ‘light bulb’ moment. There was a need to ensure
staff could carry out the essentials of caring for a patient on
Peritoneal Dialysis (PD). I chose the acronym BYILD as it represents the
essentials of peritoneal dialysis. BYILD refers to the following
procedures:
B - Bag Exchange
Y - Your skills in Peritoneal Dialysis
I – Injecting
L - Line Change
D - Dressing the Exit Site
Knowing that I needed to ensure all staff could carry out the essentials
in Bag Exchange, Line Change, Injecting, etc. I looked for a way in
which it would sound ‘snappy’ and interesting to those who will use the
CD-Rom given to each ward and satellite unit, and also for each ward
and nurse to access the Web Pages that have been set up. This CD-Rom
is to help you increase your skills in the area of Peritoneal Dialysis.
5. A ‘pop up’ will appear on the screen, this will tell you what action
you have to carry out in order to see the photograph that is relevant
to you.
Pop up looks like this:
6. Press and hold the Ctrl button on the keypad, then left click the
mouse or touchpad on a laptop once. A photograph of the action
should then appear.
B
52
PERITONEAL CATHETER PLACED IN SMALL INTESTINE
C. Navarro Sanchez, L. Guardiola Perez, A. Rabadan Armero,
P. Collado, M. Cozar, F. Gomez;
H.U.V.A. MURCIA, El palmar (murcia), SPAIN.
he incorrect functioning of a peritoneal catheter is normally caused
by its shifting or by it being caught by the epithelium. We present a
case of a catheter caught in the bowel.
Case Report
33 year-old patient. Unknown CRI diagnosed, with a Braun 2T selfpositioning surgical peritoneal catheter. Its correct placement had been
previously checked through X-rays.
Training on the correct use of the system starts on 27th March 2003.
At the very beginning of the process, as the catheter was caught inside
the bowel, the patient felt instant need to defecate, his faeces being
plain liquid. An X-ray with contrast reveals that the peritoneal catheter
is placed inside the bowel. It was then extracted and a new one was
placed in Douglas.
When the first catheter was placed, the patient suffered an abscess on
his scar.
The study of the exuded matter was positive for enterobacter cloacae,
which was treated with ciprofloxacina. The patient responded well to
the treatment.
The second catheter did not function as it should, neither for infusion
nor for drainage. A new X-ray with contrast is done and it revealed that
the catheter is caught by the epithelium.
Such problem was solved through an omentectomy. From May 2003
both the functioning and the positioning of the catheter have been
correct and the patient has suffered neither abdominal problems nor
"peritonitis".
T
SEXUAL PROBLEMS OF THE PATIENTS PERFORMING CAPD
AND APD
^
FUNGAL PERITONITIS DEVELOPED DURING PERITONEAL DIALYSIS:
TWO CASE REPORTS
^
S. Hanci, N. Kural, B. Yıldız;
OGU Medical school, Eskisehir, TURKEY.
N. Özerdogan, N. Kösgeroglu, D. Sayıner, S. Giray, C. Demirüstü;
´
Osmangazi University, Eskisehir, TURKEY.
n this report, two patients who had the diagnosis and the treatment
of fungal peritonitis during peritoneal dialysis were presented.
Case Reports
Case 1: Seven-year-old girl who had been in CAPD followed up over one
year admitted with abdominal pain and difficulty of drainage.
Peritoneal fluid culture was yielded Candida Parapisilosis. Intravenous
and intra-peritoneal antifungal treatment was continued for two weeks.
Since the patient did not give response to the treatment, the catheter
was removed. Intravenous treatment for six weeks and haemodialysis
for 6 months were continued. With her family request, peritoneal
dialysis catheter was placed and dialysis was continued successfully
following the treatment of fungal infection.
Case 2: Fourteen-year-old girl who had been in CAPD follow up since
five year admitted with abdominal pain and fever. Peritoneal fluid
culture was yielded Candida Parapisilosis. Since the family was living in
a village very far away from our hospital, family rejected the removal of
catheter. With her catheter in its place, Intravenous and intra-peritoneal
antifungal treatment was begun. The infection was controlled. She was
discharged and continued the peritoneal dialysis successfully.
Conclusion:
Fungal peritonitis is one of the serious complications of peritoneal
dialysis. If it occurs, it results a failure in dialysis, the catheter removal
and a significant morbidity and mortality. Some social indications and
necessities, and especially the families and the patient’s request in
favour of continuing with peritoneal dialysis forced us to find
alternative solutions rather than a switch to haemodialysis.
urpose: This descriptive study has been done to determine the
sexual problems of the patients who are having Continuous
Ambulatory Peritoneal Dialysis (CAPD) and Automated Peritoneal
Dialysis (APD) at home.
Material and Method: The sample group of the study is composed of
the patients living in Eskisehir and followed up at Osmangazi University
at the Department of Nephrology who are sexually active (20 patients
performing CAPD and APD at their home). The collection of the data is
through a questionnaire. To analyse the data percentage, Wilcoxon
Signed Ranks, McNemar and T tests have been performed.
Results: It has been concluded that before the treatment of CAPD, the
patients’ feeling after sexual relation is happiness, they don’t get
disgusted, they are not ashamed and they do not feel guilty, after CAPD
and APD therapies these feelings have totally changed in a negative
way (p<0.001). After CAPD and APD performance it is concluded that
sexual desire, orgasm and the number of erections have reduced
(P=0.001), and the disgust of sexual relations, avoidance from sexual
relation and dyspareunia have increased (p<0,001). It has been found
that 20% of the patients have a problem with the idea that having the
catheter in their body affects their partner badly, 40% of the patients
think that the performance of this catheter and dialysis causes
continuous sexual problems.
´
I
P
IDEAL PATIENT NUMBER AND DURATION OF PD NURSING
SERVICES FOR QUALIFIED CARE
REASONS FOR DROP-OUTS IN PERITONEAL DIALYSIS PROGRAM
R. Dolgun1, M. Vergili2, T. Aksoy3, E. Uca4, S. Guvenc4;
1
Samatya S.S.K. Peritoneal Dialysis Unit, Istanbul, TURKEY, 2Sisli Etfal
´ ´
Hospital Peritoneal Dialysis Unit, Istanbul, TURKEY, 3I.U.Cerrahpafla
Medical Faculty Peritoneal Dialysis Unit, Istanbul, TURKEY, 4Eczacıbası´
Baxter Renal Products, Istanbul, TURKEY.
im: To evaluate nursing services given to PD patients at three
dialysis centres for one year.
Method: Study enrolled a total of 290 patients. Activities of 6 nurses at
3 centres were evaluated in 2003 under 5 categories:
1. Services provided (patient education, replacement of connection
points).
2. Services that could not be provided (home visit, group education).
3. Mandatory tasks (haemodialysis catheter implantation, purchasing
supplies).
4. Services given but not mentioned (communication within team,
patient-nurse communication over 24 hours).
5. Non-routine services (intern nurse education, participation in
scientific studies).
Mandatory tasks, duration and frequency of tasks were determined.
Annual working hours were calculated, excluding annual leaves. Total
duration of services provided and not provided was calculated. Number
of patients that a nurse was responsible for was obtained by dividing
that number into annual working hours. This calculation excluded
Category 3, 4, 5 since duration of these was unknown.
Conclusion: Duration of services that a nurse should provide and
mandatory tasks were found similar. Since time spent for Category 4
and 5 could not be determined, number of patients that each nurse
was responsible for giving health-care services was 42.6 patients
(table). After including these categories, it was concluded that ideally 1
PD nurse could provide qualified healthcare to 25-30 patients.
A
A. Yardim, H. Pelenk;
SSK Ankara Hospital, Ankara, TURKEY.
his study was performed to assess reasons for drop-outs among
CAPD patients and to relate these reasons to patient selection
criteria and patient education.
235 patients participating in peritoneal dialysis program between
January 2002 and December 2003 were followed. During this period, 45
patients discontinued their peritoneal dialysis therapy. Of these
patients, 22 were women and 23 were men; their mean age was 44.4
(range: 19-75) and length of therapy was 24.02 months (range: 2-69
months). Five patients received continuous cycler-assisted peritoneal
dialysis (CCPD). Three patients were diabetic. Of our 45 patients, cause
of discontinued peritoneal dialysis program was death in 19 (42.2%)
and renal Tx in 6 (13.3%). 20 patients (44.4%) switched to
haemodialysis therapy for various reasons. Of our 19 patients, 5
(26.3%) died from infection, 7 (36.8%) due to cardiac causes, 3 (15.8%)
from a cerebrovascular event, 1 (5.3%) from a metastatic tumour and 3
(15.8%) due to other medical conditions. Of our 20 patients, 7 switched
to haemodialysis therapy due to peritonitis (35%), 2 (10%) due to noncompliance to therapy, 10 (50%) due to ultrafiltration failure and 1 (5%)
for dialysis failure. Among 10 patients with ultrafiltration failure, 3 had
history of frequently repeating peritonitis.
In conclusion, peritonitis is the leading cause of discontinuation from
therapy in our centre. It was observed that peritonitis also
accompanied ultrafiltration failure which was among the reasons for
switching to haemodialysis therapy. Infections are the second cause of
death. This mandates repeated patient education in patients with
history of peritonitis.
T
Total Duration of Category 1 and 2 (days)
1555
Annual working days of each nurse
228
Number of patients that each nurse was responsible to provide healthcare services 42.6
Number of patients that each nurse could provide qualified healthcare services
25-30
53
FACTORS AFFECTING PERITONITIS AND CATHETER OUTLET
INFECTION
eritonitis and frequency of catheter outlet infections (COIs) were
assessed among 117 PD patients between 1995-2003. Patients were
divided into several groups in retrospective study. Different parameters
that were believed to affect the incidence of peritonitis and catheter
outlet infection were selected. With respect to their association with
infection, age, presence of diabetes, residence area, presence of a
caregiver and self-determination for receiving therapy were evaluated.
Of 117 patients, 78 were found to have history of peritonitis. 42
patients had 1 episode of peritonitis, 30 had 2-4 episodes and 6 had 5
or more episodes.
Of 117 patients, 45 were found to have a catheter outlet infection. 25
patients had 1 episode of catheter outlet infection, 14 patients had 2-4
episodes and 6 had 5 or more episodes. We aimed to determine
correctable and preventable issues by evaluating factors that could
affect infection incidence. Data can be seen in tables below.
P
Education Level vs Peritonitis and COI
EDUCATION LEVEL
Primary school graduate
High school graduate
University graduate
COI EPISODE
0,1
0,1
0,3
PERITONITIS EPISODE
0,3
0,1
0,3
Cause of starting Treatment vs. Peritonitis and COI
CAUSE OF STARTING TREATMENTCOI EPISODE
Compulsory indication
0,1
Self-determination
0,4
PERITONITIS EPISODE
0,2
0,3
ROLE OF SOCIOECONOMICAL FACTORS ON PERITONITIS RATE IN
CHILDREN ON CAPD
^
Ü. Zaimoglu, P. Mert;
Dr. SamiUlus Children’s Hospital, Paediatric Nephrology Department,
Ankara, TURKEY.
ocio-economic status of the family affect the success of continuous
ambulatory peritoneal dialysis (CAPD). In this study we investigated
the role of these factors on the rate of peritonitis that is the major
complication of CAPD. Between September 1993 and December 2004
we followed 110 patients on CAPD. 65 patients followed up at least 6
months (6-97 months-total 1660 patient months) were included in the
study. Of these 47 had 143 peritonitis attacks with a rate of 1/11.6
patient months. 21 patients in families with incomes less than
minimum wage (350 YTL) had 1/6.6 patient months while 44 patients
with higher incomes had 1/15.4 patient months which were significantly
different (p<0.05). Mothers of 21 patients were illiterate and peritonitis
rate was 1/5.3 patient months while it was 1/17.4 patient months in the
children of literate mothers with a significant difference (p<0.05). The
number of children in the family had no effect on peritonitis rate
(p>0.05) although it was 1/8 patient months in 29 families with more
than 3 children and 1/15.5 patient months in 36 families with 3 or less
children. In conclusion, being a reference hospital for the patients with
low socio-economic and cultural status our total peritonitis rate is not
higher than the world literature although we showed that economical
and cultural status of the patients affect the success of CAPD
treatment. The mortality and morbidity will be reduced with giving a
more intense training programme to these people with higher risk.
S
54
Presence of a caregiver vs Peritonitis and COI
PRESENCE OF A CAREGIVER
Relatives
Self-caring
COI EPISODE
0,3
0,1
PERITONITIS EPISODE
0,1
0,5
Residence Area vs Peritonitis and COI
RESIDENCE AREA
Rural
Urban
COI EPISODE
0,1
0,5
PERITONITIS EPISODE
0,4
0,3
Presence of Diabetes Mellitus vs. Peritonitis and COI
PRESENCE OF DIABETES MELLITUS
With diabetes
Without diabetes
COI EPISODE
0,4
0,2
PERITONITIS EPISODE
0,6
0,3
Age vs. Peritonitis and COI
AGE
Over 50
Less than 49
COI EPISODE
0,2
0,1
PERITONITIS EPISODE
0,5
0,2
Conclusion: Presence of diabetes was observed to lead to increased
rates of peritonitis and COI. Education level, areas of residence, reason
for starting treatment were found not to affect frequency of peritonitis
and COI. Rates of peritonitis and catheter outlet infection were higher
in patients over 50 years of age compared to patients younger than 49.
In patients who administered PD therapy themselves, incidence of
peritonitis was higher and rate of COI was lower compared to patients
who were treated by a caregiver. Further studies are needed to reach
definite conclusions and to take measures by determining issues that
need correction.
ERECTILE DYSFUNCTION AND SEXUAL PROBLEMS IN PERITONEAL
DIALYSIS PATIENTS
F. Özgür, Z. Aydin, R. Korkmaz, Z. Dogrusoz, &. Akdag, M. Yavuz,
S. Kahveci, P. Aydın;
Uludag University School of Medicine, Division of Nephrology, Bursa,
TURKEY.
^
H. Pelenk1, A. Yardim1, E. Ozturk2;
1
SSK Ankara Hospital, Ankara, TURKEY, 2Eczacibasi Baxter, Ankara,
TURKEY.
bjectives: Erectile Dysfunction (ED) is reported to affect 52-67% of
men between 40-70 years of age. Defined risk factors that is
associated with ED include age over 40, cardiac disease, peripheral
vascular diseases, chronic disorders such as hypertension, diabetes,
hyperlipidemia, renal disorders, depression and drugs used to treat
these conditions, radiotherapy, cigarette smoking and a sedentary life
style. In our study we aimed to assess ED levels of peritoneal dialysis
patients and their sexual condition.
Materials-methods: Study was conducted at PD unit of our faculty
between 01.06.2004 and 28.01.2005 and enrolled married, sexually
active subjects between 20-60 years of age who have been undergoing
PD for over one year. 13 patients with mean age of 47 ± 8 were
enrolled. Patients were given surveys with 15 questions that were
included in International Erectile Dysfunction Form published by R.
Roson et al in 1997. Forms were collected by third-persons.
Results: One patient (7%) with severe ED, 2 (15%) with moderate ED, 4
(30%) with mild ED were discovered and 5 (38%) patients were graded
as normal. 8 patients (61%) reported that they had less than one
sexual intercourse during past four weeks and all of the patients who
had sexual intercourse stated that they had satisfaction.
Conclusions: In our society, patients experience difficulty in expressing
their sexual problems. Given the high incidence of these problems in
patients with chronic disorders, we might assume that resolving these
problems with current modern therapies can increase self-confidence
of patients who partially isolate themselves from outside world.
O
RELATIONS BETWEEN GLOMERIAL FILTRATION RATE, KTV,
CREATININE CLEARANCE AND SERUM PHOSPHORUS LEVELS IN
CAPD PATIENTS
F. Candan1, S. Arslan1, A. Yılmaz1, N. Nur1, K. Caskurlu2;
1
Cumhuriyet University, School of Medicine, Department of Internal
Medicine, Peritoneal Dialysis Unit, Sivas, TURKEY, 2Eczac›bas›-Baxter,
Sivas, TURKEY.
o evaluate the relations between Glomerial Filtration Rate(GFR),
KTV, diet phosphorus content, and creatinine clearance (CCL) which
are among the factors that affect serum phosphorus level.
Method: 23 patients were enrolled in this study. Diet phosphorus
content of the patients was calculated using 3-days’ diet lists. Mean
phosphorus intake was 962,282+ (497-962). All patients were on
calcium carbonate 1 g, 3 times daily, as a phosphate binding agent. 16
of 23 patients had RRF. CCL, KT/V, and GFR were obtained. Correlation
analysis between GFR and KT/V, GFR and CCL, and GFR and serum
phosphorus, and relation between CCL and serum phosphorus levels
were investigated.
Findings: Mean age, mean daily protein intake, mean systolic blood
pressure, mean diastolic blood pressure, and mean BMI of the group
were 43,0435+12,45 years, 54,3096+19,94g, 117,3913+16,00,
77,3913+9,63, and 23,9087+4,37, respectively. Mean Kt/v, mean CCL,
mean BSA, nPCR, mean diuresis, mean serum phosphorus level, mean
GFR, mean diet phosphorus intake were 2,0552+0,38, 65,1735+19,30,
1,6974+0,18, 0,8387+0,18, 40,9130+17,05 ml/24hrs., 5,1174+1,72mg/L,
1,112+1,76 ml/min., 962,282+371,20 mg/day, respectively. Daily
phosphorus intake was very similar among the patients.
Insignificant, positive, medium level correlation between GFR and Kt/V,
a significant positive correlation between GFR and CCL, and
insignificant negative correlation between GFR and serum phosphorus
were found(Table 1)
T
Negative significant correlation between serum phosphorus and CCL
was found as in Table 2.There was low level insignificant correlation
between serum phosphorus and Kt/V.
Result: A correlation between serum phosphorus level and CCL was
found and protection of RRF is important to maintain normal levels of
serum phosphorus.
Table1: Correlation of GFR with Kt/v, CCL and Serum Phosphorus (n= 23)
GFR
Kt/v
CCL
Serum phosphorus
R
+0.362
+0.624
-0.274
Test
P= 0.090
P= 0.001
P= 0.206
Table 2: Correlation of Serum Phosphorus with CCl and Kt/v (n= 23)
Serum phosphorus
CCL
Kt/v
EVALUATION OF BIOELECTRICAL IMPEDANCE ANALYSIS FOR
DIAGNOSIS OF HYPERVOLEMIA IN CAPD PATIENTS
r
-0.439
-0.265
Test
P= 0.036
P= 0.221
MANAGEMENT OF DIALYSATE LEAKAGE IN CAPD PATIENTS WITH
ABDOMINAL EXERCISES
L. Yildirim1, G. Onar1, O. Koseler2;
1
Osmangazi University, Eskisehir, TURKEY, 2Eczacibasi-Baxter, Bursa,
TURKEY.
L. Tekeli1, A. Yuksel1, K. Reis1, U. Derici1, A. Konar2;
1
Gazi University Hospital, Department of Nephrology, CAPD Unit,
Ankara, TURKEY, 2Eczacibasi-Baxter, Ankara, TURKEY.
ntroduction: As it is difficult to find out the dry weight in patients
with ESRD, risk of morbidity and mortality increases substantially in
patients undergoing HD and especially PD unless fluid balance is
restored. Thus, dry weight is important.
Aim of this study is to assess the value of bioelectrical impedance
analysis method for diagnosis of subclinical hypervolemia in PD
patients.
Method: 26 PD patients (F: 13, M: 13, Mean age: 43.88) participated in
study under stable clinical conditions and at least for 6 months. No
patient had clinical findings of hypervolemia. Vena Cava Diameter
(VCD) and BIA measurements were made after peritoneal fluid
drainage. Anticipated total body fluid (TBW) was calculated according
to Watson (W) formula for each patient. Range between measured
values of W plus 3% body weight and W minus 3% body weight was
considered normal TBW for the patient.
Results: Of 26 patients, 7 had VCD values higher than 11 mm and 12
patients had TBW values greater than anticipated upper limit. All
patients with increased VCD had high TBW values.
Patients with high VCD had higher values compared to those with
normal VCD (67.257 ±, %263- 58.232 ± 1, 907% body weight, p<0.01).
With BIA and TBW measurements and with assistance of ROC analysis
method sensitivity was calculated as 100% and sensitivity as 71.4%.
Conclusion: TBW with BIA is very sensitive and simple test for
diagnosis of hypervolemia in peritoneal dialysis patients. However,
small TBW excess should be confirmed by other methods like VCD.
im: To analyze the effect of exercise on dialysate leakage towards
anterior abdominal wall.
Dialysate leakage towards anterior abdominal wall is an important noninfectious complication in CAPD patients. Leakage might be from the
insertion site of catheter into peritoneal cavity, soft tissue and facia
defects and also might be towards scrotum in males and labia in
females. Several approaches are practised to prevent leakage. One of
these is giving a pause for CAPD for variable durations. However this
practise has problems.
Materials and Methods: 3 CAPD and 1 APD (2 female, 2 male) patients
were enrolled. Leakage was towards scrotum in two male patients,
labia in one and lateral abdominal grooves in the other female patient.
According to the biochemical parameters PD treatment is continued in
one CAPD patient without change in dialysate volume and with
decreasing 500 ml. Dialysate volume in 2 CAPD patients. In APD patient
abdomen left dry in day-time without changing volume. All patients
started an exercise program. After drainage, before filling, they first
pulled and pushed each and then two lower extremities and made cycle
movements like riding bicycle in supine position for 10 minutes four
times a day. Exercise program continued for 7-10 days. In all patients
leakage disappeared and they returned to their normal programs. In 6
months follow-up no leakage reported in any patient.
Conclusion: In CAPD patients, exercises that strengthen abdominal
muscle might be an effective approach to manage the leakage towards
abdominal wall and genital organs without interrupting PD.
I
A
55
PERITONITIS RATE IN THE PATIENTS WHERE PERITONEAL DIALYSIS
WAS A SECOND CHOICE TREATMENT
D. Kavrakova;
Clinical Centre Skopje, Skopje, THE FORMER YUGOSLAV REPUBLIC OF
MACEDONIA.
eritonitis rate (PR) is the strongest factor related with drop-outs and
patient outcomes in the PD programme.The overall PR in our PD
population was 1 episode/19 pts months. There was a big difference
between two subgroups of pts: Group 1. Pts who started PD as a first
choice treatment PR was 1 episode/33 pts months and Group 2. Pts
who started PD as a second choice treatment PR was 1 episode/9 pts
months.
In a Continuous Quality Improvement (CQI) programme we have
focused on adherence to treatment using the PR as a measurement of
outcome. A number of 8 pts who started PD as a second choice of
treatment were highlighted as having difficulty in adhering to aspects
of their treatment and reasons explored. An individual programme was
mutually agreed with regular reviews. Their treatment was analyzed in
detail. Safe parameters were discussed and documented highlighting
where non adherence affected their PR results providing the pt with the
opportunity of sharing responsibility for their treatment. Over 2 years
period through this programme peritonitis rate was decreased to 1
episode/24 pts months in this group of pts. This CQI programme
demonstrates the apparent change in the pts attitude and overall
wellbeing.
P
ANXIETY, DEPRESSION AND PERITONEAL DIALYSIS
^
THE EFFECTS OF SOCIAL SUPPORT ON HAEMODIALYSIS PATIENTS
Ü. Karabacak1, L. Senturan1, N. Sabuncu1, Ecevit1, D. Sak1,
´
B. Yürügen2;
.
1
2
Marmara University High Nursing School,
. Istanbul, TURKEY, Istanbul
University Bakırköy Health High School, Istanbul, TURKEY.
Z. Aydın, F. Ozgur, Z. Dogrusoz, R. Korkmaz, S. Kahveci, &. Akdag, M.
Yavuz, P. Aydın;
Uludag University School of Medicine, Division of Nephrology, Bursa,
TURKEY.
ntroduction: Haemodialysis is a one method of Renal Replacement
Therapy (RRT). When patients are evaluated psychosocially,
difficulties in communicating, anger and complaints about family
problems, depression and anxiety are observed, these are results of
the difficulties and losses involved in the RRT.
Aims: This study was carried out to investigate the perception of the
social support given of the haemodialysis patients and the effect of this
support on the anxiety of these patients.
Material and Method: The sample of the study was formed from the
patients registered in a private dialysis centre. The sample group was a
total of 136 haemodialysis patients, who were being treated for more
than six months, willing to take part in the study, older than 18 years of
age, 52 woman and 84 men. In the collection of the data the patient
description form, “Multidimensional Scale of Perceived Social Support”
and “State-Trait Anxiety Inventory” were used. The collected data were
evaluated by frequency dissociations, Mann-Whitney U test and
Spearman correlation analyses methods.
Findings: The average social support perceived level results of the
haemodialysis patients were ´ = 57.02±15.27, average situation anxiety
results were 41.64±6.38 and average continuous anxiety results were
44.33±10.58.
Conclusion: It was found that there was a weak positive relation
(p < 0.01, r = 0.26) between the social support perceived by the patient
scores with the state anxiety scores and a medium degree negative
relation (p < 0.01, r = -0.33) with the trait anxiety scores.
bjectives: PD patients are exposed to many physical and
psychological stressors. Major cause of stress is the dialysis
procedure. Mental disorders are thought to be common in patients
with chronic renal failure (CRF).
Aim of this study was to compare mental disorders in CRF patients
monitored in our PD patients with those in healthy control subjects.
Materials-methods: Study was conducted at the dialysis unit of our
faculty between 01.06.2004 and 28.01.2005.
A total of 24 patients (8 women and 16 men; mean age: 42.2 ± 10.8)
who have been undergoing dialysis treatment for over one year were
enrolled. Control group comprised 21 subjects (15 women, 6 men;
mean age: 33.6 ± 7.5) who were our faculty’s personnel.
Both groups were given surveys with 14 questions, with grading for
anxiety and depression. These forms were collected by a third-person.
Results: In the patient group, 5 (21%) subjects with significant anxiety,
14 (58%) subjects with depression and 5 (21%) subjects with both
conditions were found. In the control group, 3 (14%) subjects had
anxiety, 3 (14%) had depression and 1 (5%) had both. When results
were evaluated, a statistical significance in comparison between the
two groups was achieved for depression (p<0.05) but no statistical
difference could be determined for co-existence of these conditions
and anxiety (p>0.05).
Conclusions: Close follow-up of patients in dialysis units not only
medically but also with regard to their psychiatric state could decrease
psychiatric morbidity and improve their quality of life.
56
^
I
O
QUALITY OF LIFE IN RENAL PATIENTS ON HOLIDAY
C. Iborra;
Clínica Vistahermosa, Alicante, SPAIN.
ntroduction: In respect to the rehabilitation of renal patients it is
important to know how tourism has an influence on these patients.
Objective: The objective of this work is to analyse the quality of life in
renal patients undergoing haemodialysis treatment on holiday.
Materials and methods: This study is composed of 166 patients from 8
haemodialysis centres. The information has been collected by “Quality
of Life and Tourism Questionnaire for Renal Patients Undergoing
Haemodialysis Treatment”, and “COOP/WONCA Questionnaire”.
Results: One hundred-sixty-six patients had been chosen for this study,
with an average age of 59.59 years, 103 (62%) men and 63 (38%)
women. The average time life in haemodialysis is 61.46 months. The
quality of life perceived from the patients is influenced by several
factors: To have an Arteriovenous Shunt. To feel fine after
haemodialysis treatment. To have good relationships with the holiday
haemodialysis centre staff.
Conclusions: 1. The renal patients think that travelling improves their
quality of life. 2. Most of them feel happy and have good quality of life.
3. Travelling in holiday is important to help them with their mental
health and for living well with their disease.
I
COMMON PROBLEMS EXPERIENCED WHEN RENAL PATIENTS ARE
ADMITTED TO A GENERAL HOSPITAL.
K. J. Cottle, E. Granger, T. Ratan;
Southmead Hospital, Bristol, UNITED KINGDOM.
B. Dring;
Renal and Transplant Unit, Nottingham City Hospital. NHS Trust,
UNITED KINGDOM.
n increasing renal population and scarcity of nephrology beds led to
renal patients with other illnesses being cared for in nonnephrology settings. Unnecessary problems were arising due to the
complex health care needs of renal patients. The purpose of the
research was to identify the difficulties encountered by general nurses
when dealing with renal patients. A qualitative mode of inquiry was
chosen, utilising semi-structured, taped interviews. These where
analysed using Burnard (1991). 6 Senior members of staff were
interviewed from a variety of wards. Participants identified
communication difficulties and a lack of specialist knowledge /
resources. Suggestions to improve patient care included an individual
to link between the renal team and wards, teaching sessions, readily
available information and a renal care pathway for medics and nursing
staff to refer to. The consensus from all interviewed was that there was
a need for specialist advice and support, ideally being a Clinical Nurse
Specialist (CNS), when caring for renal patients.
The study has identified that general wards have a need for renal
support. How this is to be delivered is still open for debate.
The important conclusion reached is that more research is needed to
look at the needs of general wards and their staff, when looking after
specialised patients.
Supporting general wards to care for renal patients would ' free up'
nephrology beds for acute / access patients.
A
AUDIT OF THE DIETETIC SERVICE PROVIDED TO HOSPITAL RENAL
TRANSPLANT PATIENTS
im: To improve our hospital out-patient dietetic service to renal
transplant patients.
Methods: (a) Information was collated for all patients (73) who had
undergone renal transplantation between 01/01/00 and 31/12/00
regarding the frequency they were seen by the dietitian and the
reasons for consultation.
(b) Patients' views of the dietetic service were assessed with a
satisfaction survey.
(c) A questionnaire was distributed to renal dietitians nationally to
compare practice with other units (30)
Literature searches were carried out on the nutritional aspects of
managing renal transplant patients to ensure an evidence base.
Results: (a) 87% of patients saw the dietitian at least once post transplant.
Reasons for consultations:
• 69% Reduced salt
• 62% Diet and immunosuppressive drugs
• 22% Increased calcium
• 7% Food safety and healthy eating
13% of patients were not seen.
(b) Patient survey:
• 58% rated the service "good", 42% "excellent".
• 12% were interested in attending group sessions.
(c) National survey of renal dietetic practice:
• 71% (18 hospitals) did not offer routine individual weight
management advice post transplant, but considered it to be
necessary. None offered group sessions.
• 27% (7 hospitals) had an agreed protocol for advice on diet and lipid
lowering drugs. Hospitals without protocols offered dietary advice
for patients with cholesterol levels between 5-6mmol/L and lipid
lowering drugs were commenced between 5-7mmols/L depending on
consultants.
Conclusion: Information from this audit will be used to update dietetic
standards and protocols which will enable the provision of consistent,
evidence based dietary advice.
A
57
INCREASED INJECTION PAIN WITH DARBEPOETIN-∞ COMPARED
TO EPOETIN-ß
L. Noback, N. Fuchs, C. Brummer, K. H. Heckert, F. Schaefer,
J. Rosenkranz, C. P. Schmitt;
University Children's Hospital, Heidelberg, GERMANY.
arbepoietin-alpha (Aranesp) is a modified erythropoietin (EPO)
applicable at longer intervals. Our experience in children suggested
increased injection pain with Aranesp relative to Epoietin-ß
(NeoRecormon), possibly related to technical differences, patient
anxiety or the injected fluids per se. 13 patients with ESRD and EPOdependent anaemia, (3-22 years), received 3 injections of Aranesp or
NeoRecormon in randomized order at 4 week intervals. Equivalent
doses (200 IU NeoRecormon/week = 1 µg Aranesp/week) were filled
into neutral syringes, diluted if necessary with saline to 0.6 ml and
injected with a 27G needle. Patients, parents and the nurse performing
the injections were blinded as to the nature of the compound. Pain
perception was recorded immediately and after 30min on a visual
analogue scale (VAS, 0=no, 10=maximal pain; complemented by 5
‘smilie’ faces).
The patients perceived more intense immediate injection pain with
Aranesp than with NeoRecormon (5.4±1 vs. 2.3±0.6, p=0.02). This was
confirmed by the impression of the parents (5.3±1 vs. 2.0±0.9, p=0.03)
and the nurses (4.4±1 vs. 2.2±0.6, p=0.02). Injection pain was inversely
related to patient age (r=-0.53, p=0.006). Interestingly, 6 patients
perceived no or mild differences in injection pain, 7 patients a marked
difference (≥ 4 VAS points). After 30 min, the injection site was largely
painless, no significant local reactions occurred with either medication.
Subcutaneous injections of Aranesp are more painful than those of
NeoRecormon in the majority of paediatric patients. This difference is
not explained by differences in injected volume or needle properties,
and may limit the subcutaneous applicability of Aranesp.
D
USE OF PLASMAPHERESIS IN TREATMENT OF GUILLAN BARRE SYNDROME
V. Pesice, J. Jukic, M. Maretic Dumic, P. Kes;
University Hospital Centre Zagreb, Zagreb, CROATIA.
uillan - Barre Syndrome also called acute inflammatory
demyelinating polyneuropathy is an inflammatory disorder of the
peripheral nerves. The process results in destruction of myelin, the
protective sheath of the axon of the neuron. The syndrome is often
preceded by an upper respiratory tract infection or a vaccination.
It is characterized by the rapid onset of weakness and, often, paralysis
of the legs, arms, breathing muscles and face. Symptoms may worsen
over first 2 weeks following onset and progress to complete paralysis.
To confirm the diagnosis a lumbar puncture and EMG are performed
(cerebral spinal fluid analysis show an elevated protein count, and EMG
show neuromuscular block).
Because progression of the disease is unpredictable, most patients are
hospitalized in an intensive care unit. Care includes use of all
supportive measures for the paralyzed patient, and use of
plasmapheresis to remove antibodies involved in disease process. High
dose intravenous immune globulins are helpful to shorten the duration
of the actual symptoms.
In the plasmapheresis process, the plasma that contains the unwanted
antibodies is separated from the blood, and replaced with 5% human
albumin. The patient is usually treated daily with 2,5l - 3,5l exchange
for 5 days, and then every other day up to 10 days. In certain cases, a
combination of plasmapheresis being followed by IVIg, but this method
has not been proved more effective than plasmapheresis alone.
G
NUTRITIONAL STATUS IN PRE-DIALYSIS PATIENTS ASSESSED BY
THE SUBJECTIVE GLOBAL ASSESSMENT AND HANDGRIP
STRENGTH
THE USE OF A TELEMEDICINE UNIT TO ASSESS AND ADVISE
SATELLITE UNIT PATIENTS REGARDING DIET.
D. Kariyawasam1, G. James2, M. Holesgrove1;
1
King's College Hospital, London, UNITED KINGDOM, 2St George's
Hospital, London, UNITED KINGDOM.
ackground: Satellite units have the benefit of being local to patients
and easily accessible. The main hospital where the dietitians are
based is some distance away from the satellite unit. This has
traditionally made it more difficult for the dietitians to assess satellite
unit patients other than at set times when all the patients are assessed
and advised in one visit. The aim of the telemedicine unit was to make
dietary assessment of satellite unit patients easier by reducing travel
time and being more accessible to patients at times when visits by the
dietitian were not scheduled.
Method: Telemedicine units were linked from the main hospital to the
satellite unit. 14 patients were assessed and advised via this method
and of these patients 8 patients were seen to have been helped with
their hyperphosphataemia.
Results: Phosphate levels on referral were 2.46 +/-0.47mmols/l and by
the following month after review by the dietitian had decreased to
2.06+/-0.43mmols/l (p=0.01).
Conclusion: This small study shows that the telemedicine unit is an
effective way to assess patients and communicate information. Travel
time has been saved and patients have had the benefit of receiving
dietary information soon after their raised phosphate result rather than
having to wait for the next scheduled visit by the dietitian.
B
58
A. A. Pagels, S. Heiwe, B. R. Hylander;
Renal dpt, Karolinska Hospital, Stockholm, SWEDEN.
ntroduction and aim: Protein-energy malnutrition (PEM) - a
combination of lack of energy and lack of protein, causing loss of
muscle mass - is a well-known problem in the care of persons with
chronic kidney disease (CKD). Continuous assessment of Nutritional
status (NS) is therefore recommended in dialysis care as well as in the
care of pre-dialysis patients (Glomerular Filtration Rate < 20ml/min).
Subjective Global Assessment (SGA) is a multifactor, subjective method
for assessment of a patient’s NS. Reduced hand grip strength (HGS) is
associated with PEM and considered to be a reliable nutritional
parameter that reflects loss of muscle mass. The aim of this
retrospective study was to analyse NS in pre-dialysis patients with
focus on the significance of HGS.
Patients and method: HGS and NS assessed by SGA, consecutively
measured in 112 individuals, were analysed. 63% of these patients had
protein restricted diet (PRD).
Results and conclusions: Relatively few patients (13%) were assessed
as malnourished, but many reported experience of fatigue, depression,
loss of appetite and a reduced level of physical activity. Few patients
(6%) were underweight (BMI <20), whereas 56 % were overweight
(BMI>25). Patients with PRD did not have impaired NS, compared to
patients without PRD. Patients who had some degree of malnutrition
tended to have reduced HGS. Among the male patients, those with a
lower level of physical activity tended to have lower HGS. Among the
female patients, those who experienced loss of appetite and/or feeling
of fatigue tended to have lower HGS. The pre-dialysis patients had
lower HGS than healthy reference values.
I
NUTRITIONAL PROFILE OF HAEMODIALYSIS
WHAT'S IN YOUR TROLLEY?
N. Ghazouani, A. Frih, M. Abbes, M. Elmay;
Hospital University Monastir-Tunisia, Monastir, TUNISIA.
F. Taylor, D. L. Green;
Hope Hospital, Salford Royal Hospital NHS Trust, Salford, UNITED
KINGDOM.
he malnutrition in haemodialysis patients is a problem which has a
great effect on the general state and the life quality of these
patients.
We started a prospective nutrition inquiry with collaboration from the
specialized “dietitian” on 20 haemodialysis patients in order to
discover their nutritional intake and the percentage of each constituent
appreciating at the same time the patient’s dialysis quality by
calculating the “P.R.U.”.
This inventory shows that our patients are in a state of protein and
calorie malnutrition (Mean calorie intake = 1938 Kcal/day) with protein
deficiency (Mean protein intake = 69 g/day) whether they are on a high
calorie diet due to a malcontrolled nutritionary education, which
affected their dialysis quality.
We conclude that our patients due to their poor income have a
deficient calorie intake and protein diet with an insufficient quantity of
dialysis.
T
ackground: There has been a rapid and sustained rise in the
number of adult patients treated with RRT. They have increasingly
complex dietary requirements with high expectations, coupled with
difficulty in recruiting Renal Dietitians we have to be increasingly
innovative in the methods we use to provide dietary advice. Patients
are routinely provided with one- to -one individual advice and given
written dietary information. On review patients only seem to retain
information on what foods to avoid.
Purpose: To identify new approaches to disseminate dietary advice,
which is patient centred and effective.
Method: Small groups of HD patients living in one geographical area
were identified and sent invitations to attend a visit to a supermarket
lasting 60 minutes. 50% of patients responded and attended the
session that involved a ‘walk and chat’ where all areas of the
haemodialysis diet were discussed. Review of the session was carried
out by questionnaire and dietary review.
Results: Following consultations with patients, the experience has been
beneficial, being away from the clinical setting made the patients feel
in control and found the foods made useful prompts when asking. It
was shown on review diet histories that there was a greater range of
foods eaten.
Conclusion: The visits have been well received by patients, who feel the
visits have given them more information about their diet than reviews
on the Renal Unit. The sessions are patient led and are based on foods
to eat and healthy eating within their dietary restrictions.
B
COMPLIANCE TO DIETARY PRESCRIPTIONS
M. Mazzocchi;
ASL RMH, ITALY.
he dietary prescriptions are very important for adequate intake of
proteins, calories, and electrolytes. The aim of this study is to
investigate the compliance to dietetic indications on haemodialysis
population (22 patients 62 ± 14 years old, in Dialysis since79 ± 80
months ) on the basis of five days dietary record .
We have questioned the dialysis patients through a questionnaire
about the knowledge of the nutritional composition of food.
T
Weight
Kcal
Protein
Carbohydrate
Lipid
Calcium
Phosphorus
Potassium
Ratio
Kt/V1
Albumin
Phosphates
Transferrin
BMI
Kg
Kg/day
gr./Kg/day
gr./day
gr./day
mg/day
mg/day
mg/day
Phos/Prot
g/dl
mg/dl
mg/dl
Kg/m2
Real
66±9
26±6
1±0,2
219±66
62±17
437±175
984±283
1650±443
15±4
1±0,
Ideal
61±7
35±0
1,2±0
277±36
82±11
1000±0
741±95
1500±0
10±0
2
3,6±0,3
5,2±1,4
191±38
24±3
P
n. s.
.00001
.0008
.0007
.00004
.00004
.0003
.05
.00002
The dietary investigation parameters showed that dietetic intake is
reduced compared to the ideal one, except for phosphorus and the
potassium. The patients show normal values of BMI, but lower level of
Albumin, proving a visceral malnutritional state.
The answers to the questionnaire we have provided showed only 57%
of them know the nutritional composition.
According the data, we learnt that general dietetic information rather
than specific knowledge can lead the patient to inadequate and
incorrect eating habits leading to a risk of malnutrition.
The constant presence of a person is necessary to check the patient’s
compliance to the dietetic regime.
The nurse can be a helpful figure for patients to specify the dietetic
requirements while the doctor should emphasise the importance of the
conforming to the dietetic regime.
59
INFLUENCES OF PATIENT AND STAFF TRAINING NEEDS ON
EDUCATION STRATEGY.
F. Taylor, J. Collier, D. Green;
Hope Hospital, Salford Royal Hospital NHS Trust, Salford, UNITED
KINGDOM.
roblem: Ensuring a skilled and competent workforce for renal
services must be a key target for all in the multidisciplinary team.
Recruitment and retention issues, decreasing numbers of experienced
nephrology professionals, expansion of services means that education
and practice standards must be audited and creative ways of providing
education must be found.
Purpose: To identify the level of staff knowledge within the renal
services.
Design: A patient education questionnaire was adapted to assess the
basic knowledge of staff. The focus was on basic knowledge and
practice that would be expected of a qualified nurse with one year’s
renal experience. The questionnaire was distributed to all staff, with
the intention of identifying differences between grades and groups of
staff. Previous patients’ results provided an interesting comparison
P
Results: Quantitative and qualitative data from the questionnaire
identified a deficiency in knowledge about patients’ dietary restrictions.
The varied responses indicated inconsistent practice with regard to
patients’ abnormal biochemistry and dietary requirements. Practices
varied in assessing fluid status of patients and calculating fluid
restrictions. Basic tools available to help assess patient fluid status
(weights, input and output charts) were overlooked in favour of more
technical tools, this response was more prevalent with less
experienced staff.
Conclusion: Basic knowledge and practice was inconsistent across the
directorate and was not at the level expected for qualified nursing staff.
The results have been used to design the current MDT in-house
education program incorporating the knowledge and skills framework
to direct staff in their education and practice development.
60
WHY IS THERE A VARIABILITY OF MALNUTRITION PREVALENCE
ACCORDING TO ANTHROPOMETRY?
J. Manzano Angua;
Center dialysis Bellavista (C.A.M.EX, S/A), Sevilla, SPAIN.
he nutritional status of patients with terminal renal disease on
dialysis can be indirectly estimated by means of the measurement
of some anthropometric parameters and its subsequent analysis. For
that purpose, there are several criteria for a nutritional classification.
The main goal of our research focused on analysing whether the use of
different criteria of nutritional classification have any influence on the
variability which characterizes the malnutrition prevalence of those
patients.
Brachial and arm muscle circumferences and the triceps skinfold were calculated in 53 patients undergoing dialysis in our medical centre. The interpretation of these measurements to classify the nutritional status was carried out using the 7 following criteria: “A”-“B”-“C”-“D”-“E”-“F” and “G”.
47.2% of the patients were diagnosed with caloric malnutrition according to “A”, “B” and “E” criteria, in opposition to 15.1% according to “F”
criterion. 13.2% presented a protein malnutrition according to “A”, “B”
and “E” criteria, in opposition to any case was found when “C” and “D”
criteria were used.
Conclusions:
• The fact of using different criteria of nutritional classification to interpret anthropometric measures caused unlike caloric-protein malnutrition prevalences.
• Professionals who look after renal patients should unify the classification criterion to interpret the anthropometric measures when the
nutritional status is estimated by means of anthropometry. In that way
will be possible for a more accurate information exchange about the
efficiency of nutritional care carried out by the different Health
Professionals.
T
Technology Posters
A PROSPECTIVE STUDY OF AMBULATORY BLOOD PRESSURE IN
THE HAEMODIALYSIS PATIENT
HAND AND WRIST PAIN IN HAEMODIALYSIS NURSES
M. Kiely, M. McQuaid, F. A. Kelly;
St Vincents University Hospital, Dublin 4, IRELAND.
I. Grop;
Karolinska, University Hospital, Stockholm, SWEDEN.
ntroduction : Ambulatory blood pressure monitoring is an established
diagnostic modality. Hypertension is a major contributing factor to End
Stage Renal Disease. The value of 24 hour blood pressure monitoring in
patients with chronic renal impairment has not been established.
Aim: This prospective study evaluated the use of 24 hour ambulatory
blood pressure monitoring in pre-dialysis patients and patients
established on haemodialysis.
Method: Suspected hypertensive patients were included in the study.
The cuff was checked for correct position and comfort. The monitor was
turned to automatic recording and the first reading taken by the
nursing staff, to ensure correct functioning. After 24 hours the patient
returned to the dialysis unit and the monitor disconnected. The records
were downloaded from the monitor for computer analysis.
Results: 10 patients were included, 7 pre-dialysis and 3 haemodialysis
patients. Each patient’s results were reported and presented in the
following formats.
Profile: Graphic display of the progression of Blood Pressure and Pulse.
Histogram: Graph of Systolic Pressure and pulse showing the difference
in percentage of the measurement value.
Correlation: Graphics showing, on the left and right respectively, the
relationship between the Systolic and Diastolic, and between the
Systolic and the Pulse. 24hour, Day and Night fields can be viewed
separately.
Statistics: Complete and partial areas are evaluated separately
Conclusion: Ambulatory 24-hour blood pressure monitoring in dialysis
patients is an example of a modality, which bridges the gap between
the patient and technology. Factors to be considered include staff skills
and training, clinical factors and technological support.
W
I
e are two nurses who have worked in haemodialysis for several
years, and during these years we have met colleagues with handand wrist pain. As a consequence, we decided to study the frequency
of hand-and wrist pain in haemodialysis nurses. The study took place
at four haemodialysis unit. A questionnaire was distributed to 104
nurses and 80 of these responded. The results showed that 64% of the
nurses experienced hand and wrist pain, 90% of these said that the
pain was related to the work at the haemodialysis unit. The results of
the study also showed that the nurses considered that certain
elements of their work caused the hand- and wrist pain. these
elements were pro-nation and supination of the hands, as for instance
when turning or screwing an item. Similar findings have been
presented in previous research.
Conclusion: Nurses working with haemodialysis experience a high
frequency of hand and wrist pain, and consider it to be caused by lining
and priming of haemodialysis-machines.
Clinical implications: in order to reduce the risk of developing handand wrist, nurses working with haemodialysis should not line and
prime more than two haemodialysis-machines a day. Also, there is a
need for technological development in order to minimise the number of
elements where manual turning or screwing is necessary.
SUITABLE COMMUNICATION SKILLS REDUCE STRESS CAUSED BY
TECHNOLOGY AND MEDICINES IN RENAL REPLACEMENT THERAPY
^
I. Logar1, M. Calić 2;
1
The Union of Kidney Patients Associations of Slovenia, Ljubljana,
SLOVENIA, 2Clinical Centre Ljubljana, Ljubljana, SLOVENIA.
t is proved that dependence on medical machines, staff, and also
medicines causes stress and discontent to patients. On the initiative
of the local association of dialyzed patients, the Slovene union of
kidney patients conducted research on communication among staff and
renal disease patients.
Methods: Questionnaire included 217 patients, 42% women and 56%
men, eldest patient being 83 years of age and youngest 23(average
53,5). Dialyzed patients numbered 78%, those with transplanted
kidney 16%, and 5% were patients on peritoneal dialysis. As different
factors influence communication process, previously identified factors
affecting appropriate or inappropriate interactive communication
between patients and staff were taken in mind. We considered
following: socioeconomic system, welfare system, particularities of
chronic diseases, as well as some factors like information, education,
awareness, stress, knowledge.
Results: Marks expressing patients' content regarding their
communication with nurses amounts to 3.5-4.0 (SD 0.80-1.09). Four as
mark seems high, when taking into account fact that most of patients
taking part are being treated with HD. Thus it is obvious from height
(M) of diagram that person-to-person aspects of communication are in
forefront; nurses are understanding, kind and make patients feel safe,
when treated by them.
Conclusion: It is evident from the analysis that good communication
affects patients’ mood, while patients' reviews are also very clear,
indicating that the key factors for good relationships are good
communications between renal nurses and-patients. Questionnaire
and its results were meant to eliminate those factors which caused
poor communication between the two.
I
61
Transplantation Posters
PREPARING THE DIALYSIS PATIENT FOR TRANSPLANTATION BY A
RENAL TRANSPLANT COORDINATOR
PHYSICAL ACTIVITIES IMPROVE QUALITY OF LIFE IN RENAL
REPLACEMENT THERAPY PATIENTS
^
R. Narkis, R. Wagner;
Rabin Medical Center. Beilinson Campus, Petah Tikva, ISRAEL.
E. Jovanović, M. Calić, M. Svetlin;
Clinical Centre Ljubljana, Ljubljana, SLOVENIA.
enal transplantation is a complicated procedure requiring the
cooperation of a multidisciplinary team.
The success of this operation depends on many resources which are
needed to bring the patient to optimal health before transplantation.
Our assumption is that the same person must be in charge of the
coordination and follow up of all procedures from the dialysis unit until
the transplantation. This person, the transplantation coordinator, must
be in contact with the patient and with the multidisciplinary team in
order to ensure that the patient is properly prepared.
The purpose of this study was that the patient be in the optimal
condition upon transplant and that the results of all tests would be
correctly documented in his files.
This was done by creating the role of Transplant coordinator and by
forming specific working guidelines.
The results were that after two years of documentation and working
according to the new guidelines, the correct parameters for each
patient were identified earlier; the patients were ready for transplant
earlier and were therefore transplanted more quickly. They also had a
more successful operation and faster recovery.
In light of these results, we recommend the use of a Transplantation
Coordinator in every dialysis unit.
he objective of patient education before and after kidney
transplantation is to achieve the patient’s active cooperation.
Regular exercise is known to benefit patients by improving their allround rehabilitation and counselling on physical activities is included in
our education programme.
Objective of our work was to assess efficacy of the education in
exercise performance and the effect exercise has on blood pressure,
laboratory investigations and quality of life.
Methods: We analysed data from 200 transplanted patients, data on
physical activities were collected by interviews. Patients were then
divided into three groups regarding time spent exercising; the inactive,
those exercising up to 3 hours weekly, and patients, exercising more
than 3 hours weekly. Data on blood pressure, serum creatinine and
haemoglobin values, blood counts, total cholesterol, HDL and intact
PTH values were then analysed.
Results have shown that 3% of transplanted patients are inactive, 35%
exercises up to 3 hours weekly and 62% exercises more than 3 hours
weekly. In our group there were 4.5% smokers and 22% actively
employed. Twenty-two percent report some hip pain. The entire group
has normal blood pressure values, (systolic 124±9.5mmHg, diastolic
77±6.2mmHg) regardless of time spent exercising, and serum
creatinine, cholesterol and intact parathormone values were
satisfactory. We found exercise favourably affects those parameters.
Physical activity statistically significantly improves sex life and quality
of life.
Conclusion: Regularly exercising patients are more content with their
quality of life, active patients have more satisfying sex life and show
higher levels of mental, social and professional rehabilitation.
R
T
EVALUATION OF OPTIONS TO INCREASE DONORS IN
TRANSPLANTATION
L. Yildirim1, G. Onar1, O. Koseler2;
Osmangazi University, Eskisehir, TURKEY, 2Eczacıbası-Baxter, Bursa,
TURKEY.
1
ncreased need for donors has led clinicians to search for new
options. The concept of the non-heart beating donor has emerged.
By this method, appropriate patients who die at the hospital or a short
while before being admitted to the hospital are catheterized femorally,
cold kidney perfusion is maintained and a nephrectomy is performed.
Aim: To determine non-heart beating (NHB) donor potential in our
hospital.
All deaths (2003) that occurred in our hospital were evaluated. Patients
with malignant diseases except brain tumour, with renal pathology at
time of death, uncontrolled hypertension and suspected sepsis and
with missing data were excluded.
Patients’ age, gender, causes of death, medical condition at the time of
death, logistic state and renal function were recorded. Medical
suitability of patients, risk factors were scored. In logistic suitability, Insitu cooling preservation at the time of death was scored according to
equipment facility.
780 deaths occurred in 2003, 480 were 3-65 years old. 264 fulfilled
criteria, but 120 patients had no data. 144 patients were enrolled.
Results: Number of potential NHB donor ranges between 56-144.
Among hospital deaths 18% could be potential NHB, 7 % high
potential. Usually, rate of NHB donors is 64.2%, mean age is 49.
Average serum creatinine level is 106.3. The highest potential for NHB
donors is in Cardiology, Neurology, Neurosurgery, PulmonaryCardiovascular services, Intensive Care Units and Emergency
Departments.
Conclusion: NHB donor teams in selected centres should be equipped
with educational, personnel and technical facilities to provide
immediate medical intervention for mortal cases and meet need for
renal graft.
I
62
Evaluation of Non-Heart beating patients
Potential
Low
Medium
High
Total Score
2-3
4
5-6
Group
A
B
C
Suitability of 144 patients
Score
1
2
3
Medical suitability
20
56
68
Logistic suitability
28
112
4
n
32
56
56
ITNS Workshops
A PROGRAMME FOR SIMULTANEOUS LIVING KIDNEY DONOR
EXCHANGE
THE GENESIS OF DIARRHOEAL DISEASE IN RENAL TRANSPLANT
PATIENTS (ITNS Lunchtime symposium)
Marry De Klerk;
Renal Transplant co-Ordinator, THE NETHERLANDS.
Bart Maes PhD;
Associate Professor, Faculty of Medicine, Department of
Patho-physiology Katholieke Universtitiet, BELGIUM.
ackground: The wait time for deceased donor kidney
transplantation has increased to 4-5 years in the Netherlands.
Strategies to expand the donor pool include a living donor kidney
exchange program. This makes it possible for patients who can not
directly receive a kidney from their intended living donor, due to ABO
blood type incompatibility or a positive cross match, to exchange
donors in order to receive a compatible kidney.
Methods: All Dutch kidney transplantation centres agreed on a
common protocol. An independent organization is responsible for the
allocation, cross matches are centrally performed and exchange takes
place on an anonymous basis. Donors travel to the recipient centres.
Surgical procedures are scheduled simultaneously.
Results: From January 2004, we registered 29 pairs with blood type
incompatibility and 31 pairs with a positive cross-match. In 4 match
procedures we created a total of 26 cross-over combinations (43%). For
5 out of the 8 (63%) registered bloodtype B recipients we found a new
donor. For bloodtype A recipients this percentage was 55% (11/20) and
for bloodtype O 29% (9/31). For 12 out of the 20 (60%) bloodtype O
donors we found a new recipient. For bloodtype B donors this
percentage was 50% (3/6) and for bloodtype A 37% (11/30). Bloodtype
combinations of the original donor-recipients that could successfully
matched were B to A (100%) and O to B (100%). The original A to O
combination was least successful but with 25% (4/16) is not without
possibilities.
Conclusion: Combining bloodtype incompatible and cross match
positive donor-recipient pairs in one programme for simultaneous
kidney exchange is a realistic option for all bloodtype combinations.
B
astrointestinal symptoms such as nausea and diarrhoea are
increasingly reported using newer immunosuppressive agents, like
mycophenolate mofetil, tacrolimus and sirolimus. However, the
pathophysiology of diarrhoea is largely unknown. Recently we
prospectively examined changes in morphological and functional integrity
and infections of the gastrointestinal tract in renal transplant recipients
with persistent afebrile diarrhoea in order to characterise its nature and
aetiology. In this well-defined subset of patients, persistent afebrile
diarrhoea was nearly always associated with erosive enterocolitis. In ± 60
% of the patients an infectious origin could be demonstrated (with
predominance of intestinal bacterial overgrowth). In ± 40 % no infectious
cause could be shown despite intensive exploration; the entero-colitis in
these patients was characterised by mild Crohn’s disease-like lesions with
focal crypt distortion and mild focal inflammation.
The observed motility disorders were of minor importance as far as
their contribution to the diarrhoea is concerned and most probably
secondary to infection or inflammation. In > 70 % of the investigated
patients malabsorption of nutrients was present. Although the nature
of these absorptive disorders may be diverse (infectious or toxic
mucosal injury), it illustrates a commonly encountered enteropathy,
which at least may contribute to the diarrhoea by stimulating colonic
secretion (bile salts, fatty acids) or osmotic activity (lactose). Diarrhoea
also caused a doubling of FK-506 trough levels despite intake of stable
doses, necessitating significant FK-506 dose reductions to obtain prediarrhoea trough levels. On the contrary, trough levels of cyclosporine A
(CsA) remained stable without major dose adjustments. This suggests
that absorption and/or metabolism is differentially altered for FK506
compared with CsA in patients with diarrhoea. However, reduction of
FK506 together with reducing/stopping MMF may lead to sustained
under-immunosuppression in FK506-MMF treated patients with
increased risk for rejection of the renal allograft; therefore, careful
monitoring of FK506 is needed during and after episodes of diarrhoea,
especially when also doses of MMF are diminished.
G
SHOULD PATIENTS TRAVEL ABROAD FOR TRANSPLANTATION? –
THE CASE IN FAVOUR
WHO SHOULD RECEIVE? ASSESSMENT FOR RENAL
TRANSPLANTATION
R. Trevitt BSc;
RN Clinical Nurse Specialist, Barts and The London Hospital. NHS Trust,
UNITED KINGDOM.
C. J. Rudge;
FRCS. Medical Director UK Transplant, UNITED KINGDOM.
s doctors, our role is to give advice and treatment to those patients who
seek it from us. We do not control the lives of patients under our care,
they are free to follow or to ignore our advice, and our advice must always
be based on the highest professional standards. We work within a
framework of legal statute, professional standards and guidelines, and
national healthcare policy. It should be dispassionate, non-judgemental
and always in the best interests of the patient.
In the case of organ transplantation, we all face a critical problem – more
patients need a transplant – specifically a kidney transplant – than there are
organs available and inevitably this shortage will drive patients to seek
alternatives – after all, we constantly tell them that a transplant is better
than dialysis. We cannot and must not support any transplant activity that
is against the law in our own country or any other – and thus I am in total
agreement that the unregulated market in living kidney donors is not
acceptable. However, I would also argue that in our obsessive desire to
stamp out the human market we risk applying the norms and cultures of our
own society to patients from other cultures, and that this can obstruct
legitimate forms of donation and transplantation. Definitions and regulation
of a suitable living donor vary even between European countries, and in
many cases prohibit donation by an individual that in another culture may
be thought to be entirely appropriate – members of the extended family or
local social group, for example. We must stick to the principles of the
altruistic living donor, but must not prevent patients having a legitimate
opportunity to seek transplantation wherever it is available.
A
he aim of the pre-transplant assessment is to establish that the
patient is fit for transplantation, to inform the patient and to record
basic medical history and contact details. Some patients will need
further investigations and review, some will be unsuitable and some
will have additional risk factors. Other issues are cadaveric vs live
donor transplant, and the allocation of cadaver kidneys.
The cardiovascular history is noted because of the risks of surgery and
of vascular disease post transplant. The primary disease which caused
the renal failure may influence whether or not the patient can go
straight onto the cadaveric list. Some primary diseases have a risk of
recurrence and it is important that the patient is aware of this. If the
patient had a previous graft we look at cause of failure and at which
centre the transplant was done. Compliance can be a difficult issue and
if such a patient is allowed onto the list then we must plan how to deal
with it. Patients who are a high anaesthetic risk need assessment by an
anaesthetist. The implications of malignancy depend on the type and
the time free of disease. HIV positive patients are not put onto the
transplant list, nor are those with active hepatitis.
Some patients will require urological or abdominal intervention before
transplantation. Patients who are obese are asked to lose weight.
Patient information is very important, time must be spent discussing
the various aspects of transplantation.
T
63
ITNS Workshops
THE IMPACT OF SOCIO-DEMOGRAPHIC FACTORS ON RENAL
ALLOGRAFT SURVIVAL
BASICS IN TRANSPLANT IMMUNOLOGY
Frank Van Gelder;
RN, BSN, ECTC, Senior Transplant Coordinator, U.Z., BELGIUM.
he daily care of transplant patients includes a much more profound
knowledge for transplant ward and dialysis nurses. The different
mechanisms of the human immune system that are activated once an
organ transplantation has taken please, are the main cause of acute or
long term failure of transplanted organs. Therefore it is essential to
have a basic knowledge of the human immune system to understand
immunosuppressive drug regimens and therapies in your patient.
What is the mechanism of rejection in organ transplantation?
Once barriers to organ transplantation are determined, we have to
understand what are the causes of these barriers. Allo –and xeno
transplantation are both seen as most harmful to the body causing
different immune reactions. The mechanism behind the immune
reaction in organ transplantation is based on the human leucocyte
antigen system. This system is the drive behind reactions of highly
mobile complex cell systems that travel throughout the body to detect
the foreign molecules attached to the transplanted organ. Essential
cells such as T-lymphocytes and especially T-helper cells are essential
in the immune reaction. The mechanism of rejection can be suppressed
by different types of medication. How those medications interact with
the different reactions in the immune cascade, make the
immunosuppressive therapy in a transplant patient more
understandable.
T
Bart Maes,
PhD, Department of Nephrology, University Hospitals, BELGIUM.
Hans Vlaminck,
MSN, Department of Nephrology, University Hospitals, BELGIUM.
ackground: Evidence on the impact of socio-demographic factors
on renal allograft survival is limited. The present study explored the
effect of relevant pre-transplant socio-demographic and medical factors
on outcome parameters post-transplantation such as hospital stay, late
acute rejections (LAR) (> 1 yrs post-transplant) and patient and renal
allograft survival. METHODS: Since 1996: 893 adult renal transplant
candidates are included in this ongoing prospective cohort study, of
which >500 patients (59.5% male, median age: 54 yrs) are already
transplanted with a cadaveric kidney. Data were obtained from medical
records and patient questionnaires. Non-adherence was assessed pretransplantation by patient self-report.
Results: Prevalence of pre-transplant non-adherence was 33.3%. One
year patient and graft survival was 94% and 89.7%. 34% of the
transplanted patients of foreign origin had severe language problems.
Significantly more LAR was seen in patients who smoked or were of
non-Caucasian origin or had more than 4 HLA mismatches. Patients
with language problems or who smoked, or a BMI show > 30 have a
significant longer hospital stay post-transplantation. Patients who still
smoke at the time of transplantation or who are non-adherent with diet
and fluid restrictions pre-transplantation have a shorter graft-survival.
Conclusions: Several socio-demographic factors pre-transplantation
allow identification of patients at risk for shorter renal graft survival
and longer hospital stay.
B
MORE THAN JUST ANOTHER KIDNEY. THE PAEDIATRIC
PERSPECTIVE
TRAVELLING FOR TRANSPLANTATION – ONE CENTRE EXPERIENCE
Gráinne M. Walsh, BSc, RN, RSCN
Paediatric Transplant Sister, Guy’s & St Thomas’ NHS Foundation Trust,
UNITED KINGDOM.
Clare Whittaker, BSc
RN Clinical Nurse Specialist, Barts and The London Hospital NHS Trust,
UNITED KINGDOM.
ptimising quality of life for the transplant recipient is to me what
transplant nursing is about and yet despite huge advances in
transplant science we are now confronted by increasing morbidity and
mortality and see more people dying from functioning grafts which is
not a milestone to be celebrated.
My patients are not simply transplant patients; they are children first
and foremost, children who happen to have had kidney transplants.
This talk will provide a clinical nurse specialist’s perspective as to long
term wellness issues which frequently feature in clinical practice.
Issues discussed will include cardiovascular risk particularly obesity
and hypercholesterolaemia,
Long term wellness is multi-factorial incorporating both physical health
and psychosocial issues; in paediatric transplantation the child’s stage
of development is central to how these issues are managed. Both ends
of the age spectrum in paediatrics (toddlers and adolescents) have
their own set of problems and this presentation will demonstrate how
these can be dealt with in clinical practice focussing on timing of
transplant, adolescent issues particularly non-adherence to therapy
and transition to adult services.
Seeing beyond the graft is an essential component of high quality
paediatric nursing care, it’s definitely more than just another kidney!
I
O
64
n the last 5 years 19 patients from our renal unit travelled abroad to
receive a renal transplant (RTx).
With the shortage of organs for transplantation, especially for patients
of minority groups and those of blood group B, patients and their
families are sourcing organs in other countries.
This paper will discuss the issue of patients travelling abroad to receive
RTx, the impact in our unit and patient outcomes.
The experience in our centre in the UK will be examined, presenting the
positive and negative outcomes some of the concerns that have been
raised due to this increasing practice.
There are many issues to discuss in this controversial practice. Should
this be encouraged for the group of patients for whom finding a match
will be difficult? What risks are our patients undertaking when they
seek this treatment elsewhere? Are they well informed of risks and
expectations following this procedure? Should we accept this practice
as it frees dialysis places in units which are overflowing? This paper
does not propose to answer these questions but to debate them.
ITNS Workshops
PREVENTION IS BETTER THAN CURE:
LONG-TERM COMPLICATIONS AFTER TRANSPLANTATION
PREGNANCY FOLLOWING RENAL TRANSPLANTATION
L.C. Elshove1, H.J. Metselaar1, A.L. Wilschut1, and W.Weimar2
Department of Gastroenterology and Hepatology1,Department of
Nephrology and Renal Transplantation2, Erasmus MC, University
Medical Centre, THE NETHERLANDS.
Clare Whittaker, BSc
RN. Clinical Nurse Specialist, Barts and The London Hospitals NHS
Trust, UNITED KINGDOM.
t is the expectation of many women that at some time they will have
a family of their own. Renal failure renders many women infertile, or
if not infertile the ability of the body to support a pregnancy to term is
severely diminished.
A renal transplant can return biochemical markers to near normal and
hormonal imbalances are rectified. It is therefore a realistic expectation
for female renal transplant recipients to contemplate pregnancy and
parenthood, although this cannot be guaranteed as it is dependent on
many factors and there may be considerable risk to the mother, child
and the renal allograft.
It is estimated that 1:50 women of childbearing age who undergo
transplantation will go on to have a pregnancy. Pregnancy post
transplant is considered to be high risk for mother baby and the
transplanted kidney.
An examination of the risks to mother, baby and the allograft and the
need for pre-conceptual counselling, education and support of the
women contemplating pregnancy will be made.
Pregnancy post transplant is considered to be high risk, these include
risks to the mother of pre-eclampsia,, rejection, an increased risk of
urinary tract infection and other infections. Risks to the baby from the
immunosuppressents as well as risks from other medication taken for
concommittent disease and conditions, increased possibility of
prematurity and low birthweight
I
ith improvement in surgical techniques and the advent of more
potent and selective immunosuppressive agents, early
complications of organ transplantation have been reduced.
Current, 1 year graft and patient survival of 90 % or higher is common
in most transplant centers.
However, the later graft survival has not kept pace with the remarkable
gains made in early graft survival. The most common cause of late
allograft loss is due to the process of chronic rejection, which is most
common in renal, heart and lung transplant patients and infrequent in
liver transplant patients. Recurrence of primary disease and sideeffects of the immunosuppressive agents are the other two main
causes of late patient or allograft loss. Hypertension, diabetes mellitus,
hyperlipidemia and overweight due to the current use of
immunosuppressive drugs cause increased cardiovascular morbidity
and mortality. Moreover, the use of the calcineurin inhibitors
tacrolimus or cyclosporine affect renal function in more than half of the
patients with end-stage renal failure and in about 10 % of the non-renal
allograft recipients.
Transplantation and the use of immunosuppressive agents increase the
risk of malignancies, such as lymphomas, skin cancer and Kaposi’s
sarcoma. The risk of developing malignancies is 10 x higher > 10 year
after transplantation.
It is important that all involved in the care of transplant patients know
about these complications long after transplantation, and are
continuously watchful for the symptoms of the long-term complications
and start treatment as early as possible.
Moreover, health education of the patients such as, tobacco use,
alcohol drinking and exposure to sun, play an important role in the
long-term care of transplant recipients. Eventually, prevention is better
than cure.
W
65
Authors Email addresses
Angele
Nursel
Muserref
Jennifer
Ione
Aarts
Akcan
Albaz
Andrews
Ashurst
Helen
Lucia
Anna
Cveta
Mirjana
Ferhan
Tami
Ilse
Nurit
Hana
Karen
Rodolfo
Riki
Pamela
Thomas
Clement
Bosiljka
Rukiye
Belinda
Rita
Geraldine A
Lynda
Jale
Ayperi
Katie
Liljana
Georgia
Néji
Handan
yvonne
Ingela
Josep Maria
Saime
Freddy
Monique
Susan
Vicky
Vicki
Tai Mooi
Debra
Carmelo
Ray
Sue
Erna
Chizuru
Deniz
Deepa
Monica/Roisin
Daniela
Mike
Andrea
Martina
Jennie
Batsheva
Anastasia
Maria
Hadasa
Hadassa
Juan Manuel
Mauro
Paula
Esperanza
Elisheva
66
[email protected]
[email protected]
[email protected]
[email protected]
ione.ashurst@
bartsandthelondon.nhs.uk
Aydın
[email protected]
Bartley
[email protected]
Blokker
[email protected]
Bokulic
[email protected]
Bonar
JenniferAnn.Williams@
Swansea-tr.wales.nhs.uk
Boulton
[email protected]
Brinke
[email protected]
Brousseau
[email protected]
Bucevac
[email protected]
Calić
[email protected]
Candan
[email protected]
Chayu
[email protected]
Claeys
[email protected]
Cohen
[email protected]
Cohen
[email protected]
Cottle
[email protected]
Crespo
[email protected]
Dahan
[email protected]
D'Arcy
[email protected]
Dechmann
[email protected]
Dequidt
[email protected]
Devcic
[email protected]
Dolgun
[email protected]
Dring
[email protected]
Elias
[email protected]
Endall
[email protected]
Engelsman
[email protected]
Erturk
[email protected]
Eyupoglu
[email protected]
Fielding
[email protected]
Gaber
[email protected]
Gerogianni
[email protected]
Ghazouani
[email protected]
Golgeli
[email protected]
Grieve
[email protected]
Grop
[email protected]
Gutiérrez Vilaplana [email protected]
Hanci
[email protected]
Hardy
[email protected]
Harskamp
[email protected]
Heatley
[email protected]
Hinton
[email protected]
Hipkiss
[email protected]
Ho
[email protected]
Hunt
[email protected]
Iborra
[email protected]
James
[email protected]
Johnson
[email protected]
Jovanović
[email protected]
Kamiya
[email protected]
Karadeniz
[email protected]
Kariyawasam
[email protected]
Kavannagh/
[email protected]
McLoughlin
Kavrakova
[email protected]
Kelly
mike.kelly@
bartsandthelondon.nhs.uk
Kesziova
[email protected]
Kiely
[email protected]
King
[email protected]
Lahav
[email protected]
Laskari
[email protected]
Lopez
[email protected]
Madar
[email protected]
Madar
[email protected]
Manzano Angua [email protected]
Mazzocchi
[email protected]
McLaren
[email protected]
Melero-Rubio
[email protected]
Milo
[email protected]
^
Zuleyha
Carol
Cees
Biserka
Gwen
Email address
First Name
Last Name
Email address
Mukadder
Nelson
Rachel
Andrea
Gareth
Fiona
Revital
Carmen
Ivana
Laura
Mollaoglu
Moreira
Morgenstern
Moriarty
Murcutt
Murphy
Narkis
Navarro Sanchez
Nikolic
Noback
Ronit
Julie
Nebahat
Fethiye
Agneta
Numan-Golan
Owen
Özerdogan
Özgür
Pagels
V.
Simone
Hayriye
Vlatka
Heather
Esther
Marica
Karen
Amanda
Katy
Susan
Genia
Maria Lúcia
Irit
Sevginar
Israel
Pat
Pamela M
Ray
Meira
Paris
Passarini
Pelenk
Pesice
Pitt
Pol
Prsa
Pugh-Clarke
Raynor
Rees
Rogers
Rovner
Sadala
Schnitzer
Senturk
Silva
Simoyi
Sinclair
Steenveld
Sternberg
Meagan
Beatrice
Faith
Leyla
Nicola
Rosamund
Joanne
Hans
Glykeria
Nikolaos
Fredrik
Wil
Jean-Pierre
Esperanza
Ronald
Nava
Ronis
M
Susan
Beverley
Yvonne
Ayla
Lutfiye
Yasemin
Emine
Dawn
Birsen
Ümmühan
Stobyfields
Szablyar
Taylor
Tekeli
Thomas
Tibbles
Tomany
Traeger
Tsouka
Tzenakis
Uhlin
van der Mark
van Waeleghem
Velez
Visser
Vitri
Wagner
Waterschoot
Wheeler
White
White
Yardim
Yildirim
Yildirim
Yildizgordu
Yokum
Yürügen
Zaimoglu
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
claus_peter_schmitt@
med.uni-heidelberg.de
[email protected]
[email protected]
[email protected]
[email protected]
agneta.aspegren-pagels@
karolinska.se
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
Sternberg_a@
hillel-yaffe.health.gov.il
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
^
Last Name
^
First Name
Authors Index
Aarts A. /27
Akcan N. /51
Albaz M. /44
Andrews J. /40
Ashurst I. /39
Aydın Z. /54
B
Bartley C. /42
Blokker C. /24
Bokulic B. /47
Bonar G. /45
Boulton H. /31
Brinke L. /39
Brousseau A. /22
Bucevac C.V. /50
C
^
Calić M. /61, 62
Candan F. /55
Chayu T. /26, 33
Claeys I. /45
Cohen N. /27, 28, 34, 49
Cohen H. /34
Cottle K.J. /57
Crespo R. /45
Dahan R. /25
Hipkiss V. /38
Ho T. /23
Hunt D.J. /35
Pol E. /41
Prsa M. /47
Pugh-Clarke K. /38
I
R
Iborra C. /57
J
Raynor A. /27
Rees K. /35
Rogers S. /26
Rovner G. /48
James R. /18, 40
Johnson S. /37, 42
Jovanović E. /62
S
K
Kamiya C. /46
Karadeniz D. /44
Kariyawasam D. /58
Kavannagh M. /44
Kavrakova D. /56
Kelly M. /37
Kesziova A. /51
Kiely M. /61
King J.A. /36
L
Lahav B. /26
Laskari A. /32
Lopez M. /22
D
M
D'Arcy P. /41
Dechmann T. /41
Dequidt C. /30
Devcic B. /50
Dolgun R. /44, 53
Dring B. /57
Madar H. /31, 33
Manzano J.M. /60
Mazzocchi M. /59
McLaren P.J. /26
McLoughlin R. /44
Melero-Rubio E. /47
Milo E. /28, 34
Mollaoglu M./34, 49
Moreira N. /49
Morgenstern R. /49
Moriarty A. /32
Murcutt G. /25, 41
Murphy F. /34
Elias R. /25
Endall G. /52
Engelsman L. /39
Erturk J. /48
Eyupoglu A. /52
F
Fielding K. /46
G
Gaber L. /43
Gerogianni G. /33
Ghazouani N. /59
Golgeli H. /31
Grieve Y. /26
Grop I. /61
Gutiérrez Vilaplana J. /38
H
Hanci S. /53
Hardy F. /27
Harskamp M. /3
Heatley S.A. /22
Hinton V.C. /36
T
Taylor F. /59, 60
Tekeli L. /55
Thomas N. /32
Tibbles R. /22
Tomany J.O. /39
Traeger H. /41
Tsouka G. /30
Tzenakis N. /29
U
Uhlin F. /46
V
van der Mark W. /29
van Waeleghem JP. /42
Velez E. /33
Visser R. /24, 43
Vitri N. /44
W
N
Narkis R. /62
Navarro Sanchez C. /52
Nikolic I. /36
Noback L. /58
Numan-Golan R. /40
Wagner R. /29
Waterschoot M. /23
Wheeler S. /34
White B. /43
White Y. /35
Y
O
Owen J.E. /31, 36
Özerdogan N. /53
Özgür F. /56
^
E
Sadala Maria L. /46
Schnitzer I. /30
Senturk S. /51
Silva I. /48
Simoyi P. /24, 37
Sinclair P. /51
Steenveld R. /28
Sternberg M. /42
Stobyfields M. /37
Szablyar B. /31, 50
P
Pagels A. /58
Paris V. /52
Passarini S. /49
Pelenk H. /53, 54
Pesice V. /58
Pitt H. /50
Yardim A. /53
Yildirim L. /55, 62
Yildirim Y.K. /23
Yildizgordu E. /47
Yokum D.A. /23
Yürügen B. /34
Z
^
A
Zaimoglu Ü. /54
67
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68

2005 Vienna Conference Abstract Book

Transcription

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