Comparison of nephrology nursing interventions across five European countries.

Comparing nursing interventions between different countries is helpful towards developing a common nursing culture within Europe. The aim of the study was to compare the frequency of 14 specific nursing interventions indicators across five European countries (Belgium, Scotland, Czech Republic, Greece and the North of England). Data were collected as an integral part of the European Practice Database Project across two cycles (2005 and 2006) involving 172 renal centres. Using Pearson's chi-square and descriptive statistics the frequency of 11 out of the 14 nurse intervention indicators was found to vary significantly across the five countries. Indeed specific nurse interventions such as delegation, telephone consultations and laboratory data interpretation potentially identify where nurse activity is changing in response to pressures such as advancing nurse roles, staff shortages and increased patient demand.

The use of phosphate binders: data from contributors to the European Practice Database.

Data of the European Practice Database (EPD) were used to investigate the use of phosphate binders in the European HD population. A cross-sectional observation among five participating countries of the cycle 2 study revealed that most patients used phosphate binders and many of them used more than one agent. Calcium-based products were most frequently used (55% of HD patients) followed by sevelamer (37%). There was a wide variation between different countries in the kind of phosphates that were used. Renal dietitians advised regularly on therapy adjustment for calcium/phosphorus metabolism in one third of European centres and their involvement is increasing.

On line UV-adsorbance measurements. Summary of the EDTNA/ERCA journal club discussion. Summer 2006.

The discussion was initiated by a paper comparing the measurement of dialysis dose (Kt/V) and solute clearance using on-line ultra-violet absorbance, blood and dialysate urea and ionic dialysance by Uhlin et al (NDT 2006). Participants from 14 countries discussed the theory behind the UV absorbance technique and the potential for its use in routine practice, the correlation between Kt/V measured using different methods, the use of ionic dialysance and the optimisation of dose monitoring. The 'take-home' messages from the discussion were that UV-absorbance could help ensure the delivery of dialysis dose as it provides real time feedback on the effect interventions such as repositioning of needles. The technology is relatively inexpensive and requires no consumables but changes in the dialysis machine settings could lead to misleading measurements if not communicated to the UV monitor. Session-to-session variation in dialysis dose can be measured using on-line clearance monitoring. If it is already on the machine and costs nothing, why not use it? Alternatively, regular access recirculation checks and a record of the total blood volume processed at each session allow problems with delivered dialysis dose to be picked up between routine blood tests.

How much is catheter flow influenced by the use of closed luer lock access devices?

BACKGROUND: To reduce infection risks in patients on hemodialysis with a long term central venous catheter, different types of closed luer lock access devices are used on the arterial and venous catheter hub. Although those connectors create a mechanically and microbiologically closed system in between two dialysis sessions, no data are available on the resistance those connectors exert on the blood flow during dialysis. Therefore, in the present study, flow resistance was determined in three different connectors. METHODS: In an in vitro setup, different connectors were attached in between a male (Bellco BL 307 dialysis tubing) and female luer: BD Q-Syte (Becton-Dickinson, Utah, USA), second edition Tego (ICU Medical, CA, USA), and Swan-LockU connector (Codan, Lensahn, Germany). For a wide range of water flow rates, pressure-flow relationships were measured, simulating catheter inflow as well as catheter outflow, by reversing the flow direction. Resistances were compared to a simple male-female connection, as in a standard bloodline-catheter connection, and mathematical corrections were performed for the use of water instead of blood. RESULTS: For a blood flow of 500 mL/min, simulating clinical dialysis, the additional pressure drop is 118 mmHg (Becton Dickinson), 52 mmHg (Codan), and 23 mmHg (Tego) in the case of catheter inflow, while it is 74 mmHg (Becton Dickinson), 40 mmHg (Codan), and 27 mmHg (Tego) in the case of catheter outflow. Resistances are also depending on the type of tubing as used during dialysis. CONCLUSIONS: In conclusion, the Tego and Codan connector show promising results for the use on a catheter hub during and in between dialysis sessions. Whether those resistances are in the safe range without the incidence of blood hemolysis will soon be investigated in an in vivo study.

Pre-dialysis education and patient choice.

The discussion was initiated by a paper on the influence of a pre-dialysis education programme on the mode of renal replacement therapy by Goovaerts et al (NDT 2005). Barriers to the uptake of self-care treatment modalities, including late referral, limited availability of treatment options, reimbursement, support from staff and families, the requirement for a helper and the length of the training programmes for home haemodialysis (HD) were discussed by 21 participants from 12 countries. The 'take-home' messages from the discussion were that to optimise the uptake of self-care modalities, renal units should try to ensure the all patients who are able to choose are fully informed before starting dialysis, even if they are referred to the unit very late. Offering a wide range of treatment options to new patients, and allowing (or encouraging) home HD without a helper, may also increase the number of patients who start and stay on a self-care modality. It should be possible to provide an acceptable level of training, without compromising on safety, within 3 weeks if the patient is confident with needling.

Middle molecule removal in low-flux polysulfone dialyzers: impact of flows and surface area on whole-body and dialyzer clearances.

Some studies found that the removal of middle molecules has a long-term effect on mortality and, even more, is enhanced by high-flux dialysis. In order to enhance middle molecule removal in a low-flux dialyzer, the present study aimed at investigating the combined impact of dialyzer flows and membrane surface area. Blood and dialysate flows were varied within the clinical range 300-500 and 500-800 mL/min, respectively, while the ultrafiltration rate was kept constant at 0.1 L/hr. Single-pass tests were performed in vitro in a single Fresenius F6HPS dialyzer (3 tests) and serially (5 tests) and parallel (3 tests) connected dialyzers. The blood substitution fluid consisted of dialysis fluid in which radioactive-labeled vitamin B12 (molecular weight 1355 Da) was dissolved. Dialyzer clearance as well as whole-body clearance was calculated from radioactivity concentrations of samples taken from the inlet and outlet bloodline. Adding a second dialyzer in series or parallel ameliorated the overall dialyzer and whole-body clearance significantly, except for the highest applied blood flows of 500 mL/min. Better solute removal was also obtained with higher dialysate flows, while the use of higher blood flows seemed advantageous only when using a single dialyzer. Analysis of the ultrafiltration profiles in the different configurations illustrated that enhancing the internal filtration rate ameliorates convective transport of middle molecules. Adequate solute removal results from a number of interactions, as there are blood and dialysate flows, membrane surface area, filtration profile and concentration profiles in the blood and dialysate compartment.

European Practice Database: comparative results of the year 1 pilot project.

The European Practice Database (EPD) project, developed by the Research Board (RB) of EDTNA/ERCA, intended to collect data on renal practice at centre level in different European countries. During the pilot phase of the project (2002-2003), Czech Republic, Italy (North East) and England (North) participated with two thirds of all their eligible dialysis centres. Comparative results presented in this paper focus on centre size and patient characteristics, peritoneal and haemodialysis techniques, transplantation, infection control and the employment of technicians, dietitians and social workers in dialysis centres. At centre level, EPD results will enable in-depth evaluation of personal practice. International comparison of the results will stimulate further research and the development of new guidelines.

EDTNA/ERCA vascular access recommendations for nephrology nurses.

In 1989, SJ. Schwab stated that providing satisfactory vascular access for haemodialysis remains one of the most challenging problems confronting the nephrology team (1). Successful long-term haemodialysis in patients with end-stage renal failure depends to a large extent upon a trouble-free vascular access. Unfortunately, the creation as well as the use, maintenance and the treatment of vascular access complications nowadays still remain a serious clinical problem despite pharmacological and technical advances during the last decade (2). Even today, vascular access failure and complications form a major cause of morbidity leading to a high percentage (20 to 30 %) of hospitalization in the dialysis population (3). Moreover, we are confronted all over the world with a clinically complicated patient population, such as diabetics, patients with advanced atherosclerosis, cardiac and peripheral vascular diseases. Also the increased blood viscosity due to the systematic use of erythropoietin and the use of high blood flows in modern dialysis therapy necessitates a vascular access of excellent quality.

European Practice Database in the Czech Republic.

The EDTNA/ERCA European Practice Database (EPD) Project has been launched with the aim to collect data on professional practice and outcome of dialysis treatment throughout Europe. The Czech Republic had the privilege of taking part in the pilot phase together with Northern England and part of Italy. We first became involved in the EPD project during the annual EDTNA/ERCA conference in Nice, France. At this time the Research Board started to prepare an EPD questionnaire for the pilot phase. The project was officially launched in the Czech Republic during the Multidisciplinary Conference in Brno organised jointly by the Czech Association of Nurses and the EDTNA/ERCA in 2003. A presentation by Jean Yves De Vos, the EPD Co-ordinator, who introduced the final EPD questionnaire in detail, was the best promotion of the project.

European study on epidemiology and the management of HCV in the haemodialysis population--Part 1: centre policy.

Haemodialysis patients are known to be at risk of infection of Hepatitis C Virus (HCV) through nosocomial spread. This paper presents the first part of a study on epidemiology and management of HCV, in a haemodialysis population, conducted by the EDTNA/ERCA Research Board. Data on HCV management and infection control procedures was collected from 136 European centres using an electronic questionnaire. The study identifies a number of possible risk factors for transmission of the virus: failing to disinfect devices between patients, sharing of single-use vials to prepare drugs or infusions for different patients, inadequate sterilisation or cleaning of machines between dialysis sessions, unsatisfactory environmental cleaning and distance less than one metre between chairs.

Management of renal anaemia: comparison of practice in the Czech Republic and Northern England.

The EDTNA/ERCA European Practice Database (EPD) questionnaire was piloted in the Czech Republic (CZ), Northern Italy and Northern England (N-ENG) in early 2003. The questionnaire used in the CZ and N-ENG featured additional questions on the use of erythropoetin (EPO) and intravenous (IV) iron. There were significant differences in the policies for anaemia management in the CZ and N-ENG, reflecting the higher level of funding available to centres in the UK. There was also a wide variation in practice between the CZ centres, but not those in N-ENG, possibly due to the adoption of guidelines that are currently unrealistic. Some centres, particularly those in the CZ, could improve outcomes or reduce overall costs by adopting a more aggressive policy for the use of intravenous iron.

The Research Board of the European Dialysis and Transplantation Nurses Association/European Renal Care Association (EDTNA/ERCA).

The Research Board (RB) of EDTNA/ERCA is a multidisciplinary group, established by the participation of renal care centres all around Europe. The RB also works with the association's Special Interest Groups (SIGs) on developing guidelines for implementing safe renal clinical practice. It is composed of six permanent members, with co-opted experts from specific fields. This article describes how the RB works and the projects implemented since 1996.

Intravenous administration of epoetin in haemodialysis patients.

Recombinant human erythropoietin (epoetin, rHuEPO) can be administered to haemodialysis patients intravenously or subcutaneously. Although the intravenous route is the originally approved and used route of administration, subcutaneous administration has been quite common throughout Europe since the introduction of prefilled syringes. The intravenous route has been shown to be as effective as the subcutaneous route, but patients should have adequate iron stores. In addition, intravenous administration is patient-friendly and results in fewer injections, less pain and bruising, and a minimised risk of immunogenicity. Furthermore, intravenous administration of epoetin is convenient for the nurse and is commonly used in Germany, Belgium and the USA. The purpose of this paper is to illustrate the very easy, practical ways of administering epoetin in prefilled syringes during dialysis at machine level, based on the authors' experiences in Belgium and Germany.