Cross-sectional audit of blood lead levels in regular outpatient haemodialysis patients dialysing in north London.

AIM: Blood lead was measured and found to be high in one haemodialysis patient with atypical abdominal pain and peripheral neuropathy. This prompted an audit of blood lead concentrations in prevalent haemodialysis patients under the care of a University Teaching hospital. METHODS: Blood lead was determined in 271 prevalent adult haemodialysis patients regularly dialysing three times a week, in five dialysis centres and/or on the home dialysis programme. All samples were carefully collected into lead-free plastic containers, and measured by graphite furnace atomic absorption spectrometry. RESULTS: 25.5% of haemodialysis patients had abnormal blood lead concentrations (>200 microg/L), compared with 59% with high-normal values of 100-200 microg/L, and only 15.5% with normal values (<100 microg/L). Blood lead increased with haemodialysis vintage (r = 0.38, P < 0.001), the use of a single carbon filter and reverse osmosis water purification device unit (r = 0.29, P < 0.001), but reduced by urine output (r = -0.44, P < 0.001). CONCLUSION: Despite UK government legislation to reduce permissible lead contamination of drinking water, blood lead was increased in 84.5% of prevalent haemodialysis patients. Single reverse osmosis machines and carbon filters may not be as effective at filtering out possible lead contamination compared with large industrial reverse osmosis devices and carbon filters, and thus blood lead testing should be considered for home haemodialysis patients, particularly in those areas where monochloramines are used to sterilize domestic water supplies.

Buttonhole cannulation: should this become the default technique for dialysis patients with native fistulas? Summary of the EDTNA/ERCA Journal Club discussion Autumn 2007.

The paper discussed during autumn 2007 was a report entitled 'Cannulating in haemodialysis: rope-ladder or buttonhole technique?' published in Nephrology Dialysis Transplantation. The authors agreed to follow the discussion and respond to points raised. Twenty-three expert contributors from 13 different countries provided evidence, opinion and historical insights into vascular access techniques for chronic haemodialysis patients. All contributors who had introduced the buttonhole technique for patients with native arterio-venous fistulas (AVFs) had found benefits for patients in terms of ease of cannulation, reduced pain and even reduced aneurysm formation. The discussion included expert advice on needling protocols, track formation and the sharp versus blunt needles debate. The buttonhole technique is virtually unheard of in some countries and the discussion covered some of the potential barriers to its introduction and offered advice on also how to overcome some of these issues.

Should we provide ultrapure dialysis fluid? Summary of the EDTNA/ERCA Journal Club discussion Winter 2006.

The paper discussed during winter 2006 was an editorial in Nephrology, Dialysis and Transplantation (NDT) entitled "Ultrapure dialysis fluid--how pure is it and do we need it" by Dr Ingrid Ledebo PhD of Gambro Corporate Research, Sweden. Thirteen people from seven different countries contributed to the wide-ranging discussion whose topics ranged from the most cost effective way of producing ultrapure dialysis fluid (UPDF) to the environmental impact of heat sanitisation and the industrial-scale bleeding of the Limulus horseshoe crab. Different methods of disinfection such as heat and UV light were discussed as well as the requirement and funding for microbial detection assays and their various sensitivities. Participants concluded that the available evidence supported the use of UPDF as standard, but identified financial pressures, via differing reimbursement systems, as the main barrier to its universal introduction.

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.

Guarding against hidden haemolysis during dialysis: an overview. Summary of the EDTNA/ERCA Journal Club discussion Spring 2007.

The paper discussed during spring 2007 was a case study report entitled "Haemolysis: A Hidden Danger" published in The Nephrology Nursing Journal. The authors, Elisabeth Harman and Paula Dutka, agreed to follow the discussion and respond to points raised. Sixteen contributors from ten different countries provided insights into the potential causes, symptoms and effects of both acute and hidden haemolysis during dialysis, as well as discussing some of the safety systems that can be used to try and minimise occurrences. The use of blood volume monitoring as a potential method of 'seeing' hidden haemolysis was explored as well as some reporting mechanisms and organisational safeguards that are used to manage the risks.

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.