Technical aspects of haemodialysis treatment: comparative results of Scotland and Belgium.

This paper reports the findings from the European Practice Database project providing an overview of the technical aspects of haemodialysis treatment, comparing practice in Scotland and Belgium. Findings identified that in Scotland almost all centres (95%) employed renal technicians compared to 67% of centres in Belgium. There was also a higher level of technical duties performed by technicians in Scotland compared with Belgium, and marked differences in the disinfection protocols of dialysis machines between the two countries. The study highlights the need for further investigation to discover why technical practice varies somuch between the two countries.

European Practice Database in Belgium.

After the successful pilot EPD Project in 2002-2003, we decided to perform the EPD project in four additional countries: Belgium, Greece, Norway and Scotland. Before starting the EPD Project in Belgium, we installed a Belgium National EPD Board in order to support the practical organisation of this project. National coordinators were Luc Picavet (Chair) and Sylviane Boullé (Wallonia). The members of the Belgium National EPD Board were Jean-Yves De Vos (President of National Association, ORPADT Flanders), Hichem Marzougui (Link member, Association of Dialysis Technicians) and Luc Vonckx (President of Association of Dialysis Technicians).

Comparison of renal care practice in Europe: centre and patient characteristics.

The European Practice Database (EPD) contains data from 8 countries including 276 centres and 21,861 dialysis patients. Comparing patients and centre characteristics, remarkable similarities and pronounced differences in renal practice between different European countries and between centres within each country were found.

European practice in haemodialysis: results of the EPD.

The European Practice Database (EPD) project, developed by the EDTNA/ERCA Research Board, collects data on renal practice at centre level in different European countries. Results presented in this paper focus on the European Practice in Haemodialysis centres from 8 European countries or regions following data collection from 2002 to 2004. These results will enable international comparison in practice and will stimulate further research and the development of new practice recommendations.

The Research Board of EDTNA/ERCA: research activities and deliverables.

The Research Board (RB) of EDTNA/ERCA was formed ten years ago to provide opportunities for our members to participate in collaborative research projects at a European level. It provides educational support in research methodology via workshops at conference and in articles published in the Journal. The group has completed a total of seven collaborative research projects in diverse areas of renal care and has recently developed an ambitious new project, the European Practice Database (EPD). The EPD project aims to capture the current practice of renal care professionals in European centres on a three-year repeating cycle. The results of projects are presented at conference and at international scientific meetings by invitation and abstract submission. Recommendations, guidelines or educational material are produced collaboratively with the renal multi-disciplinary community.

Transplant practice in Europe: selection of patients.

This paper reports the findings from the European Practice Database project (1) providing an overview of transplant practice in Europe and patient selection. From the 276 centres surveyed 25 recorded performing patient transplants across eight different countries. The overall figures indicate that the waiting list for transplants is made up of 38% women and 9% of patients above the age of 65 years. All countries offered pre-transplant counselling and screening and post-transplant follow-up, but the extent to which these activities occurred varied. The waiting/transplant ratio ranged from one in Norway to eight in Slovakia. Differences still exist as a result of country specific policies and legislation regarding transplantation.

Sero-conversion of HCV negative patients: a European study on the epidemiology and management of HCV haemodialysis patients.

This paper reports part of the findings from a larger study reported earlier, the European study on epidemiology and the management of HCV in the haemodialysis population (1). Centres recruited to the larger study were monitored for a further one year observation period to measure and generate a deeper understanding of HCV sero-conversion. From 4724 patients who were studied at the baseline, in 68 centres, only 13 patients were found to have sero-converted. These sero-conversions occurred in 7 hospitals within 5 different countries. Possible routes of transmission and risk factors are described with respect to the individual centres and good practice recommendations based on current evidence presented.

Infection control practice across Europe: results of the EPD.

The European Practice Database (EPD) project, developed by the EDTNA/ERCA Research Board, collects data on renal practice at centre level in different European countries. Results presented in this paper focus on infection control practice in haemodialysis centres from 8 different European countries or regions following data collection from 2002 up to 2004. The prevalence of hepatitis B (HBV), hepatitis C (HCV), human immune deficiency (HIV) and methicillin-resistant staphylococcus Aureus (MRSA) was studied as well as the use of screening and preventive actions. These results will enable international comparison in practice and will stimulate further research and the development of new practice recommendations.

Development of indicators to measure European variation of nursing activities.

This paper describes a study to capture the key roles and activities of nephrology nurses across different countries in Europe. The concept of the study and the need to clarify the activities of the nephrology nurse arose as part of a larger study to develop the European Practice Database (EPD) (1). The Research Board (EDTNA/ERCA) needed to identify key questions that would detect significant differences in the role and responsibilities of nephrology nurses in different countries and monitor the evolution over time of nephrology nursing practice in Europe. It was therefore appropriate to devise a separate small study to generate evidence based questions for the EPD and confirm the reliability and usefulness of the information captured.

The organisation of paediatric renal care in different European countries: results of the PAC project.

The Paediatric Access Care (PAC) project, organised by the Research Board of EDTNA/ERCA, aimed to study the organisation of paediatric renal care in Europe and to investigate the practice of access care for both haemodialysis (HD) and peritoneal dialysis (PD) paediatric patients. This paper reports on the organisation of paediatric renal care. The majority of paediatric renal care units were located in specific paediatric units of university hospitals. Most of the centres had offered HD, PD and transplantation (Tx) for more than 20 years. Half of nursing staff had qualifications in paediatric and renal nursing. Most of the centres offered an extended multidisciplinary team approach with the family actively involved in the care of the patient. PD and HD were equally used. Automatic Peritoneal Dialysis (APD) was offered as the standard PD treatment in 2 out of 3 centres. The HD schedule mostly utilised was 3 x 4 hours a week. Half of the patients were on the Tx waiting list and one third of registered patients were transplanted in 2004.

Paediatric access care in Europe: results of the Paediatric Access Care (PAC) project.

Part two of the Paediatric Access Care (PAC) project, a research project of EDTNA/ERCA, investigated PAC in HD and PD patients including the policy for the creation and maintenance of access, and the registration of access related complications that occurred during the registration year of 2004. Data were collected from 39 centres of 13 European countries and included 379 paediatric patients. Fatal complications, resulting in terminating the use of the access, were noted in 59 HD and 22 PD patients. Paediatric access care varied considerably between European centres and in many areas consensus or best practice evidence is still lacking. There is a need for recommendations for the paediatric renal nurse, handling access care in the paediatric renal population.

The European practice database (EPD): results of the study in thte North-East of Italy.

The survey, realized in 2002-03 in the North-East of Italy, describes renal care in dialysis services. A questionnaire, structured at European level, was sent to all dialysis centres by mail. The questionnaire was returned from 21 centres (61.8%) and related satellite units. Results show nonhomogeneity in renal care. Some important results were: low use of peritoneal dialysis (18%), compared to the rest of Europe, elevated presence of older people on haemodialysis, reduced percentage of patients on transplantation waiting list, diffused use of isolation for HCV positive patients, high use of AV fistulae (84%), low employment of renal technicians, absence of renal dieticians and social workers and nurses performing prevalently direct care. Data can be used for different goals: benchmarking activities, selection of deeper research topics and development of more oriented continuous education activities.

European practice database: results from Greece.

The survey (EPD) took place during December 2002-January 2003 and presents renal care in Greece. A questionnaire, structured at European level and translated into Greek, was sent to all dialysis centres (114) by post. The questionnaire was returned from 74 centres (64.9%). Some important results were: low use of peritoneal dialysis (13.3%), half of PD patients over 65 years old, one ninth of patients on transplantation waiting list, isolation for HBV positive patients (less for HCV and HIV), high use of AV fistulae (71.2%), maintenance and repair of dialysis machines by company technicians, absence of renal dieticians and social workers (but availability from hospital employees) one nurse every 5.54 patients (3.72 if nurse assistants are included), disinfection between shifts carried out chemically (hot or cold) and puncturing of vascular access performed mainly by nurses and nurse assistants. Data can be used to pressurise government for more scientists in the multidisciplinary team to be hired in hospitals, develop further research topics and to develop continuous education programmes.

Polyunsaturated fatty acids of the n-3 class in chronic dialysis.

N-3 PUFAs are believed to 1) reduce serum lipids, 2) modify the complement activating system, 3) increase red blood cell elasticity, and 4) decrease thrombotic events. These four parameters were investigated in 19 chronic stabilized dialysis patients assessed by 1) the control of the serum lipids, 2) the degree of leukopenia 10 minutes after the start of dialysis, 3) the degree of red cell fragmentation (RCF) during dialysis, and 4) the reusability of the dialyzer. The patients were their own controls during four periods: 1) no PUFAs for longer than 6 months, 2) 4 x 425 mg of PUFAs/day for 6 weeks, 3) 6 x 425 mg PUFAs/day for 6 weeks, and 4) no PUFAs during at least 6 weeks. Previous diets and medications remained unchanged. It was concluded that there was no significant effect on serum lipids in the given dosages, and no effect on the degree of leukopenia, red blood cell elasticity or bleeding, and/or antithrombotic activity. No change was seen in insulinemia, fibrinogenemia, or arterial pressure. No serious side effects were noted other than a "fishy aftertaste."

Diffusive clearance of small and middle-sized molecules in combined dialyzer flow configurations.

Clearance of low (LMW) and middle molecular weight (MMW) solutes was investigated in vitro for different dialyzer configurations and mutual flow directions. Single pass tests were performed with two low flux Fresenius F6HPS hemodialyzers placed in series (12 tests) and in parallel (6 tests), and results were compared with those for one single dialyzer (2 tests). Either high concentrated (45mS/cm) bicarbonate dialysis fluid (surrogate LMW) or trisodiumphosphate (surrogate MMW) concentration (31mS/cm) was used as blood substitution fluid. Standard blood and dialysate flows of 250 and 500ml/min, respectively, were prescribed. Clearance was derived from conductivity measurements in blood and dialysate compartment, correcting for the overall ultrafiltration rate of 0.1-0.5l/h. In a single dialyzer, changing the counter current flow to co-current deteriorates diffusive clearance by 14% (LMW) and 18% (MMW). Compared to one single dialyzer using counter current flow, clearance increases by 3 to 8% (LMW) and by 15 to 18% (MMW) using two dialyzers in parallel and in series, respectively. As a consequence, the benefit by using a second dialyzer is more prominent for larger molecules. Moreover, pressure profiles drawn for the different configurations show the impact of limited convection on diffusive clearance.

Blood trauma in plastic haemodialysis cannulae.

To investigate the haemolysis in haemodialysis cannulae, an in-vitro set up is built, using a unipuncture dialysis system. This system is connected to a bag with fresh calf's blood, by the cannula under test, mounted in a large bloodline (5 mm diameter). The blood characteristics are kept constant by means of a bicarbonate dialysate in the dialyser. During a 6 h period, haematological parameters are regularly samples. Flow through the cannulae is recorded, which is about 500 mL/min. Four different cannulae are tested and compared to the results obtained without any cannula in the circuit. In all cases a linear increase in plasma free haemoglobin levels is found after 6 h. The cannulae can be ranked from 8F catheter over 13G, 14G to 16G cannula, the latter producing the highest degree of haemolysis. When using plastic cannulae at high blood flows, their haemolytic effect may not be neglected.

Anticoagulation therapy in acute renal failure extracorporeal treated patients.

In extracorporeal techniques, as used for Acute Renal Failure (ARF) treatments, blood is constantly exposed to foreign surfaces. These foreign surfaces include the catheter(s), blood tubings, the dialyser membrane and all artificial materials used for such techniques in general. Blood begins to clot as soon as it strikes a foreign surface. The foreign surface initiates the clotting process. The extracorporeal circuit is prone to clotting during acute treatments unless some form of anticoagulation is employed. On the other hand, this specific group of patients is often at increased risk of bleeding (cfr. Post-operative patients and post-renal-transplant patients, patients with Multiple Organ Failure (MOF) often including liver disturbances). It should be kept in mind that patients with renal failure have a defect in platelet function resulting in altered platelet-vessel wall interaction. Over time, as the extracorporeal treatment progresses, the platelets become more adhesive or sticky. The blood becomes more likely to clot. Performing effective therapy with low bleeding risk in ARF patients is a challenge requiring knowledge, skills and experience.

Heparinisation in chronic haemodialysis treatment: bolus injection or continuous homogeneous infusion?

After several incidents where patients either bled after dialysis or suffered severe anaphylactic reactions caused by intravenous heparin injections, we decided to administer heparin as a continuous homogeneous intravenous infusion. This had been usual practice in our unit in the past. Following the shocking experience of the death of a patient due to an anaphylactic reaction during his first dialysis, we wanted to warn colleagues for the potential dangers of administering intravenous heparin as a bolus injection.

Quality monitoring of care: ask the patient.

In 1998 and 1999, we organised a questionnaire to be filled out by chronic haemodialysis patients. The first part dealt with general information data on the specific patient and the second part dealt with quality assessment data given as experienced by the individual patient. This second part included a ranking of preference by the patients and aspects patients wanted to see improved in the future. As we implemented the EDTNA/ERCA Clinical Standards and Core Curriculum, the monitoring tool, as described in this paper, was developed in order to monitor the effect of implementation. As a result of this two-year monitoring process of quality of care, we can follow up the care provided by our multidisciplinary team. It has proven a very useful tool to find out what is to stay as it is and what is to be improved. Simply closing the loop!

Automated on-line bicarbonate concentrate production: microbiological, chemical and economic benefits.

We all know that "bicarbonate dialysate" became the world wide used fluid for use in haemodialysis and related techniques. To prepare bicarbonate dialysate we actually have to use two separate concentrates: one containing sodium bicarbonate, solely or in combination with other electrolytes other than calcium, and a second concentrate containing mostly all the other electrolytes (sodium, magnesium, potassium, chloride and/or some acetate).