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The coagulation cascade is complex but well studied. Dialysis membranes and lines are inherently pro-coagulant and activate both the intrinsic and extrinsic pathways of coagulation, as well as platelets and other circulating cellular elements. To provide safe and effective dialysis, appropriate anticoagulant measures must be applied. Haemodialysis, including anticoagulation, is prescribed by dialysis doctors but delivered by dialysis nurses. The main agents used in clinical practice for anticoagulation during haemodialysis are unfractionated heparin (UF heparin) and low-molecular-weight heparin (LMWH). LMWH has a number of potential advantages, apart from cost. One of the most serious complications of the use of any form of heparin is heparin-induced thrombocytopaenia (HIT) Type II, which occurs more commonly with UF heparin than LMWH. HIT Type II risks severe morbidity and mortality and is challenging to treat successfully in both the acute and chronic phase. In HIT Type II anticoagulation must be delivered without heparin. A wide array of newer anticoagulants are becoming progressively available, each with unique advantages and disadvantages. In maintenance haemodialysis patients with an increased risk of bleeding, a 'no heparin' dialysis may be undertaken, or regional anticoagulation considered. Because this aspect of dialysis is so important to the safe and effective delivery of haemodialysis therapy, dialysis clinicians need to review and update their knowledge of dialysis anticoagulation on a regular basis.

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

Patients with significant renal impairment have difficulties maintaining a viable pregnancy due to maternal and fetal complications. Both peritoneal dialysis and hemodialysis support throughout pregnancy has been reported to assist in these pregnancies. We report our experience with the use of peritoneal dialysis in five cases leading to successful deliveries with minimal complications.

To compare injection site pain of subcutaneous (sc) epoetin beta and darbepoetin alfa in adult patients with chronic kidney disease.This was a multi-centre, randomised, two-arm, single-blind, cross-over study. Patients were randomised to receive weekly sc darbepoetin alfa 30 mug or weekly sc epoetin beta 6000 IU for 2 weeks and were then crossed over to the alternative treatment for 2 weeks. Injection site pain was assessed using a 10 cm ungraduated visual analogue scale (0 = no pain, 10 = worst pain) and a six-point verbal rating scale. Patient preference for treatment was also assessed.http://clinicaltrials. gov/(NCT00377481).All randomised patients (N = 48) completed the study. The sample comprised 29 chronic kidney disease patients (Stage 3 or Stage 4), 11 peritoneal dialysis patients and 8 renal transplant patients. Patients perceived significantly less pain with epoetin beta than darbepoetin alfa, using the visual analogue scale (relative pain score = 2.75, darbepoetin alfa:epoetin beta, 95% CI: 1.85, 4.07; p0.0001) and the verbal rating scale (median: 0.5, 95% CI: 0.5, 1.0 vs. median: 1.5, 95% CI: 1.0, 2.0; p0.0001). Epoetin beta was preferred by significantly more patients (65%) than darbepoetin alfa (10%) (p0.001); 25% of patients reported no preference.Limitations included lack of an epoetin alfa comparator and limited blinding (patients were blinded to treatment, however, an unblinded nurse administered treatment). We show that sc injection of epoetin beta is significantly less painful than darbepoetin alfa and patient preference for epoetin beta confirms that the difference is clinically meaningful.

Patients with end stage renal disease (ESRD) are predisposed to malignancy. A patient who presented with a persisting fever, episodically above 38 degrees C, of unknown origin is described. The diagnosis of the illness remained elusive, over repeated hospital admissions and comprehensive investigations for over 11 weeks, until her last admission when the patient finally represented with features of acute liver cell failure and succumbed shortly afterwards. A liver biopsy revealed high grade lymphoma, an uncommon presentation for lymphoma. While malignancy is increased in dialysis patients, lymphoma is a relatively uncommon malignancy described. This case is a rare incidence of diffuse Non-Hodgkin's Lymphoma (NHL) isolated to the liver, causing fever, liver cell failure and death in a hemodialysis patient.

An integrated intake, information and intervention service, Triple I (Hub) was evaluated against its goal to be streamlined, co-ordinated and patient focussed. The integrated service co-located six previously disparate services, often accessed by the same patients and healthcare professionals. The service was evaluated five months after implementation.Review methods included satisfaction surveys and observations made by an external expert.Survey findings from 118 participants indicated positive perceptions of all aspects of the service provided by Triple I (Hub), with similar ratings provided by staff (n = 56) and clients (n = 62). The external expert reported that there was improved job satisfaction expressed by staff, and there was significant reduction in processing time of aged care referrals from 3 weeks to less than 24 hours.Evidence from mixed methods evaluation was used. Quantitative survey results only reported satisfaction by users, but observations provided supplementary indications for service development.

The following case reports are of two patients who have developed hypersensitivity reactions to the red cell growth hormones, darbepoietin and erythropoietin. The subsequent skin testing and clinical course suggested that the cause of these reactions was due to the excipient polysorbate 80. This finding might have implications in the recent increase in the incidence of pure red cell aplasia.

A tool for assessing the suitability of candidates for home dialysis (Jo-Pre-training Assessment Tool version 2.1 - JPAT) was developed, pilot-tested at one hospital and field-tested at two major teaching hospitals in Sydney. JPAT acts as a screening instrument to distinguish suitable candidates for the home dialysis programme, identifying patients with the greatest chance of learning to manage the programme. This study included an interview/test of home dialysis patients based on the Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36). JPAT version 2.1 is in the form of an interview questionnaire consisting of 38 assessment items in six domains: physical stability, nutritional status, communication ability, ability to maintain self-care, psychological suitability and social support. Overall, results suggest that JPAT version 2.1 is sufficiently reliable to be used as a tool for assessing patients who suffer from end-stage renal disease (ESRD), and to identify patients most likely to succeed in a home dialysis programme.

The carers of home dialysis patients often play a major role in the patient's general well-being. However, the well-being of the carers themselves should also not be overlooked. There is a need to gain a better understanding of the factors which contribute to the overall levels of negative affect amongst home dialysis carers. The direct effects of patient health factors (namely disease severity and functional impairment or disability) and carer cognitive factors (namely carer locus of control and choice of coping strategies) were examined on carer negative affect. Moreover, a cognitive mediational model, which proposed that the carer cognitive factors serve as mediator variables, was tested. Questionnaires were administered to 38 home dialysis patients and their carers. Of this sample, 15 patients were on home haemodialysis and 23 on peritoneal dialysis. The patient's level of functional impairment was found to have a significant impact on the carer's affect. As hypothesised, even when controlling for pat...

Summary A tool for assessing the suitability of candidates for home dialysis (Jo-Pre-training Assessment Tool - JPAT) was developed. JPAT acts as a screening instrument to identify suitable candidates for the home dialysis programme, and therefore increases a patient's chance of learning to manage the programme. JPAT is in the form of an interview questionnaire consisting of 38 assessment items in six domains: physical stability, nutritional status, communication, ability to maintain self-care, psychological suitability and social support. A pilot study was conducted (n = 20, 1996–1997) using a descriptive study design, with subjects randomly selected from an existing dialysis programme. Pearson correlation and 2-tailed tests were employed to explore the relationship between the assessment outcome (i.e. the initial JPAT scores) and the follow up data (i.e. data collected within the seven days following the initial JPAT assessment). Many of the variables attained statistical significance (p < 0.05). The inter-rater reliability was calculated at an average Kappa value of 0.909. Overall, results suggest that JPAT is sufficiently reliable to be used as a tool for assessing patients who suffer from ESRD.

The aims of this study were to: (1) validate the proximal–distal (PD) model in predialysis and early dialysis and (2) examine the role of hemoglobin on quality of life (QoL) in these patient groups. Cross-sectional observational studies of 475 participants recruited from four major university teaching hospitals were conducted. The multi-sample structural equation modeling with latent composite techniques was employed to test the PD model. Seven factors were measured, including QoL, positive affect, depression, physical functioning, kidney disease symptoms, comorbidity and hemoglobin. The results showed that both the equality-constrained and equality-unconstrained PD models were supported by fit statistics. The chi square difference test of the two models was non-significant, indicating that the PD model was consistent across groups. The alternative models were rejected by fit statistics, suggesting that hemoglobin does not impact on psychological states but QoL. This study validates the PD model across the end-stage renal disease (ESRD) patient groups and shows a hierarchical causal relationship between clinical factors, physical functioning, psychological states and QoL, with hemoglobin as an exception. This model provides an empirical framework for integrating and studying a range of clinical factors and health outcomes in ESRD.

Longer, more frequent dialysis at home can improve life expectancy for patients with chronic kidney disease. Increased use of home dialysis therapies also benefits the hospital system, allowing for more efficient allocation of clinic resources. However, the Australian and New Zealand Data Registry statistics highlight the low uptake of home haemodialysis and peritoneal dialysis across Australia.In August 2009, the Australia's HOME Network was established as a national initiative to engage and empower healthcare professionals working in the home dialysis specialty. The aim was to develop solutions to advocate for and ultimately increase the use of home therapies. This paper describes the development, achievement and future plan of the Australian HOME Network.Achievements to date include: a survey of HOME Network members to assess the current state of patient and healthcare professional-targeted education resources; development of two patient case studies and activities addressing how to overcome the financial burden experienced by patients on home dialysis. Future projects aim to improve patient and healthcare professional education, and advocacy for home dialysis therapies.The HOME Network is supporting healthcare professionals working in the home dialysis specialty to develop solutions and tools that will help to facilitate greater utilisation of home dialysis therapies.

This multicentre, prospective, open label, randomised controlled trial was to determine whether buttonhole cannulation technique in new and established haemodialysis fistula reduced complications and prolonged the access life compared to usual practice.Seventy subjects were recruited for this study. Subjects randomised to the buttonhole group had their fistula cannulated by the same staff member for two to four weeks at the same angle and direction with sharp needles. Once the tunnel was developed, blunt needles were used. The control group continued with usual practice (rope ladder rotation technique).Infection at the cannulation site occurred in four patients in the buttonhole group and one in the rope ladder rotation group (p = 0.11). Haematomas at the cannulation site and site pain experienced during the dialysis session were more often recorded for the buttonhole group (p0.05).This study showed that buttonhole cannulation resulted more infections, haematoma formation and site pain during dialysis than with the rope ladder rotation group. A further larger scale longitudinal study is recommended.

The aim of this project was to evaluate the introduction of Assistant in Nursing (AINs) in the haemodialysis units at a major tertiary Area Health Service in Sydney, Australia. All nursing staff were asked to complete a baseline and follow-up survey to determine changes to their attitudes to the new skill mix model and their satisfaction with the new organization of care delivery in their dialysis units. Comparison of the baseline and follow-up surveys in the paired data was favourable with nurses acknowledging that they would cope well with the introduction of AINs, and they were more likely to disagree with the statement that their workload would increase after the introduction of AINs in the follow-up survey. There was little difference in (i) the workload of the dialysis units before and during the intervention; and (ii) the incidence of patient and nursed related adverse outcome events.

Studies have shown that patients converted to short daily haemodialysis (SDHD) have reported many clinical benefits, decreased complications during dialysis and a better quality of life.A six-month prospective cohort study was conducted to examine the efficacy of SDHD to patients previously receiving three times per week haemodialysis therapy. Following informed consent, participants received haemodialysis daily, Monday-Saturday, between 2 and 2.5 hours for each treatment and followed-up for a six-month period. The participants continued to experience hypotension, cramping and headache and were noncompliant with fluid intake. There was a gradual reduction in blood pressure, cessation of antihypertensives and reduction of erythropoietin therapy (ERT). There were no hospital admissions or reports of access complications. The nursing staff reported an increase in activity levels and nursing interventions with the participants following conversion to SDHD. However, the participants reported a better quality of life.

Objective Research into the association between psychosocial factors and depression in End-Stage Renal Disease (ESRD) has expanded considerably in recent years identifying a range of factors that may act as important risk and protective factors of depression for this population. The present study provides the first systematic review and meta-analysis of this body of research. Methods Published studies reporting associations between any psychosocial factor and depression were identified and retrieved from Medline, Embase, and PsycINFO, by applying optimised search strategies. Mean effect sizes were calculated for the associations across five psychosocial constructs (social support, personality attributes, cognitive appraisal, coping process, stress/stressor). Multiple hierarchical meta-regression analysis was applied to examine the moderating effects of methodological and substantive factors on the strength of the observed associations. Results 57 studies covering 58 independent samples with 5956 participants were identified, resulting in 246 effect sizes of the association between a range of psychosocial factors and depression. The overall mean effect size (Pearsons correlation coefficient) of the association between psychosocial factor and depression was 0.36. The effect sizes between the five psychosocial constructs and depression ranged from medium (0.27) to large levels (0.46) with personality attributes (0.46) and cognitive appraisal (0.46) having the largest effect sizes. In the meta-regression analyses, identified demographic (gender, age, location of study) and treatment (type of dialysis) characteristics moderated the strength of the associations with depression. Conclusion The current analysis documents a moderate to large association between the presence of psychosocial risk factors and depression in ESRD.

SUMMARY Aim: The aim of the project is to determine the effectiveness of using online access flow measurement, thermodilution method (Fresenius BTM™), in detecting and predicting thrombosis or stenosis of the haemodialysis fistula, so that early intervention could be instituted. Methodology: All haemodialysis patients with permanent vascular dialysis access, either arteriovenous fistula (AVF) or arteriovenous fistula graft (AVG), in a large tertiary referral Dialysis Service in Australia were included in this prospective observational quality project, conducted over 12 months. Results: Out of 165 patients studied, 36 patients were found to have poor dialysis access flow, defined as AVF—flow of

Needle-stick injury (NSI) is a major occupational health and safety issue facing healthcare professionals. The administration of erythropoiesis-stimulating agents (ESA) in haemodialysis patients represents a major cause for injections. The purpose of this initiative was to familiarise nursing staff with needle-free administration of an ESA in haemodialysis patients to reduce the risk of NSI. Epoetin beta comes in a commercial presentation with a detached needle. Epoetin beta was administered to 10 haemodialysis patients via the venous bubble trap short line of the haemodialysis circuit. An audit was conducted that included a retrospective assessment of NSI for the previous six months; and a prospective assessment for eight weeks to assess whether there is a nursing staff preference for needle-free administration of ESA. There were no reports of NSI in the needle-free group. Haemoglobin levels were maintained. Ninety-one percent of the nursing staff preferred needle-free administration of ESA. In conclusion, the commercial presentation of epoetin beta with the detached needle presents an opportunity to reduce the potential risk of NSI in haemodialysis units.

Renal transplantation remains the therapy of choice for children and adolescents with ESRD. Differences in graft survival are observed in kidney transplant recipients of different race and ethnicities. Data in pediatric populations are limited and confounded by disparities in access to health care. We performed a retrospective single Canadian centre database review to determine the short- and long-term outcomes of kidney transplantation in Aboriginal children compared to non-Aboriginals. A total of 159 primary renal transplant recipients at BCCH between 1985 and 2005 were examined (15% Aboriginal). Aboriginal children had different etiologies of ESRD, and a higher percentage of females, but were similar in age at transplantation, cold ischemia time and living donation rate. Early graft outcomes such as delayed graft function, episodes of acute rejection in the first year post-transplant and estimated glomerular function rate at one yr were similar in both groups. Long-term graft survival, however, was significantly worse in the Aboriginal group, with a significantly increased rate of late rejections: 50% compared with 26.7% among non-Aboriginals (p = 0.03). In a province with uniform access to health care, significant differences in long-term graft outcome exist among Aboriginal children compared with non-Aboriginals.

Background and objectives: In kidney disease, the concept of loss is widely discussed but minimally researched. It appears that dialysis patients who grieve a range of losses suffer increased depression and reduced quality of life (QoL). Limited research is partly due to the lack of a relevant loss measure. The study presented here developed a measure and tested the criterion validity of loss in relation to depression and QoL. Design, setting, participants, & measurements: In a cross-sectional observational study, 151 long-term dialysis patients were interviewed using standardized psychometric measures and the Kidney Disease Loss Scale (KDLS), developed for the study. Factor, path and multigroup analyses were conducted. Results: The factor structure and reliability of KDLS were supported. The path analyses supported the criterion validity of loss. It was a stronger contributor to depression than other clinical variables. Its effect on QoL was fully mediated by depression and positive affect (coping). The magnitude of the paths from loss to QoL through depression and positive affect was larger in home-based dialysis patients than in hospital-based patients. Conclusions: KDLS is a promising measure of loss. Patient-defined losses may contribute to the high level of depression and in turn a reduction in patients’ coping and QoL. These findings suggest several points of intervention to improve long-term dialysis patients’ QoL.

A new beam-combination and detection system has been installed in the Sydney University Stellar Interferometer working at the red end of the visual spectrum (wavelength range 500-950 nm) to complement the existing blue-sensitive system (wavelength range 430-520 nm) and to provide an increase in sensitivity. Dichroic beam-splitters have been introduced to allow simultaneous observations with both spectral system, albeit with some restriction on the spectral range of the longer wavelength system (wavelength range 550-760 nm). The blue system has been upgraded to allow remote selection of wavelength and spectral bandpass, and to enable simultaneous operation with the red system with the latter providing fringe-envelope tracking. The new system and upgrades are described and examples of commissioning tests presented. As an illustration of the improvement in performance the measurement of the angular diameter of the southern F supergiant delta CMa is described and compared with previous determinations., Comment: 13 pages, 14 figures

The following case reports are of two patients who have developed hypersensitivity reactions to the red cell growth hormones, darbepoietin and erythropoietin. The subsequent skin testing and clinical course suggested that the cause of these reactions was due to the excipient polysorbate 80. This finding might have implications in the recent increase in the incidence of pure red cell aplasia.

SUMMARY: The use of acute vascular access catheters (AVACs) has facilitated the delivery of haemodialysis to patients lacking functioning access. A review of the experience of a tertiary Australian renal treatment centre, consisting of 205 sequential AVACs in 93 patients, was undertaken over 1 year, to identify issues limiting technique survival. Acute vascular access catheters were inserted as acute dialysis access for patients with chronic renal failure (CRF; 21%), failed grafts or fistulae (18%), acute renal failure (12%), failed chronic ambulatory peritoneal dialysis (CAPD; 8%) or failed prior AVACs (37%). The majority of AVACs were on the right (74%), and the placement site was simple jugular (69%), tunnelled jugular (15%), femoral (12%), or subclavian (4%). During follow up, 198 of 205 AVACs were removed. The mean AVAC survival was superior (P

Objectives This multicenter, prospective, open-label randomized controlled trial will be undertaken to determine whether or not the buttonhole cannulation technique in new and established hemodialysis fistula reduces complications and prolongs access life compared to usual practice. Methods A total of 70 subjects will be recruited for this study. Subjects randomized to the buttonhole group will have their fistula cannulated by the same staff member for 2-4 weeks at the same angle and direction with sharp needles. Once the tunnel is developed, blunt needles will be used. The control group will continue with usual practice (rope ladder rotation technique). Measurement of treatment effects will include: (1) quality of life; (2) pain assessment of cannulation; (3) lignocaine use; (4) intradialytic blood flow rate and venous and arterial pressures; (5) dialysis adequacy; (6) cannulation proficiency; and (7) hemostasis time. Conclusion This study has been designed to provide evidence to help renal clinicians and their hemodialysis patients determine the optimal cannulation technique for prevention of fistula access complications.