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Objective. The objective of this study was to design and implement an efficient pathway to ensure a smooth transition of patients with advanced chronic kidney disease to dialysis. Setting. In our dialysis service, as elsewhere, we recognized that there was an unacceptably high rate of inadequately prepared patients commencing dialysis. Knowledge of clinical practice and research-based guidelines has not in itself changed clinical practice and patient management. Main measures. To address these problems, multidisciplinary process redesign teams reviewed pre-existing arrangements by assessing current practice. The review identified critical points where problems could occur: failure to notify patients to dialysis service, late referral for vascular surgery, and inadequate pre-dialysis education. As a result of this process, we have formulated a modified and coordinated pre-dialysis programme. Results. In association with process redesign, the proportion of patients registered ‘late’ decreased from 29% in July–September 2000 (pre-implementation) to 6% in January–March 2004 ( P < 0.01) with the corresponding median time from registration to commencement of dialysis increasing from

With the advent of Raman spectrometers based on CCD array detectors, instruments have been coupled to optical microscopes leading to all the advantages of bright field microscopy with the added advantage of a direct chemical probe. The primary biological solvent, water, is a weak Raman scatterer and so these instruments can now be used to investigate the chemistry of living systems at spatial resolutions of 1 µm and below. We have developed techniques that allow us to study functional red blood cells and monitor the exchange of ligands and the development and chemistry of disease processes. These techniques take advantage of Aggregated Enhanced Raman Spectroscopy, which enables us to use the haem group of the haemoglobins and related haem pigments, such as the malarial pigment haemozoin, as a sensitive probe for changes in oxidation state, spin state and electronic structure. We have used the Raman microprobe to investigate the effect of drugs such as quinoline on the food vacuole of the malarial parasite in vivo. Sickle cell disease affects 1 out of 600 African American births and is caused by a mutant form ( β6 glu→ val) of haemoglobin (HbS). HbS polymerizes and forms higher order aggregates under hypoxic conditions, leading to distortion and rigidity of the erythrocyte. These rigid cells can block the microvasculature resulting in tissue ischaemia, organ damage, and ultimately death. The sensitivity of the Raman technique to haem aggregation provides a tool with which we can analyse the changes that occur between normal and sickle cells.