Comment: Injury time – losing out in acute kidney injury
John Bradley
pp 3-3
Acute renal failure, now termed acute kidney injury, is common and complex, and often has serious consequences. Considerable resources have recently been invested in formulating classification systems to assess the scale of the problem, stratify risk, facilitate research and guide therapy of acute kidney injury.
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The risks of mineral bone disease in CKD patients
Fouad Al-Baaj
pp 4-7
Patients with chronic renal failure are prone to developing multiple complications. The incidence
of these complications generally increases with the progressive deterioration of renal function. It is often enhanced by the introduction of renal replacement therapy (RRT) and the perpetuation of the uraemic state.
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A review of assisted peritoneal dialysis
Edwina A Brown
pp 8-10
Chronic kidney disease (CKD) is largely a disease of the elderly, with a prevalence of CKD 3–5 of 25% in the general population over the age of 70 years and 30% over the age of 80, compared with 11% overall. An even higher prevalence of CKD 3–5 – 80% – is suggested in the residential care population, which presumably has a greater burden of co-morbidities. Although only a small proportion of individuals with CKD will progress to end-stage renal disease (ESRD), increasing life expectancy means that the number of older people with ESRD will escalate.
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Bioimpedance and fluid management in dialysis patients
Elizabeth Lindley
pp 11-13
Bioimpedance monitors can provide quick, cheap, non-invasive bedside measurements of fluid status with good reproducibility. This is just what we need to help manage patients who are frequently fluid-overloaded, sometimes dehydrated and prone to weight loss. So, why is routine bioimpedance monitoring not widely used in renal units?
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Quality, innovation, prevention and productivity
Donal J ODonoghue
pp 14-14
The NHS is facing a major challenge. Public debt has doubled from 40% to 79% of gross domestic product as a result of the banking bailout. That debt will have to be repaid, which will put pressure on the NHS and other public services. David Nicholson, NHS Chief Executive, has estimated that we will have to find £15–20 billion and the King’s Fund has predicted an even bigger shortfall after 2011 – £20–26 billion. One thing is sure: the next seven years will be years of relative famine and a period of massive change.
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What I tell my patients about contract medium toxicity
Aimun Ahmed, Glyn Williams and Ian Stott
pp 15-18
Contrast media are colourless solutions, which are used to assist in diagnostic and interventional procedures such as X-rays with dye, angiography (which is used to outline blood vessels, see Figure 1), computed tomography (CT) scans and magnetic resonance imaging (MRI). These contrast media can occasionally cause kidney damage, especially in patients who already have kidney disease. Contrast media are of different types, some of which are more ‘kidney-friendly’ than others.
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Developing a national specification for the peritoneal dialysis pathway
Lindsey Barker
pp 19-21
The strong history of peritoneal dialysis (PD) in the UK has fallen of late, with wide regional variation. At the same time, a population that isincreasingly elderly and frail may be restricted to a choice between hospital haemodialysis (HD) and conservative care. As patient numbers fall, commercial suppliers may leave the market. With the current renaissance of interest in home therapies, our group set out to restore patient choice and increase opportunity for providers by initiating patient pathway-driven commissioning of enhanced PD care nationally.
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Key questions on intradialytic parenteral nutrition
Elizabeth Southcott, Jeanette Calder and Mark Wright
pp 22-24
Protein-energy malnutrition affects 30–70% of haemodialysis patients. It is strongly associated with adverse outcomes. There are numerous reasons why dialysis patients become malnourished. Essentially, there are factors that reduce nutrient intake, and factors that promote catabolism or suppress anabolism. There is no single nutritional marker that reliably tells us who is, or is not, malnourished.
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The composition of dialysate
Nicholas A Hoenich
pp 25-27
During haemodialysis, removal of waste products from the blood, exchange of electrolytes between the blood and the dialysis fluid, and the partial restoration of acid–base equilibrium occurs across a semipermeable membrane. Dialysis fluid is derived from mixing treated tap water with electrolytes and a buffer. Historically, it was batch mixed manually, but today this is performed automatically and continuously by a proportionating system, as part of the ialysis monitor.
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Phenytoin-facilitated hypoglycaemia in ESRF
Andrew Coutinho, Luxy John, Ian Casson and Craig Gradden
pp 28-29
Renal failure (RF) can reduce insulin requirements in patients with diabetes mellitus, causing more frequent hypoglycaemic events. Spontaneous hypoglycaemia is recognised in patients with severe renal impairment who do not have diabetes mellitus; its aetiology is multifactorial
and includes drug toxicity. Phenytoin toxicity is usually associated with hyperglycaemia, but there are cases where phenytoin was implicated in facilitating hypoglycaemia in patients with normal renal function. This report shows the potential effect of phenytoin in causing hypoglycaemia in RF patients.
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Results of a national enquiry into patient death from AKI
James Stewart, George Findlay and Neil Smith
pp 30-31
In June 2009, the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) published its latest report, Adding Insult to Injury, an enquiry into the care received by patients dying with a primary diagnosis of acute kidney injury (AKI). This study was designed to look specifically at the care of patients with AKI, particularly in terms of clinical assessment, investigation, management and referral, as well as organisational factors such as access to nephrologists, radiology services and renal replacement therapy (RRT). In turn, it was hoped that remediable factors in AKI care could be identified. This article will summarise the key findings of the study.
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