Comment: Challenging behaviour John Bradley pp 3-3 Lord Darzi has set out a vision
for a personalised NHS that is
‘tailored to the needs and wants of
each individual, especially the most
vulnerable and those in greatest need,
providing access to services at the time
and place of their choice’. The focus for
change is on primary care, where more
than 80% of patient contact takes place.
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Crescentic IgA nephropathy Naushad Junglee, Meryl Griffiths and Menna Clatworthy pp 4-7 IgA nephropathy (IgAN) is one of the most
common causes of primary glomerulonephritis
(GN) and of end-stage renal failure (ESRF). Most
patients with IgAN present with microscopic
haematuria with or without a variable degree of
renal impairment. Renal biopsy typically
demonstrates glomerular mesangial hypercellularity
with IgA deposition. A minority of
patients with IgAN (<5%) present
with acute renal failure and a
rapidly progressive course.
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Violence and aggression on haemodialysis units Julia Jones, Gayle Ridge, Sarah Eales, Neil Ashman and Patrick Callaghan pp 8-9 Disruptive, abusive and violent behaviour by
patients and occasionally their family members
is becoming a significant problem in
some haemodialysis (HD) units, with literature
suggesting that this is an emerging
problem both nationally and internationally. Aggressive behaviour by a small but
significant minority of dialysis patients
towards staff and fellow patients consumes
disproportionately large amounts of clinical
time and resources.
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What to look for in vascular access catheters Nicki Angell-Barrick and Janson CH Leung pp 10-12 It is widely accepted that an arteriovenous fistula
(AVF) is the ‘gold standard’ in vascular access in
haemodialysis (HD) patients as they have fewer
associated infections, fewer issues with morbidity
and mortality, fewer complications, and are
generally more acceptable to patients than vascular
access catheters (VACs). However, there will
be times throughout a patient’s dialysis life when
they will need to rely on a VAC for access to their
bloodstream to allow HD.
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My 30 years on home dialysis – one patient’s story Robert Hinson pp 13-14 On 5 October 1977 I started my very first dialysis
session at Douglas House in Trumpington
Road, Cambridge, which was then the dialysis
centre for Addenbrooke’s Hospital. Thirty years,
10,000 needles and approximately 20,000
hours, or three years spent on a machine later, I
find myself writing this article.
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What I tell my patients about glomerulonephritis Heather Kerr and Neil Turner pp 15-18 Glomeruli are the filters of our kidneys. They clear the blood of unwanted waste products, allowing these to be excreted in the urine. We should have approximately one million glomeruli in each kidney. They are incredibly tiny – you could fit ten side by side on the head of a pin. A tube (tubule) leading out of each glomerulus is actually a processing device from which 99% of the filtered fluid is reprocessed back into the blood, leaving waste products, excess salt and so on, to flow out into the urine.
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Nephrotic syndrome secondary to shunt nephritis in a 37-year-old female Ramaswamy Diwakar and Peter A Andrews pp 19-21 A 37-year-old lady presented with a six-week history
of ankle and facial swelling. There was no
history of upper respiratory tract infection, joint
pain or skin rash. Two weeks earlier, she had
developed cellulitis of the lower leg, for which
she had been prescribed erythromycin. Her past
history included spina bifida and childhood
hydrocephalus, for which she was initially
treated with a ventriculopleural shunt, which
had been converted to a ventriculoatrial (VA)
shunt ten years earlier.
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Heparins in renal failure Madeleine A Vernon pp 22-24 Heparin is a widely used anticoagulant that has
a range of clinical applications. Different preparations
vary in their pharmacokinetic and pharmacodynamic
profile. The low molecular
weight heparins (LMWHs) introduced in the
1990s undergo renal elimination and their role
and safety in patients with impaired renal function
remains unclear and controversial.
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Symptom control for patients dying with advanced CKD Claire Douglas, Fliss Murtagh and John Ellershaw pp 25-27 Despite the common belief that uraemic death is
relatively symptom-free, the evidence does not
support this. A recent systematic review of literature
has shown that symptom prevalence is high
in dialysis patients, and that patients managed
conservatively (without dialysis) also have a high
symptom burden. Common symptoms include
pain, fatigue, dyspnoea and anxiety.
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Practicalities of implementing online haemodiafiltration Mark S MacGregor, Nestor Velasco, Andrew Innes, Ann Dunlop, John Wright and Ian G Mackay pp 28-31 Only 43% of patients are alive five years after
starting renal replacement therapy. For haemodialysis
(HD) patients, further increases in urea
clearance seem to offer limited opportunities for
improvements in mortality rate. Increased dialysis
frequency, longer dialysis hours or a combination
of the two may improve survival, but
are challenging to implement for the majority of
patients. Recently, two large observational studies
showed that haemodiafiltration (HDF) was
associated with a 35–37% reduction in mortality.
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