Where observational studies score
		How age influences outcomes
		Elderly haemodialysis patients risk malnutrition
		UK lags in fistula race

This longitudinal study of haemodialysis patients now involved 20 units in the UK, Dr Roger Greenwood, Chairman of the session, Highlights from IDOPPS, said.

"After many months of hard work by many individual people the results of DOPPS have started to trickle though over the last 12 months and have created many discussions.

"So a DOPPS session at the symposium was thought to be very informative," Dr Greenwood, who is Clinical Director at the Lister Hospital, Stevenage, explained.

Dr Sean Leavey, of the University of Michagan, set the scene by explaining what DOPPS was intended to achieve. Where observational studies score. He stressed that, as an observational study, its major advantage was that it allowed us to test some parameters which could not be tested in a clinical-trial setting because of feasibility or ethical limitations.

He went on to illustrate his theme by telling delegates that data from the survey suggested that mild to moderate obesity might improve survival among haemodialysis patients.

"Observational studies describe the actual treatment practices. They can test numerous hypotheses and they can address the questions that are not accessible to be addressed by clinical trials," Dr Leavey said.
"Findings can lead to new trials and, while correlation and association from observational research does not prove causation. If you multiply, adjust for confounding factors, take the necessary adjustments into account, and you see consistency across different studies, then you begin to get data which can provide reasonable inferences for practising physicians," he concluded.

Renal disease affects people of all ages and a section of DOPPS has aimed to clarify whether both the treatment and the outcomes vary according to the age of the patient, the session heard.

Heather Jayasekera, Research & Practice Development Sister at Hope Hospital, Salford, has been looking at patient mortality, their hospitalisation, their vascular access, and their quality of life in relation to age. How age influences outcome.


"The data analysis from the DOPPS study has confirmed:

		l the risk of death rate increases with age,
		the risk of hospitalisation increases with age,
		the patients' physical quality of life decreases with age while their mental quality of life remains relatively constant,"

Nurse team leader in the Haemodialysis Unit at the Lister Hospital, Stevenage, Victoria Riggs then told the session that she, too, had been using the DOPPS data to look at the health differences among age groups of haemodialysis patients within the study. Elderly haemodialysis patients risk malnutrition. She had looked especially at health differences and adherence to diet among age groups in the seven participating countries: France Germany, Italy, Japan Spain UK and USA.

She had found that elderly haemodialysis patients were more likely to suffer from malnutrition but were less likely to skip dialysis sessions, she said.

In response to a question from the floor, Victoria Riggs agreed that renal units could, where appropriate, consider feeding patients while they dialyse to combat this problem.

Returning to Dr Leavey's theme in the final presentation of the session, Dr Hugh Rayner, Medical Director of Birmingham Heartlands Hospital, stressed that DOPPS was a study in progress and a lot of the data that had been discussed at the session was the baseline description of the populations being studied. UK lags in fistula race.

"There is clearly a lot more analysis of this enormous database that needs to be done and will be done," he said.

"This presentation is designed to demonstrate what questions can be asked and to get some evidence behind our practice patterns where they have largely been built upon tradition and urban mythology.

"The biggest issue we have in the UK is getting fistulas created and getting them usable. We therefore rely on a large number of temporary catheters.

"If we had a more efficient way of creating fistulas and then using them, this would reduce the time period in which temporary access may be required."

However, in this country, the use of the fistula tended to be delayed because current practice cautioned that if you needled the fistula early, you might traumatise it, damage it and reduce its long-term survival, he explained.

"So, I was interested to see whether the DOPPS database could tell us whether this practice pattern was based on any real evidence," Hugh Rayner said.

And he found that early needling of fistulas did not seem to jeopardise their long-term survival.

But this finding did not answer the most significant concern, which had emerged from his research.

"The two major issues so far coming out of DOPPS are dialysis dose and access. Dialysis dose in the UK at the moment is pretty equivalent to the rest of Europe, but access is our huge weakness and we've got to do something about it," Hugh Rayner concluded.

During the lunch interval an extensive exhibition of poster presentations was staffed by their authors and three in particular caught nephronline's eye.

If you would like more information about DOPPS send an email to info@nephronline.org

Renal technicians want more status

More status, please, say technicians

Renal technicians want more status and to be more widely recognised as an integral part of the kidney-patient care team, according to spokesman for the Association of Renal Technicians Mark Forrest[link to article More status, please, say technicians]. They would also like to see greater standardisation of their line management.

He told nephronline: "We really need to enhance the status of renal technicians.

"In a lot of units the technician is not a part of the team. We need to promote the team cause.

"Our overall maintenance role is probably going down as machines are being built better. They run better. The service intervals have increased and mean time between failures has improved. The days when we just soldered circuit boards have gone," he said.

Renal pharmacists launch FAQ booklet

Travel vaccines vade mecum

Pharmacists at the Royal Free Hospital, London, have come up with an information booklet to answer the most common questions they get from the renal healthcare team and patients during the summer months. Travel vaccines vade mecum

"Especially in the summer months, we're forever being telephoned by health professionals or patients asking: Which vaccines can I use in transplant patients? Which vaccines can I use in dialysis patients? Which malaria can they safely take? So, we thought we'd do a leaflet," renal pharmacist Caroline Ashley told nephronline.

"But the telephone calls are not going down because word has gone out that we've done it so we get telephone calls about that now!" she added.

Exercise works out in dialysis

link to article in June update (make walking sticks a relic of the past) Exercising isn't naff

Following on from her successful cycling while dialysing regime, clinical scientist at the Lister Hospital, Stevenage, Chiew Kong is encouraging patients to exercise between dialysis sessions. Exercising isn't naff

Her poster presentation at Nephrology in Practice 2001 described how she had linked up with a local health club to arrange three-months free use by 10 patients. Each had pre-training assessment and a fitness test by a fitness instructor and a training programme was drawn up for each individual patient.

At the end of the three months the fitness test was repeated. The patients were also asked their views of their physical fitness both before and after the trial.

Her idea of linking up with heath club was to overcome resistance from some patients to exercise, especially the young, Chiew Kong told nephronline.

"Some people consider cycling during dialysis as naff, especially the younger ones or maybe the bike doesn't give them the level of exercise that they want," she said.

"Another reason is to shift the emphasis or focus from sickness to health. It might make exercise more appealing, more sexy to them. 'I want to be with these healthy people exercising.' So, that was the rational behind getting them to the gym to exercise," she explained.

Healthy Heart, Healthy Start

Treating anaemia regresses LVH

A packed afternoon included a session called Healthy Heart, Healthy Start, during which specialist registrar in renal medicine at Ninewells Hospital, Dundee, Dr Graham Stewart told delegates that boosting haemoglobin levels in patients approaching dialysis appeared to regress left-ventricular hypertrophy. Treating anaemia regresses LVH.

"The effect of this on subsequent end-stage renal failure cardiovascular mortality isn't yet known, but is an exciting potential therapeutic option," he said.

He explained that LVH was common in patients approaching end-stage renal failure (ESRF) and was seen early in the progression of the disease. He outlined the aetiology of the condition in the uraemic patient and went on to describe the health problems it could cause.

But there was hope on the horizon, he continued.

There had been several studies that have shown that if you can partially correct the anaemia in end-stage renal disease you can partially regress the left ventricular hypertrophy, he said.

According to these studies, LVH was present at the early stages of progressive renal disease and increased with the decline in renal function and correlated very closely with the fall in haemoglobin.

This suggested, he continued, that early normalisation of haemoglobin and the treatment of other cardiac risk factors might improve survival.

"And we now believe that correcting anaemia with recombinant erythropoietin in patients with ESRF regresses LVH. Unfortunately, we still do not know how this will affect mortality," he concluded.


Innovative practice

Nurse consultants pivotal to pre-dialysis care

When the term nurse consultant was first really taken on board by the Department of Health within its White Paper, Making a Difference, it came as a bit of a shock to many people, including some within the DOH, Frances Coldstream, Nurse Consultant at Guy's and St Thomas' Hospital Trust, London, told another afternoon session. Nurse consultants pivotal to pre-dialysis care

"Within this document there was no definition of a nurse consultant as such. And it is still not clear whether there is a definition," she said.

But Making a Difference was not just about launching the nurse consultant role, she continued. It looked at the role's potential within the NHS.

One road would be to use the recommendations of a framework document from the Kidney Alliance, which the Alliance hopes will be used by a variety of people and groups to improve equity and quality in renal care, she said.

Frances Coldstream then discussed the seven national service standards this document set out and how nurse consultants could play a key role in the provision of pre-dialysis care.

"Both the developing role of the nurse consultant and the area of pre-dialysis care are exciting developments which can be brought together to enhance patient care. For information about The Pre-dialysis Forum send an email to info@predialysis.org

"Both areas merit interest and research to take what has been achieved so far forward," Frances Coldstream concluded.

In his welcoming letter to the conference, president of the British Renal Symposium Dr Donal O'Donoghue hoped that delegates would enjoy participating in the symposium. Judging from the number of questions from the floor each presentation generated it seemed his hopes were fulfilled.