Vascular access surveillance : the role of the access nurse in the renal dialysis unit.

Introduction
In January 2006, the Renal Dialysis Unit at Geelong Hospital appointed a Vascular Access Nurse. A Transonic Flow Qc HDO2 Ultrasound Dilution Monitor was purchased to monitor access flow and recirculation in arteriovenous fistulae in an attempt to predict AVF stenoses requiring early surgical correction.

Methods
A bi-monthly monitoring program tested all facility-based patients. 82 patients were assessed for access flow and recirculation between February and December 2006.

Results
18 (22%) had poor AVF function; 13 with access flows <500ml/minute on initial testing and 5 with an access flow decreasing >25% over a four month period. Of the 18 patients shown to have poor access flow, 2 died within one month of measurement while 5 were too frail to attempt corrective surgery. The remaining 11 proceeded to ultrasound or fistulography. A >50% stenosis was detected in all 11 cases. Of these, 4 had successful vein patch surgery and one had PTFE grafting, each with marked improvement in access flow. One had failed vein patch surgery requiring creation of a femoral AVF, one patient required cvc insertion to await AVF creation, and one had failed stenting requiring a permanent cvc. 3 died before planned surgery.

Conclusion
5 of the 82 patients that had access flow assessment, and needed further evaluation, proceeded to successful pre-emptive surgical intervention. We believe the Transonic is a useful adjunct to routine clinical AVF surveillance, in providing early evidence of AVF failure that can be avoided by pre-emptive surgery.

A combined strength and balance exercise program to decrease falls risk in dialysis patients : a feasibility study

People suffering end-stage kidney disease receiving hemodialysis have a greater risk of falling and suffering debilitating injuries. The purpose of this study was to examine the feasibility and impact of a combined strength and balance exercise intervention on falls risk in hemodialysis patients. Twenty-four adults (mean age = 67.8 yrs) from two Australian outpatient hemodialysis clinics completed the intervention. Falls risk was measured using the Physiological Profile Assessment (PPA). There was a significant reduction in the median overall falls risk z-score from 1.67 to .52 (z = -3.11, P<.008; r = .45). Median reaction time improved from .30 to .26 sec (z = -2.86, P<.008; r = .41). A strength and balance intervention to reduce the falls risk for dialysis patients is feasible and may reduce falls risk for at risk patients.

Nutrition screening by nurses in dialysis

Aims and objectives : To determine whether a nurse-completed dialysis nutritional screening tool improves referral rates for nutritional support and compare nutrition sensitive biochemical indices, mortality rates and patient-centred quality of life outcomes between referred and non-referred dialysis patients.

Background : People with chronic kidney disease requiring dialysis are nutritionally at risk. Nutrition screening has been shown to identify dialysis patients who are nutritionally at risk to refer to dietitian expertise.

Design : Prospective cluster-randomised control trial.

Methods : Monthly nurse-completed nutrition screening was completed for six consecutive months using a validated four-item instrument measuring weight change, serum phosphate, serum potassium and appetite. Participants (n = 81) were haemodialysis patients from four satellite haemodialysis centres in one Australian metropolitan health service. Primary outcome measure was rate of referral to dietetic services for nutrition support for intervention vs. control groups at six months. Secondary outcome measures were blood pressure, biochemical indices and mortality for referred vs. non-referred patients at six and nine months, and generic and dialysis-specific quality of life for referred vs. non-referred at nine months was examined.

Results : There were three times as many dietetic referrals in the intervention group than in the control group (26·3 vs. 9·3%). Serum phosphate increased significantly more in the referred patients than the non-referred patients. There were no clinically significant changes between groups in quality of life, blood pressure, mortality rates or other biochemical indices at either six or nine months.

Conclusion : Nurse-completed nutritional screening can lead to appropriate dietetic referrals for nutritional support by nutritional expert clinicians.

Relevance to clinical practice : This study is the first to demonstrate that monthly systematic nurse-completed nutritional screening can facilitate appropriate dietetic referrals that may lead to increased nutritional care for people in satellite dialysis centres.

Using images to communicate the hidden struggles of life on dialysis

Background Nurse‐patient communication in the hemodialysis context is unique given the amount of time spent together in a confined clinical room. Poor communication may lead to low-quality nursing care and undesirable patient outcomes.

Aim To explore the use of images as a visual communication technique for nurses and patients in the hemodialysis context.

Methods Descriptive qualitative design. Fifty-two cards containing specific photos, illustrations, and words were used to facilitate conversations about being on hemodialysis between patients (n = 9) and two nurse interviewers. Interview transcripts were thematically analysed.

Findings An overall theme titled ‘revealing the hidden struggles of living on dialysis’ conceptually captured three sub-themes: (1) the increased importance of relationships; (2) the struggle with money; and (3) quality over quantity of life. The cards assisted in uncovering these often covert (to nurses) aspects of dialysis patients' lives.

Conclusion Nurses may need to be aware of the dialysis patients' hidden struggles which include the importance of relationships, financial issues, and the importance of quality aspects such as travel. The use of images may assist in revealing the important issues for each patient struggling with the restrictive life that is imposed by dialysis.

Developing a dialysis centre foot screening culture

Foot lesions are common in the dialysis population and contribute to increased morbidity and mortality (Broersma 2004). lmportantly, patients on dialysis with and without diabetes are at increased risk of foot ulcers (Jones et al. 2012) and lower limb amputation (Kaminski, Frescos & Tucker 2012). Simple foot screening in dialysis centres can identify those at risk of foot complications and the presence of foot ulcers (Ahmad 2009; Ng et al. 2003). Valid and reliable foot screening tools have been developed in the dialysis context to identify those at risk and those with actual ulcers (Murphy et al. 2012).ln 2011, following the completion of a Diabetes and Renal Pilot Study and staff education, Moorabbin Haemodialysis Unit and Southern Health, identified the need to formalise foot screening for all patients and increase the rate at which these were conducted. The aim of this report is to present a summary of the audit evaluation of foot health screens and referrals in our dialysis centre.

Mothers requiring dialysis: parenting and end-stage kidney disease

Background
Mothers requiring dialysis to treat end-stage kidney disease face the challenging demands of the disease and dialysis treatment in addition to their role as a parent.

Objective
To describe the experience of mothers who require haemodialysis.

Methods
Four mothers receiving haemodialysis treatment for end-stage kidney disease in regional Australia were interviewed to explore the mothers' experiences, attitudes, beliefs and values of their dual role as mothers and haemodialysis recipients.

Results
The overarching theme emerging from the data was the competing roles of motherhood and dialysis. Four key sub-themes emerged: fitting everything in, internal family challenges, lost connections and striving for normality.

Conclusion
Being a mother adds a range of complexities to being on dialysis. While managing dialysis, mothers struggle to care for their children and stay connected with family life. Nephrology health professionals are uniquely placed to support mothers and need to develop strategies to ease their burdens of care.

Laughter and humor therapy in dialysis

Laughter and humor therapy have been used in health care to achieve physiological and psychological health-related benefits. The application of these therapies to the dialysis context remains unclear. This paper reviews the evidence related to laughter and humor therapy as a medical therapy relevant to the dialysis patient population. Studies from other groups such as children, the elderly, and persons with mental health, cancer, and other chronic conditions are included to inform potential applications of laughter therapy to the dialysis population. Therapeutic interventions could range from humorous videos, stories, laughter clowns through to raucous simulated laughter and Laughter Yoga. The effect of laughter and humor on depression, anxiety, pain, immunity, fatigue, sleep quality, respiratory function and blood glucose may have applications to the dialysis context and require further research.

The information needs of older people who choose supportive care over dialysis: A case study approach

Background: Supportive care is increasingly being viewed as an appropriate alternative option to dialysis or transplantation for older people with advanced chronic kidney disease (ACKD). The purpose of this study was to explore the information needs of older people with ACKD who choose supportive care as their treatment. Methods: A case study approach using semi-structured interviews and medical case note review methods was used to explore the information needs of six older people receiving supportive care. Results: The majority of the information the participants had recalled receiving placed a greater emphasis on dialysis over supportive care. Although they did not want dialysis, they were not clear on what supportive care meant or whether they had a supportive care plan. Participants perceived they had never been given specific information about supportive care. Medical case note review revealed infrequent and non-systematic documentation in medical case notes. Conclusions: In the absence of a formal nephrology supportive care program, information may be provided in an unplanned, non-systematic approach to older people and their families who choose supportive care.

Investigation of hybrid ion-exchange membranes reinforced with non-woven metal meshes for electro-dialysis applications

Salt and solvent permeations across ion-exchange membranes used in electro-dialysis are directly related to the membrane material structure and chemistry. Although primarily used for aqueous effluents desalination, electro-dialysis was recently shown to be a promising technology for industrial wastewater and co-solvent mixtures purification. The harsh working conditions imposed by these liquid effluents, including high suspended solids, require the development of more chemically and mechanically resistant membranes. In this study, commercial porous stainless steel media filters (240 μm thick) were used as a backbone to prepare hybrid ion-exchange membranes by casting ion-exchange materials within the porous metal structure. The surface of the metal reinforcements was modified by plasma treatment prior to sol-gel silane grafting to improve the interface between the metal and the ion-exchange resins. The morphology of novel hybrid materials and the interface between the metal fibers and the ion-exchange material have been characterized using techniques such as scanning electron microscopy and FTIR mapping. The thickness of the silane coating was found to lie between 1 and 2 μm while water contact angle tests performed on membrane surfaces and corrosion test behaviors revealed the formation of a thin passivating oxide layer on the material surfaces providing anchoring for the silane grafting and adequate surface energy for the proper incorporation of the ion-exchange material. The hybrid membranes desalination performance were then tested in a bench top electro-dialysis cell over a range of flow rate, current densities and salt concentration conditions to evaluate the ability of the novel hybrid materials to desalinate model streams. The performance of the hybrid membranes were benchmarked and critically compared against commercially available membranes (Selemion™). Although the salt transfer kinetics across the hybrid ion-exchange composite membranes were shown to be comparable to that of the commercial membranes, the low porosity of the stainless steel reinforcements, around 60%, was shown to impede absolute salt permeations. The hybrid ion-exchange membranes were however found to be competitive at low current density and low flow velocity desalination conditions.

Investigation of hybrid ion-exchange membranes reinforced with non-woven metal meshes for electro-dialysis applications

Salt and solvent permeations across ion-exchange membranes used in electro-dialysis are directly related to the membrane material structure and chemistry. Although primarily used for aqueous effluents desalination, electro-dialysis was recently shown to be a promising technology for industrial wastewater and co-solvent mixtures purification. The harsh working conditions imposed by these liquid effluents, including high suspended solids, require the development of more chemically and mechanically resistant membranes. In this study, commercial porous stainless steel media filters (240. μm thick) were used as a backbone to prepare hybrid ion-exchange membranes by casting ion-exchange materials within the porous metal structure. The surface of the metal reinforcements was modified by plasma treatment prior to sol-gel silane grafting to improve the interface between the metal and the ion-exchange resins. The morphology of novel hybrid materials and the interface between the metal fibers and the ion-exchange material have been characterized using techniques such as scanning electron microscopy and FTIR mapping. The thickness of the silane coating was found to lie between 1 and 2. μm while water contact angle tests performed on membrane surfaces and corrosion test behaviors revealed the formation of a thin passivating oxide layer on the material surfaces providing anchoring for the silane grafting and adequate surface energy for the proper incorporation of the ion-exchange material. The hybrid membranes desalination performance were then tested in a bench top electro-dialysis cell over a range of flow rate, current densities and salt concentration conditions to evaluate the ability of the novel hybrid materials to desalinate model streams. The performance of the hybrid membranes were benchmarked and critically compared against commercially available membranes (Selemion™). Although the salt transfer kinetics across the hybrid ion-exchange composite membranes were shown to be comparable to that of the commercial membranes, the low porosity of the stainless steel reinforcements, around 60%, was shown to impede absolute salt permeations. The hybrid ion-exchange membranes were however found to be competitive at low current density and low flow velocity desalination conditions.

Gasto energético e sua relação com leptina, insulina e mediadores inflamatórios em pacientes em diálise peritoneal

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