Comment: Sweet clover - from toxin to treatment
John Bradley
pp 3-3
In 1940, the agent that caused ‘sweet clover disease’, a haemorrhagic affliction of cattle that had eaten improperly cured silage or hay made from sweet clovers, was purified from spoiled hay. The agent was identified the following year as 3,3’- methylenebis(4-hydroxycoumarin) by researchers at the Wisconsin Agricultural Experiment Station of the University of Wisconsin–Madison, leading to the synthesis of a number of analogues, one of which was warfarin.
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Warfarin management in haemodialysis patients
Timothy Sadler, Kelvin Bao, Sanjay KK Ojha and Lisa C Willcocks
pp 4-5
Patients on haemodialysis may be anticoagulated with warfarin for a number of conditions, including atrial fibrillation, previous venous thromboembolic disease and dialysis access thrombosis. In any patient treated with warfarin, the benefits that go with prevention of thromboembolic disease have to be offset against the risk of bleeding. Patients with endstage renal failure who are treated with warfarin have an increased risk of bleeding. This risk is difficult to quantify, as no bleeding risk scoring systems have been validated in this population specifically.
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Warfarin management in advanced kidney disease
Kathrine Parker, Jecko Thachil and Sandip Mitra
pp 6-8
In the general population, warfarin has been shown to be a highly effective therapy for the treatment and prophylaxis of thromboembolic disease.However, to date, there are no studies to validate its clinical effectiveness in the endstage renal disease population. Safe warfarin treatment requires appropriate monitoring to maintain the international normalised ratio (INR) within a narrow therapeutic range. An INR that falls within 0.5 of the target value is deemed acceptable. Marked deviations above and below the INR range are associated with excessive bleeding and under-anticoagulation respectively. The frequency of monitoring can be variable and is dependent on the stability of both the prior measurements and the patient’s medical condition.
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Kidney policy matters
Donal J O’Donoghue
pp 9-9
The NHS remains a turbulent place and a bit of a political football. One could think it is more about the government, British Medical Association or Royal College of Nursing – or commissioning, regulation and inspections – than the health of the nation. Of course, all these are necessary for the efficient and effective functioning of healthcare services, but our shared purpose is to add value for individuals and populations by reducing the impact of disease and providing care to manage its consequences, including high-quality end-of-life care.
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Painful legs in patients with type 1 diabetes and chronic kidney disease
Gorav N Wali, Ramesh B Naik and Matthew Gibson
pp 10-14
Painful legs in diabetic patients have a broad range of differential diagnoses, including cellulitis, necrotising fasciitis, deep vein thrombosis, haematoma, myositis, tumour and trauma. Two of the more rare causes of painful legs are diabetic muscle infarction and diabetic pyomyositis. Both can present in a very similar fashion, but require different treatments and can result in markedly different outcomes. They tend to occur in patients with microvascular complications of diabetes, such as diabetic nephropathy, and thus are likely to present to the renal physician. Despite this, there are few reports in the renal literature.
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What I tell my patients about renal diets for children with CKD
Pearl Pugh
pp 15-18
Changes to the diet are recommended in all patients with chronic kidney disease (CKD). One distinct factor that sets children apart from adults is the fact that they are still growing. The growth issue must be championed in the dietary prescription, which will require frequent review by family and specialised paediatric renal dietitians. Many years ago, before the advances in renal replacement therapy, dialysing a newborn with CKD was a technological challenge.
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Awareness of organ donation in the South Asian community
Adnaan Haq, Haseebullah Wardak, Haroen Sahak, Naaila Haq and David Oliviera
pp 19-21
The South Asian community in the UK is the most under-represented population among organ donors. The South Asian community makes up a mere 1–2% of the donors on the NHS organ donor register, despite the fact that this population group is more likely to require certain transplants. For example, South Asians are three times more likely than the general population to require kidney transplants, due to their increased susceptibility to chronic conditions such as hypertension and diabetic nephropathy.
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An Ethnic Liaison Support Worker for South Asian renal patients
John Stoves, Tahira Akhtar, Vicki Hipkiss, Ramla Mumtaz, Tony Coman and Chris Lacey Investigation
pp 22-25
A large number of patients with advanced chronic kidney disease in Bradford are of South Asian origin. Effective delivery of care for these patients demands a consistently high standard of communication between patients, their families and renal unit staff. Communication may be problematic for a number of reasons, including language barriers and an incomplete appreciation of important cultural or religious beliefs. In 2010, we were successful in applying to the British Kidney Patient Association for funding to employ an Ethnic Liaison Support Worker (ELSW). The ELSW is able to engage with and support patients, relatives and other members of the multidisciplinary team.
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Survey of patients with advanced CKD receiving active supportive care
Rachel E Davison, Therese Wood and Alison L Brown
pp 26-28
Patients with advanced chronic kidney disease (CKD) are known to have a high symptom burden, reported to be comparable to terminal cancer. With an aging population and a greater awareness of CKD, more people referred to specialist nephrology clinics have multiple co-morbidities and impaired functional levels. Not all these patients will progress to end-stage renal disease, but many will experience distressing symptoms from their renal insufficiency.
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What you need to know about transplantation
Nicholas Palmer
pp 29-31
A transplant is widely regarded as the ‘gold standard’ for a person approaching end-stage renal failure. For some, this may be a pre-emptive transplant (to avoid dialysis) with a live donor, while for others already on dialysis, it is an opportunity to regain control of their life and body. Either way, a transplant is a gift of life, underpinned by love, bravery, generosity and morality, delivered with the dexterity, skill, diligence and care of the transplant team and nursing staff, with its long-term survival secured by research from around the globe.
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