The choice of dialyser matters The recently presented initial data from the European Membrane Permeability Outcome ( MPO) study strengthens the evidence that the middle molecule removal offered by high- flux dialysis membranes is clinically important. This study enrolled only new patients to dialysis and focused on those at risk, characterised by having a serum albumin level below 4 g/ dl. Patients randomised to start dialysis with a high- flux rather than a low- flux membrane showed a significant 37% risk reduction for all- cause death, after case mix adjustment. Diabetic dialysis patients also showed a significant risk reduction with high- flux membranes. We eagerly wait for the full MPO study data to be published. Meanwhile the HEMO study, which reused dialysers to a large extent, failed to show a significant effect of membrane flux on all- cause mortality in the full study population of prevalent dialysis patients. However, patients already on dialysis for some years responded differently, with improved survival when randomised to a high- flux membrane. Recently published post hoc analysis of the HEMO study data indicates that in these patients cardiac death is significantly associated with the amount of middle molecule removal, expressed as b2- microglobulin ( b2m) Kt/ V. Each 0.1 unit increase in b2m Kt/ V was associated with a 7% risk reduction for cardiac death. A similar risk reduction, although not significant, was seen for infectious death. A recent paper from US investigators highlighted that synthetic high- flux membranes may differ significantly in their capacity to remove middle molecules during HD treatments. In direct cross- over comparisons of different high- flux dialyser brands, they found small molecule removal to be mainly unaffected by membrane composition, while large molecule removal depended significantly on membrane composition and morphology. Polyflux ® high- flux dialysers showed efficient removal of b2m as well as of other middle molecules ( angiogenin, leptin and complement factor D). Presentation by Prof. F. Locatelli during the ERA- EDTA Congress 2007. Cheung AK, et al: Effects of high- flux hemodialysis on clinical outcomes: results of the HEMO study. J Am Soc Nephrol. 2003; 14( 12): 3251- 63. Cheung AK, et al: Association between serum 2- microglobulin level and infectious mortality in hemodialysis patients. Clin J Am Soc Nephrol. 2008; 3( 1): 69- 77. For more information about the Polyflux dialysers mentioned in this piece, contact Samantha Ford 01480 444006 samantha. ford@ gambro. com Long term follow- up of clotting incidence at reduced heparinisation with the AN69ST dialyser In a single- centre study, 170 regular HD patients were randomised to be dialysed either with a heparinised AN69ST dialyser at a reduced dose of unfractionated heparin ( 2718± 1388 U) or another dialyser at regular heparin dose ( 4800± 1555 U). Over 15 months 26,626 sessions were provided with registration of clotting events. Making HDF easier Raigmore Hospital in Inverness has experienced excellent results with the use of ULTRACONTROL, which uses pressure control haemodiafiltration ( HDF) instead of the traditional HDF with volume control. Ward Manager Anne Allan says: " We are already finding it a simpler, safer tool to use, with easy treatment set up. There is a reduced risk of excessive haemoconcentration and the exchange volumes are greater." Raigmore's renal unit has 16 dialysis stations and is equipped with the latest Gambro AK 200 Ultra S dialysis machines, and ULTRACONTROLis integrated into these, although it can also be adopted as an upgrade to earlier machines. Volume control can be difficult to perform successfully, with pressure control demanding great operator experience. But with ULTRACONTROL, simply set the weight loss required and the treatment time, initiate ULTRACONTROL to carry out an initial scan, then scan again every hour to maintain the optimal infusion volume. A detailed case study is available that introduces ULTRACONTROLand the benefits presented to both the patient and clinical team. For a copy of the case study, contact Brian May 01480 444016 brian. may@ gambro. com 6 clinical corner Gambro's quality systems put to the test Gambro's commitment to high- quality processes and procedures was tested recently by independent third party audits carried out by both MHRA and BSI. " It was very pleasing that we passed these tests without significant issues," says Shaun Hurlow, Gambro's Quality and Process Manager, North West Europe. " But of greater satisfaction for all involved were the complimentary comments made during both inspections. " It was very encouraging to hear government agencies and our notified body praise our working methods, the way we manage our business through key performance measures and our use of customer feedback to drive improvements. That is not to say that we will rest on our laurels and we will always look to improve what we do. Through the ongoing development and implementation of good processes we will continue to strive to be the best company in the renal care environment." ContactShaun Hurlow 01480 444010 shaun. hurlow@ gambro. com

Moderate clotting in the drip chamber was more frequently seen in the low- heparin group, as well as red patches in the dialyser at treatment end. However, massive clotting was similar in the two groups, with 1.4 events/ 1,000 sessions in the AN69ST/ low heparinised group versus 1.6 events/ 1,000 sessions in the control group. Haemoglobin levels and erythropoietin needs remained stable in both groups. Chanard J et al; Nephrol Dial Transplant 2008; 23: 2003- 9 ( http:// ndt. oxfordjournals. org/ cgi/ content/ abstract/ 23/ 6/ 2003) Better survival with short daily HD The five- centre experience of 415 patients from Europe and the USA starting a short daily HD programme between 1982 and 2005 has been reviewed. Approximately two thirds of the patients were treated at home or in a self- care unit, while the others were treated in- centre. Weekly StdKt/ V was 2.9± 0.6 and 2.6± 0.5 for the US and European patients respectively. The five- year survival in these patients was 68%. When compared to matched patients in the USRDS registry, this was 2- 3 times higher. The predicted time to 50% survival was 2- 11 years longer in the short daily group. Kjellstrand K et al; Nephrol Dial Transplant Advance Access May 5, 2008 Buttonhole cannulation practice reviewed Expert opinions and historical insights into vascular access techniques for chronic haemodialysis have been gathered in an email discussion club. Contributors with experience in the buttonhole technique for patients with native arterio- venous fistulas found benefits to be easier cannulation, reduced pain and reduced aneurysm formation. The paper discusses barriers to introducing the buttonhole technique and how to overcome these. Advice is provided on needling protocols, track formation and the preferred type of needle. Murcutt G; Buttonhole cannulation: should this become the default technique for dialysis patients with native fistulas? Summary of the EDTNA/ ERCA Journal Club discussion Autumn 2007. J Ren Care. 2008 Jun; 34( 2): 101- 8 Gambro's blunt AVF needles enable use of the button- hole technique for easier, gentle puncture for repeated and painless cannulation at the same site. For more information contact Samantha Ford 01480 444006 samantha. ford@ gambro. com 7 Here's the latest summary from our clinical specialists of the dialysis- related papers published recently. Shaun Hurlow reports positive feedback from MHRA and BSI inspectors Antibacterial catheter reduces the risk of infection Through its Dolphin Protect ® technology, Gambro offers an indwelling catheter that addresses the issue of catheter- related infection for haemodialysis patients. The integration of the antibacterial Bi additive into the catheter's surface coating reduces bacterial adhesion, inhibits proliferation and inhibits biofilm formation. Dolphin Protect is the first product on the market to use this coating system, rather than other methods which may release pharmaceuticals or other components like silver. The microdomain surface of the catheter reduces interaction between cells, plasma proteins and the surface of the catheter, significantly improving the catheter's biocompatibility. The coating also creates a stable and smooth surface which covers the catheter body, effectively reducing blood activation to help prevent catheter biodegradtion. It also prohibits the emission of X- ray contrast medium ( BaSO4) particles into the blood. ContactLloyd Buck 01480 444049 lloyd. buck@ gambro. com Dolphin Protect offers improved biocompatibility and reduced catheter biodegradtion " It was encouraging to hear government agencies and our notified body praise our working methods."