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Notes: Background and Aims:  Acute cholecystitis in critically ill patients has a high morbidity and mortality. We observed a number of patients presenting with Legionella pneumonia and acute renal failure who subsequently developed acute cholecystitis. There has previously been no reported association between Legionella pneumonia, renal failure and cholecystitis, prompting this examination of the cases and review of the available literature.Methods:  The Western Hospital patient record discharge codes (DRG) from 1993 to 2001 were searched retrospectively for all cases of Legionella pneumonia or acute renal failure requiring dialysis (ARF) at presentation or during their period of hospitalization. Acute cholecystitis was then included as a cross-search and results analysed.Results:  Twenty-six cases of isolated Legionella pneumonia and 112 of ARF were identified with a further 10 having both conditions simultaneously. Of these 10 cases, three were identified as also having acute cholecystitis. The combination of Legionella pneumonia and ARF was associated with an increased risk of acute cholecystitis (P = 0.002) whereas neither condition in isolation demonstrated this association.Conclusions:  Patients with Legionella pneumonia can become critically ill with multiple complications including acute renal failure requiring dialysis. In this setting, they may have an increased risk of developing acute cholecystitis, which clinically can be difficult to ascertain. Diagnosis requires a high index of suspicion and vigilance.

Notes: The nutritional wellbeing and dialysis adequacy of 57 stable haemodialysis patients (34 males and 23 females) from two satellite dialysis centres were assessed. Nutritional and anthropometric assessment comprised a variety of serological, historical and somatic parameters. A previously validated urea monitor was used to assess dialysis dose (Kt/V) and normalized protein catabolic rate (nPCR). Over 70% were malnourished (19% severely), 60% had a nPCR 〈 1.2 g/kg per day, and 80% failed to reach an adequate energy intake. A close correlation was observed between the various measures of nutritional assessment. Almost half of the group (47%) demonstrated a Kt/V 〈 1.2, with a significantly higher level identified in females (1.3 ± 0.2 vs 1.0 ± 0.2, P 〈 0.05). This was in contrast to the nutritional data where there was an equal sex distribution. A close correlation was found between dialysis adequacy and the different nutritional and anthropometric parameters in subjects with a Kt/V 〈 1.2 (P 〈 0.01 to P 〈 0.001). Males appear to be at higher risk of malnutrition from inadequate dialysis, however, a higher than expected incidence of malnutrition was observed in both sexes who were adequately dialysed.

Notes: SUMMARY: Simplicity and sufficiency in the management of renal anaemia were first envisaged with the development and production of recombinant human erythropoietin (epoetin). Recent years, however, have seen the publication of several studies examining the optimal administration of epoetin, the emergence of a new erythropoietic agent (Novel Erythropoietic Stimulating Protein, NESP), recognition of the need for supraphysiological iron levels, and the possible use of many potential adjuvant agents. Together, these factors have made the management of renal anaemia substantially more complex, perhaps even to the point of confusion. the purpose of this review, therefore, is to examine the evidence relating to these factors in order to offer a summary of their known effects on anaemia management, hopefully with some progress towards the initial goals.

Notes: Background:  Numerous prior studies have reported that a substantially higher dose of epoetin is required to maintain haemoglobin (Hb) concentration when patients are switched from a subcutaneous (SC) to intravenous (IV) route of administration. Many of the reported trials, however, involved patients who did not have adequate serum iron levels. It was hypothesized that patients with adequate iron stores who are switched from one route of administration to the other without a change in dose will experience substantially less change in their Hb concentration.Methods:  Haemodialysis patients who were iron replete (ferritin 300–800 µg/L, transferrin saturation (TSAT) 25–50%) participated in a prospective, randomized cross-over trial receiving epoetin for 3 months either by SC or IV injection followed by a further 3 months of epoetin via the other route. The principal aim was to determine changes in Hb concentration without altering the weekly epoetin dose. The secondary aim was to assess whether the frequency of dosing (once, twice or thrice weekly) influenced the Hb concentration response.Results:  Eighty-one patients (mean age 62 years, 60% male) entered the study and 15 withdrew prior to study completion. Forty-three patients began SC epoetin alfa administration (group A) and 38 on IV (group B). Median ferritin and TSAT at entry for groups A and B were 409 and 394 µg/L (NS) and 31 and 32% (NS), respectively, which remained within the target range during the study. Median epoetin doses for groups A and B were similar (90 vs 93 IU/kg per week, NS). After 3 months, the mean Hb concentration rose for group A (SC; 118.7–121.9 g/L (P = 0.03)) but it fell for group B (IV; 119.1–116.0 g/L (P = 0.019)). Following the change in route of administration, the Hb concentration for group A (IV) fell by 5.1% over 3 months (121.9–115.4, P 〈 0.001) and rose by 2.8% for group B (SC) over 3 months (116.0–119.7, P = 0.001). Similar significant changes in the Hb concentration were seen at different dosing frequencies.Conclusion:  Subcutaneuos administration of epoetin produces a significant, although slight clinical change in Hb concentration compared with IV administration in stable, iron replete, haemodialysis patients. A similar effect appears to prevail regardless of the frequency of injections given.