Large differences in vascular access use exist between EUR and the US, even after adjustment for patient characteristics. The results strongly suggest that a facility's preferences and approaches to vascular access practice are major determinants of vascular access use.

In a wide variety of HD patient subgroups, differing with respect to their baseline health status, increasing body size correlates with a decreased mortality risk. This contrasts with the association between BMI and mortality in the general population, and deserves further study.

The large differences in haemodialysis practice and outcomes in the Euro-DOPPS countries suggest opportunities for improvement in patient care.

This study demonstrates differences in the management of haemodialysis patients across Euro-DOPPS and offers opportunities for improving dialysis dose, adherence and nutrition. Correlation of differences in practice patterns at the dialysis unit level with patient outcomes will offer new insights into improving dialysis therapy.

Patients on chronic hemodialysis may suffer from a latent protein deficiency, and therapy with essential amino acids has been recommended. In a double blind cross-over study, 13 hemodialysis patients received orally 15.7 g of essential amino acids daily over a 3-month period. Patients were on a liberal diet, containing 1 g of protein per kilogram of body weight per day. Hemodialysis was adequate. Therapy resulted in an increase in urea, uric acid, C3 c complement factor and a fall in C4. Lysine levels increased and phenylalanine fell. Malnutrition could not account for the observed metabolic changes, which are more likely due to uremic metabolic disturbances. A liberal diet of 1 g of protein per kilogram of body weight appears sufficient for patients on hemodialysis. Treatment with essential amino acids offers no advantage.

SUMMARY In 18 patients suffering from chronic renal failure (being haemodialysed three times weekly for 22-2±27'9 months), sensory conduction velocity and relative refractory period of the sural nerve were estimated immediately before and after dialysis. Before haemodialysis all but one patient had conduction velocities within the normal range (x ±2 SD), but 50% had prolonged refractory periods. After dialysis the refractory period decreased to become normal in all but one patient. Visual evoked potential latencies showed no systematic alterations. A membrane abnormality due to uraemic poisoning is assumed to cause the reversible prolongation of the refractory period.Peripheral neuropathy was known to be a rare neurologic disorder in renal failure'-4 before long-term haemodialysis and renal transplantation programmes were developed for the treatment of terminal uraemia. 5-8 In the following studies, uraemic neuropathy was found in between 40% and 65% of patients prior to or shortly after starting dialysis,8'10 but declined to 10-20% during chronic haemodialysis"l"13 and after successful transplantation.14-15 Despite intensive research the pathogenesis of uraemic neuropathy is still unclear,16-17 and neurophysiological findings seem to correlate poorly with clinical and laboratory data.'0 [16][17][18][19] In evaluating the adequacy of haemodialysis, the reliability of neurophysiological parameters is disputed. Whereas some authors have observed long-term improvement of motor conduction velocity,20 others were unable to find any significant correlation between clinical, laboratory, and neurophysiological data during short and long haemodialysis treatment schedules.2122These conflicting findings cannot be explained by the histopathological abnormalities reported in uraemic nerves, which comprise mainly axonal degeneration with secondary demyelination.23 24 Address for reprint requests: ProfDr Klaus Lowitzsch, Dept ofNeurology, Univ. Mainz Langenbeckstr I, D-6500 Mainz (FRG).

In 15 ambulatory patients with renal insufficiency (creatinine clearance, 9.9 +/- 3.0 ml/min) the effect of oral supplementation with alpha-ketoacids has been compared with that of placebo. The protein intake amounted to 0.55 g protein per kilogram body weight of high biological value, as estimated by dietary recordings. After a control period of 3 months the patients received, in a double-blind study, 1.05 g alpha-ketoacids/10 kg body weight per day or a placebo for 6 weeks with a subsequent cross-over. Fasting blood samples were analyzed at 3-week intervals for routine laboratory parameters and 17 proteins. Anthropometric and clinical data have been recorded every 3 weeks. While therapy with alpha-ketoacids diminished PO4 levels (P less than 0.05), no other significant effect could be demonstrated. No signs of protein deficiency existed either before or during alpha-ketoacid therapy. Therefore, supplementation with alpha-ketoacids appears to be superfluous in patients with renal insufficiency maintained on a 40-g protein diet.

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