This study, looking at a large cohort, has established the incidence and outcome of ANCA +ve and ANCA -ve RPGN in a defined stable population. It stresses the similarities between ANCA +ve and ANCA -ve cases and supports the notion that pauci-immune RPGN is part of a continuum of vasculitic illness. In this series transplantation is a safe option.

The proportion of elderly people in the United Kingdom is increasing. The increasing number of those with renal failure is reflected in an increase in the total number of elderly patients receiving renal replacement. In 1992, 12% of patients undergoing such treatmnent were over 75 compared with 3% in 1982.Dialysis is feasible in elderly people,`' but there may be bias against referring elderly patients with renal failure to nephrologists."4 The reasons for low referral rates are unclear but may include lack of resources, poor prognosis, or judgments about the quality of life of elderly people. To study the factors applying to the referral of elderly patients with renal failure we undertook a questionnaire survey of hospital physicians. Subjects, methods, and resultsWe sent 203 questionnaires to general physicians and elderly care physicians and 20 to nephrologists based in the south west of England and the Channel Islands. The questionnaire consisted of 14 brief case histories (see table 1) of patients aged 65-87 who were likely to need renal dialysis to survive. Physicians other than nephrologists were asked if they would refer the patient to a nephrologist for assessment while nephrologists were asked if they would accept the patient on to their dialysis programme. Further questions asked about the factors that would increase the probability of or would act as contraindications to referral or acceptance.A total of 165 questionnaires were returned; nine were blank (70% response rate; 18/20 (90%) nephrologists and 138/203 (68%) physicians responded). More patients in the 14 case histories would have been accepted by the nephrologists than would have been referred by physicians (median 13 v 10; P<0.001 in Mann-Whitney U test). Table 1 shows the relative frequency of acceptance or referral for each case in rank order. Most nephrologists and physicians would accept or refer a patient if either the patient or the relatives wished treatment. Only a few in both groups thought that fear of a law suit would make any difference to referral or acceptance. Both liver metastases and dementia were regarded as contraindications to dialysis by most physicians and nephrologists (by 133 and 129 physicians respectively and by 17 and 16 nephrologists respectively). Age was not a contraindication except when a patient was over 80, when 79 physicians (57%) and seven (39%) nephrologists thought it was a relative contraindication. Myeloma, hemiplegia, faecal incontinence, and being bed bound were thought to be only relative contraindications to treatment by most physicians and nephrologists.Physicians were more likely to refer if they had a Although our questionnaire measured only attitudes and not behaviour, the findings are consistent with a rising acceptance rate of elderly patients on to dialysis programmes. Elderly patients often have clinically significant comorbidity, develop complications on dialysis, and need a lot of social support. These factors point to the need for a multidisciplinary approach to treatment of elderly peop...

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Background: Most positive antineutrophil cytoplasmic antibody (ANCA) results are associated with nonvasculitic conditions, and guidelines have been proposed for the judicious use of this test. The outcome of applying similar guidelines in a routine laboratory is reported. Methods: All immunology requests (6500) over six months were selected, and those requesting ANCA were studied for the appropriateness of the clinical data supporting the request, the presence of ANCA in those samples tested, and the final diagnosis. Antibodies were detected by indirect immunofluorescence. Results: ANCA testing was requested in 287 samples. Application of a ''gating policy'', which refuses analysis on requests that are not supported by clinical data suggestive of systemic vasculitis, made clinicians more selective about the patients for whom they requested ANCA testing. The percentage of ''appropriate'' screens for systemic vasculitis was relatively high (212 of 287 requests: 72.5%). Only one of the remainder, for whom ANCA testing was initially refused, developed an ANCA related systemic vasculitis in the two years after the study, but the delay in reporting her positive ANCA was only two days. Most of the samples tested were negative (155 of 212), but most (42 of 57) of the patients with positive ANCA results were found to have a systemic vasculitis. Conclusions: A gating policy to select requests supported by clinical data suggestive of systemic vasculitis makes ANCA testing more clinically relevant and cost effective. Studies where guidelines can be proposed and their effects measured are important in the light of clinical governance and evidence based medicine.

Twenty -two continuous ambulatory peritoneal dialysis (CAPD) patients, mean age 48 years, at 3 U.K. renal units were assessed with the Nottingham Health Profile (N HP) before and after treatment with recombinant human erythropoietin (r-HuEPO). Mean (SD) hemoglobin (Hb) at baseline was 7.5 (1.0) gIn/dl and 10.8 (1.5) gIn/dl at retest. There were significant improvements in energy (p<0.0001), social life (p<0.005), relationships at home (p<0.05) and leisure pursuits (p<0.05). Twelve patients, mean age 51 years, who had already completed more than 9 months on r-HuEPO treatment were reassessed to determine the changes sustained. Mean (SD) Hb at second retest was 12.8 (1.3) gm/dl. Improvement in energy continued to be significant, and emotional wellbeing showed further improvement. Problems with household tasks, which had not shown significant improvement at Test B, were now considerably reduced (p=0.016). The study showed far-reaching benefits similar to those reported in hemodialysis patients, in a population with a higher mean age and higher potential coexisting illness or disability than most reported hemodialysis studies.