Orientador: André Luís Balbi / Resumo: Introdução - A mortalidade de pacientes com Lesão Renal Aguda (LRA) que necessitam de suporte renal agudo (SRA) é elevada. Alguns estudos sugerem que o SRA indicado tardiamente associa-se a piores desfechos. Outros, avaliando dose de diálise, não encontraram benefício com uso de SRA mais intenso. Entretanto, são escassos os trabalhos que avaliaram estes tópicos em pacientes dialisados por Hemodiálise Prolongada (HDP) e considerando a LRA exclusivamente associada a sepse. Objetivo - Avaliar a sobrevida de pacientes com LRA associada a sepse, submetidos a HDP, de acordo com o momento da indicação e a dose de diálise recebida. Material e Métodos - Coorte retrospectiva de pacientes críticos com LRA associada a sepse, estágio 3 segundo classificação AKIN, submetidos a HDP, de abril de 2008 a outubro de 2014, em dois hospitais de referência em nefrologia. De acordo com o momento da indicação do SRA, os pacientes foram divididos em grupo SRA precoce (início até 24 horas após atingido estágio 3 da LRA) e SRA tardio (início depois de 24 horas após atingido estágio 3 da LRA). A dose de diálise obtida por sessão foi calculada e, de acordo com a média do Kt/V semanal recebido, os pacientes também foram divididos em grupo SRA intenso (Kt/V maior ou igual a média) e grupo SRA menos intenso (Kt/V menor que a média). O desfecho estudado foi mortalidade intra-hospitalar. Considerado nível de significância de 5%. Resultados - Foram estudados 361 pacientes, com média de idade de 59,7 ± 15,7 ano... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Introduction - The mortality of patients with Acute Kidney Injury (AKI) requiring Acute Renal Support (ARS) is high. Some studies suggest that ARS indicated lately is associated with worse outcomes. Other, assessing dialysis dose, found no benefits with an intense use of ARS. However, few studies assessed those topics in dialyzed patients under extended hemodialysis and considering the Acute Kidney Injury exclusively associated with sepsis. Objective - To assess survival in patients with AKI associated with sepsis subject to extended hemodialysis according to the time of prescription and dialysis dose received. Material and Methods - Retrospective cohort of critically ill patients with AKI associated with sepsis, stage 3, according to AKIN classification, subjected to extended hemodialysis, from April 2008 to October 2014, in two referral hospitals in nephrology. According to the time of ARS indication patients were divided into early ARS group (beginning within 24 hours of reaching Stage 3 of AKI) and late ARS (beginning after 24 hours of reaching Stage 3 of AKI). Dialysis dose obtained by session was calculated and according to the average of weekly Kt/V received, patients were also divided into heavy ARS group (Kt/V ≥ average) and less intense ARS group (Kt/V < average). The study outcome was in-hospital mortality, considering a significance level of 5%. Results - 361 patients were studied aged between 59.7 ± 15.7 years old and 65.6% men. In AKI AKIN 3 diagnosis, 62.1% pre... (Complete abstract click electronic access below) / Doutor

INTRODUÇÃO: A necessidade de diálise e a mudança iminente no estilo e qualidade de vida são grandes responsabilidades depositadas nos pacientes com doença renal crônica (DRC) em processo de escolha do método dialítico. Alguns dos temas mais frequentemente implicados na escolha de um ou outro método dialítico são depressão, ansiedade e estresse. Nos pacientes renais crônicos pré-dialíticos ainda não foi evidenciado se a ansiedade está associada a desfechos clínicos, tais como início da diálise, hospitalizações ou morte. Tem-se sugerido que a depressão afeta os desfechos clínicos em pacientes com DRC pré-dialítica, podendo impactar no estado nutricional e na redução da observância da diálise prescrita. O estresse é um fator muito comum em indivíduos com uma doença de longa duração, incluindo aqueles com DRC. Altos níveis de estresse podem ter um impacto nos resultados psicológicos e clínicos, além de contribuir para os comportamentos de saúde, como as preferências pelo método dialítico. MÉTODOS: Este é um estudo observacional prospectivo no qual 67 pacientes foram abordados em dois momentos: durante primeira consulta no Ambulatório Multidisciplinar de Orientações do serviço de Nefrologia HC-FMUSP e, depois, no período entre 1 e 3 meses após o início da diálise. Foram utilizados os instrumentos Escala Hospitalar de Ansiedade e Depressão (HADS), Escala de Estresse Percebido (PSS) e Questionário de fatores pessoais que interferem na escolha do método dialítico, instrumento elaborado pelo autor. Características demográficas e clínicas também foram avaliadas. RESULTADOS: A média de idade foi de 59±15 anos, em sua maioria homens (53,7%), brancos (59,7%) e casados (57,8%). As principais comorbidades foram HAS (83,6%) e DM (42,6%). As principais causas de DRC foram nefroesclerose (26,9%) e nefropatia diabética (22,4%). A média de eGFR por CKD-EPI foi 16±7. As medianas de escores de ansiedade, depressão e estresse foram, respectivamente, de 6 (4/10), 9 (5/12) e 30 (21/35). A partir dos valores de corte estabelecidos, 34,3% dos indivíduos foram considerados \"com ansiedade\" e 52,2% \"com depressão\". A comparação de escores de ansiedade revela não haver diferença entre homens e mulheres (p= 0,136), havendo, porém, tendência de maiores escores de depressão entre mulheres (p= 0,074) e de estresse entre homens (p= 0,081). Não foram observadas diferenças nos escores de ansiedade (p= 0,556), depressão (p= 0,467) e estresse (p= 0,971) entre grupos DP e HD. Houve correlação positiva entre ansiedade e depressão (r2= 0,574, p < 0,0001), ansiedade e estresse (r2= 0,555, p < 0,0001) e depressão e estresse (r2= 0,521, p < 0,0001). Após início da terapia dialítica, foram observadas reduções significativas nos escores de ansiedade (p < 0,0001), depressão (p < 0,0001) e estresse (p < 0,0001). Os motivos relacionados à família são os que mais influenciaram na escolha do método (32,8%, p= 0,165). A incompatibilidade com a rotina pessoal/de trabalho foi o principal motivo para não escolha do outro método dialítico (26,9%). CONCLUSÕES: Embora o processo de tomada de decisões na escolha do método dialítico esteja associado a altos escores de ansiedade, depressão e estresse, tais sintomas são atenuados de forma significativa após o início da terapia dialítica. Escores de ansiedade, depressão e estresse não foram determinantes na escolha do método dialítico / BACKGROUND: The need for dialysis and the imminent change in style and quality of life are great responsibilities deposited in patients with chronic kidney disease (CKD) in the process of choosing the dialysis modality. Some of the issues most often involved in choosing one or another dialytic method are depression, anxiety, and stress. In pre-dialysis CKD patients, it has not yet been shown whether anxiety is associated with clinical outcomes such as initiation of dialysis, hospitalization, or death. It has been suggested that depression affects clinical outcomes in patients with predialytic CKD, which may impact nutritional status and reduce adherence to prescribed dialysis. Stress is a very common factor in individuals with a long-term illness, including those with CKD. High levels of stress can have an impact on psychological and clinical outcomes, as well as contribute to health behaviors such as dialysis preferences. METHODS: This is a prospective observational study in which 67 patients were approached in two moments: during the first visit at the Dialysis Education Program of the HC-FMUSP Nephrology Service and then in the period between 1 and 3 months after the initiation of the dialysis. We used the Hospital Anxiety and Depression Scale (HADS), Perceived Stress Scale (PSS) and Survey on personal factors that affects the choice of the dialysis method, an instrument developed by the author. Demographic and clinical characteristics were also evaluated. RESULTS: The mean age was 59 ± 15 years, mostly men (53.7%), caucasian (59.7%) and married (57.8%). The main comorbidities were hypertension (83.6%) and DM (42.6%). The main causes of CKD were nephrosclerosis (26.9%) and diabetic nephropathy (22.4%). The mean eGFR by CKD-EPI was 16 ± 7. Median anxiety, depression and stress scores were, respectively, 6 (4/10), 9 (5/12) and 30 (21/35). According to the established cutoff values, 34.3% of the individuals were considered \"with anxiety\" and 52.2% \"with depression\". The comparison of anxiety scores revealed no difference between men and women (p= 0.136), but there was a tendency for higher depression scores among women (p= 0.074) and stress among men (p= 0.081). There were no differences in anxiety scores (p= 0.556), depression (p= 0.467) and stress (p = 0.971) between DP and HD groups. There was a positive correlation between anxiety and depression (r2 = 0.574, p < 0.0001), anxiety and stress (r2 = 0.555, p < 0.0001) and depression and stress (r2 = 0.521, p < 0.0001). After initiation of dialysis therapy, significant reductions in anxiety scores (p < 0.0001), depression (p < 0.0001) and stress (p < 0.0001) were observed. The reasons related to the family were the ones that influenced the choice of the method (32.8%, p= 0.165). The incompatibility with the personal / work routine was the main reason for not choosing the other dialytic method (26.9%). CONCLUSION: Although the decision-making process in the dialysis modality choice is associated with high anxiety, depression and stress scores, such symptoms are significantly attenuated after the initiation of dialysis therapy. Anxiety, depression, and stress scores were not determinant in the choice of dialysis method

This study looked into paients’ experiences of end stage renal disease (ESRD) and renal replacement therapy (RRT). A qualitative me thodology was employed involving fifteen patients between the ages of 20 – 60 years that were interviewed on their experiences using the semi structured approach to interviewing. The knowledge gained was analysed thematically. The study was explored within two theoretical frameworks, namely the biopsychosocial and the ecological models. Results of the study revealed that ESRD and RRT posed many psychosocial challenges at a micro and macro level, as patients attempted to reconcil e these experiences with their lifestyles and lives. Challenges were expressed in the areas of functional capacity, work and sexuality. Family life was seriously affected when patients had to make themselves available for life long tr eatment that depended on machines. Recommendations included mobilisatio n of positive support networks, religion/spirituality, and pr ofessional support playing an interrelational role in enabling patients to cope through the long term process so that they may emerge from it with a modicum of quality in their life. Thus a team approach was key to optimal living for the patient. From an ecological perspective, macrosystemic change was also considered important for government to introduce policies that ensure economically productive living for persons with kidney dysfunction. / Thesis (M.A.)-University of KwaZulu-Natal, Durban, 2008.

Submitted by JULIANA MARIA GERA ABRÃO null (abrao_ju@hotmail.com) on 2016-03-01T22:23:24Z No. of bitstreams: 1 Doutorado TESE PRONTA.pdf: 3017853 bytes, checksum: 6ca4182dd56e2776225f4551e215c0c4 (MD5) / Approved for entry into archive by Ana Paula Grisoto (grisotoana@reitoria.unesp.br) on 2016-03-04T12:50:16Z (GMT) No. of bitstreams: 1 abrao_jmg_dr_bot.pdf: 3017853 bytes, checksum: 6ca4182dd56e2776225f4551e215c0c4 (MD5) / Made available in DSpace on 2016-03-04T12:50:16Z (GMT). No. of bitstreams: 1 abrao_jmg_dr_bot.pdf: 3017853 bytes, checksum: 6ca4182dd56e2776225f4551e215c0c4 (MD5) Previous issue date: 2016-02-26 / Introdução - A mortalidade de pacientes com Lesão Renal Aguda (LRA) que necessitam de suporte renal agudo (SRA) é elevada. Alguns estudos sugerem que o SRA indicado tardiamente associa-se a piores desfechos. Outros, avaliando dose de diálise, não encontraram benefício com uso de SRA mais intenso. Entretanto, são escassos os trabalhos que avaliaram estes tópicos em pacientes dialisados por Hemodiálise Prolongada (HDP) e considerando a LRA exclusivamente associada a sepse. Objetivo - Avaliar a sobrevida de pacientes com LRA associada a sepse, submetidos a HDP, de acordo com o momento da indicação e a dose de diálise recebida. Material e Métodos - Coorte retrospectiva de pacientes críticos com LRA associada a sepse, estágio 3 segundo classificação AKIN, submetidos a HDP, de abril de 2008 a outubro de 2014, em dois hospitais de referência em nefrologia. De acordo com o momento da indicação do SRA, os pacientes foram divididos em grupo SRA precoce (início até 24 horas após atingido estágio 3 da LRA) e SRA tardio (início depois de 24 horas após atingido estágio 3 da LRA). A dose de diálise obtida por sessão foi calculada e, de acordo com a média do Kt/V semanal recebido, os pacientes também foram divididos em grupo SRA intenso (Kt/V maior ou igual a média) e grupo SRA menos intenso (Kt/V menor que a média). O desfecho estudado foi mortalidade intra-hospitalar. Considerado nível de significância de 5%. Resultados - Foram estudados 361 pacientes, com média de idade de 59,7 ± 15,7 anos, sendo 65,6% homens. No diagnóstico da LRA AKIN 3, 62,1% apresentavam oligúria. A mortalidade intra-hospitalar foi de 82,5%. Em 54% dos casos o SRA foi tardio e a média do Kt/V semanal foi de 6,59 ± 1,6. Entre os pacientes que evoluíram para óbito foram observados maior média de idade (61,1 ± 14,8 versus 53,1 ± 18,3 anos; p=0,002), maior ATN-ISS (0,65 versus 0,60; p=0,002), maior percentagem de oligúricos (66,4 versus 41,3%; p<0,001) e menor creatinina sérica (3,6 versus 4,4 mg/dL). Neste mesmo grupo, houve mais indicação tardia de SRA, com tendência à diferença estatística (56,4% versus 42,9%; p=0,05). O Kt/V semanal foi semelhante entre os grupos óbito e não óbito. A análise multivariada mostrou que idade (OR=1,03; p<0,001), SRA tardio (OR=1,91; p=0,033) e oligúria (OR=2,83; p=0,001) foram associados a maior risco de óbito, enquanto maior valor de creatinina (OR=0,86; p=0,048) foi fator de proteção. Houve maior mortalidade no grupo SRA tardio, com tendência a diferença estatística (86,2% versus 78,3%; p=0,05) e foi observada melhor curva de sobrevida no subgrupo de pacientes oligúricos submetidos a SRA precoce (p=0,016). A mortalidade (82,2% no grupo SRA intenso versus 82,8% no grupo SRA menos intenso; p=0,888) e as curvas de sobrevida foram semelhantes nos grupos SRA intenso e SRA menos intenso. Conclusão – Quando avaliados pacientes com LRA associada a sepse e dialisados com HDP, a indicação precoce do SRA está associada a menor mortalidade, em especial entre pacientes oligúricos, e não há benefício em fornecer diálise mais intensa. / Introduction - The mortality of patients with Acute Kidney Injury (AKI) requiring Acute Renal Support (ARS) is high. Some studies suggest that ARS indicated lately is associated with worse outcomes. Other, assessing dialysis dose, found no benefits with an intense use of ARS. However, few studies assessed those topics in dialyzed patients under extended hemodialysis and considering the Acute Kidney Injury exclusively associated with sepsis. Objective - To assess survival in patients with AKI associated with sepsis subject to extended hemodialysis according to the time of prescription and dialysis dose received. Material and Methods - Retrospective cohort of critically ill patients with AKI associated with sepsis, stage 3, according to AKIN classification, subjected to extended hemodialysis, from April 2008 to October 2014, in two referral hospitals in nephrology. According to the time of ARS indication patients were divided into early ARS group (beginning within 24 hours of reaching Stage 3 of AKI) and late ARS (beginning after 24 hours of reaching Stage 3 of AKI). Dialysis dose obtained by session was calculated and according to the average of weekly Kt/V received, patients were also divided into heavy ARS group (Kt/V ≥ average) and less intense ARS group (Kt/V < average). The study outcome was in-hospital mortality, considering a significance level of 5%. Results - 361 patients were studied aged between 59.7 ± 15.7 years old and 65.6% men. In AKI AKIN 3 diagnosis, 62.1% presented oliguria. In-hospital mortality was 82.5%. In 54% of the cases the ARS was late and the average of weekly Kt/V was 6.59 ± 1.6. Among the patients who died, it was observed higher mean age (61.1 ± 14.8 versus 53.1 ± 18.3 years; p = 0.002), higher ATN-ISS (0.65 versus 0.60; p = 0.002), higher percentage of patients with oliguria (66.4 vs. 41.3%; p <0.001) and lower serum creatinine (3.6 vs. 4.4 mg / dl). In this same group, there was more of later indication of ARS, prone to statistical difference (56.4% versus 42.9%; p = 0.05). The weekly Kt/V was similar between the death and non- death groups. Multivariate analysis showed that age (OR = 1.03; p <0.001), late ARS (OR = 1.91; p = 0.033) and oliguria (OR = 2.83; p = 0.001) were associated with increased risk of death, while higher values of creatinine (OR = 0.86; p = 0.048) was a protective factor. There was a higher mortality rate in the late ARS group, prone to statistical difference (86.2% versus 78.3%; p = 0.05) and was observed better survival rate in the subgroup of patients with oliguria undergoing the early ARS (p = 0.016 ). The mortality (82.2% in the intense ARS group versus 82.8% in the less intense ARS group; p = 0.888) and survival curves were similar between the groups intense and less intense ARS. Conclusion - In patients with AKI associated with sepsis and dialyzed with Extended Hemodialysis the early indication of ARS is associated with lower mortality especially among patients with oliguria and there is no benefit in providing more intensive dialysis.

INTRODUÇÃO: A necessidade de diálise e a mudança iminente no estilo e qualidade de vida são grandes responsabilidades depositadas nos pacientes com doença renal crônica (DRC) em processo de escolha do método dialítico. Alguns dos temas mais frequentemente implicados na escolha de um ou outro método dialítico são depressão, ansiedade e estresse. Nos pacientes renais crônicos pré-dialíticos ainda não foi evidenciado se a ansiedade está associada a desfechos clínicos, tais como início da diálise, hospitalizações ou morte. Tem-se sugerido que a depressão afeta os desfechos clínicos em pacientes com DRC pré-dialítica, podendo impactar no estado nutricional e na redução da observância da diálise prescrita. O estresse é um fator muito comum em indivíduos com uma doença de longa duração, incluindo aqueles com DRC. Altos níveis de estresse podem ter um impacto nos resultados psicológicos e clínicos, além de contribuir para os comportamentos de saúde, como as preferências pelo método dialítico. MÉTODOS: Este é um estudo observacional prospectivo no qual 67 pacientes foram abordados em dois momentos: durante primeira consulta no Ambulatório Multidisciplinar de Orientações do serviço de Nefrologia HC-FMUSP e, depois, no período entre 1 e 3 meses após o início da diálise. Foram utilizados os instrumentos Escala Hospitalar de Ansiedade e Depressão (HADS), Escala de Estresse Percebido (PSS) e Questionário de fatores pessoais que interferem na escolha do método dialítico, instrumento elaborado pelo autor. Características demográficas e clínicas também foram avaliadas. RESULTADOS: A média de idade foi de 59±15 anos, em sua maioria homens (53,7%), brancos (59,7%) e casados (57,8%). As principais comorbidades foram HAS (83,6%) e DM (42,6%). As principais causas de DRC foram nefroesclerose (26,9%) e nefropatia diabética (22,4%). A média de eGFR por CKD-EPI foi 16±7. As medianas de escores de ansiedade, depressão e estresse foram, respectivamente, de 6 (4/10), 9 (5/12) e 30 (21/35). A partir dos valores de corte estabelecidos, 34,3% dos indivíduos foram considerados \"com ansiedade\" e 52,2% \"com depressão\". A comparação de escores de ansiedade revela não haver diferença entre homens e mulheres (p= 0,136), havendo, porém, tendência de maiores escores de depressão entre mulheres (p= 0,074) e de estresse entre homens (p= 0,081). Não foram observadas diferenças nos escores de ansiedade (p= 0,556), depressão (p= 0,467) e estresse (p= 0,971) entre grupos DP e HD. Houve correlação positiva entre ansiedade e depressão (r2= 0,574, p < 0,0001), ansiedade e estresse (r2= 0,555, p < 0,0001) e depressão e estresse (r2= 0,521, p < 0,0001). Após início da terapia dialítica, foram observadas reduções significativas nos escores de ansiedade (p < 0,0001), depressão (p < 0,0001) e estresse (p < 0,0001). Os motivos relacionados à família são os que mais influenciaram na escolha do método (32,8%, p= 0,165). A incompatibilidade com a rotina pessoal/de trabalho foi o principal motivo para não escolha do outro método dialítico (26,9%). CONCLUSÕES: Embora o processo de tomada de decisões na escolha do método dialítico esteja associado a altos escores de ansiedade, depressão e estresse, tais sintomas são atenuados de forma significativa após o início da terapia dialítica. Escores de ansiedade, depressão e estresse não foram determinantes na escolha do método dialítico / BACKGROUND: The need for dialysis and the imminent change in style and quality of life are great responsibilities deposited in patients with chronic kidney disease (CKD) in the process of choosing the dialysis modality. Some of the issues most often involved in choosing one or another dialytic method are depression, anxiety, and stress. In pre-dialysis CKD patients, it has not yet been shown whether anxiety is associated with clinical outcomes such as initiation of dialysis, hospitalization, or death. It has been suggested that depression affects clinical outcomes in patients with predialytic CKD, which may impact nutritional status and reduce adherence to prescribed dialysis. Stress is a very common factor in individuals with a long-term illness, including those with CKD. High levels of stress can have an impact on psychological and clinical outcomes, as well as contribute to health behaviors such as dialysis preferences. METHODS: This is a prospective observational study in which 67 patients were approached in two moments: during the first visit at the Dialysis Education Program of the HC-FMUSP Nephrology Service and then in the period between 1 and 3 months after the initiation of the dialysis. We used the Hospital Anxiety and Depression Scale (HADS), Perceived Stress Scale (PSS) and Survey on personal factors that affects the choice of the dialysis method, an instrument developed by the author. Demographic and clinical characteristics were also evaluated. RESULTS: The mean age was 59 ± 15 years, mostly men (53.7%), caucasian (59.7%) and married (57.8%). The main comorbidities were hypertension (83.6%) and DM (42.6%). The main causes of CKD were nephrosclerosis (26.9%) and diabetic nephropathy (22.4%). The mean eGFR by CKD-EPI was 16 ± 7. Median anxiety, depression and stress scores were, respectively, 6 (4/10), 9 (5/12) and 30 (21/35). According to the established cutoff values, 34.3% of the individuals were considered \"with anxiety\" and 52.2% \"with depression\". The comparison of anxiety scores revealed no difference between men and women (p= 0.136), but there was a tendency for higher depression scores among women (p= 0.074) and stress among men (p= 0.081). There were no differences in anxiety scores (p= 0.556), depression (p= 0.467) and stress (p = 0.971) between DP and HD groups. There was a positive correlation between anxiety and depression (r2 = 0.574, p < 0.0001), anxiety and stress (r2 = 0.555, p < 0.0001) and depression and stress (r2 = 0.521, p < 0.0001). After initiation of dialysis therapy, significant reductions in anxiety scores (p < 0.0001), depression (p < 0.0001) and stress (p < 0.0001) were observed. The reasons related to the family were the ones that influenced the choice of the method (32.8%, p= 0.165). The incompatibility with the personal / work routine was the main reason for not choosing the other dialytic method (26.9%). CONCLUSION: Although the decision-making process in the dialysis modality choice is associated with high anxiety, depression and stress scores, such symptoms are significantly attenuated after the initiation of dialysis therapy. Anxiety, depression, and stress scores were not determinant in the choice of dialysis method

Les objectifs sont d’évaluer l’efficience (survie, qualité de vie et le coût) des deux techniques de dialyse de rechercher les déterminants qui orientent le choix vers l’une ou l’autre des techniques de dialyse et d’évaluer le parcours de soins des patients en dialyse. La première partie de ce travail de thèse à analyser les données de la région PACA issues du registre REIN. Cette analyse est descriptive et porte sur le profil des patients démarrent un traitement en dialyse (HD et DP). Une analyse de survie a été réalisée selon la technique de dialyse initiale et selon le parcours de soins. Dans une seconde partie, le coût et sur la qualité de vie ont été évalués selon les différentes techniques de dialyse afin d’évaluer l’efficience de ces modalités à partir des données recueillies dans un PHRC régional. Dans une troisième partie, les facteurs liés au choix initial de la technique de dialyse, DP ou HD ont été recherchés. Ce travail a fait l’objet d’une étude ciblée auprès de patients et de néphrologues au sein de 4 structures de dialyse. La survie et la qualité de vie des patients sont similaires entre HD et DP. Le changement de technique, de la DP vers l'HD, a un impact positif sur la survie. La DP est moins coûteuse que l’HD. Les contre-indications médicales à la DP ne concernaient que 26,7% des patients inclus. En absence de contre-indications, la préférence du patient et les pratiques des professionnelles (information et pratiques de centre) sont les deux principaux facteurs liés au choix initial de la technique de dialyse, notamment par la DP. Une meilleure information pourrait contribuer à augmenter le choix de la DP. / The objectives of this work were to assess and compare the efficiency (survival, quality of life and cost) of patients initially treated with peritoneal dialysis (PD) or hemodialysis (HD), to search determinants that guide the initial choice towards either dialysis techniques and to assess the trajectory between dialysis modalities. The first part of this thesis was to analyze the database, from the PACA region (2004 – 2014), issue from the French REIN registry. This analysis was descriptive and focused to analyze main characteristics and outcome (survival) of dialysis patients (initial dialysis and switching) and to identify risk factors. The second part of this thesis was to measure and compare dialysis patient quality of life and health’s care costs between dialysis modalities (HD and PD). Database was issued from PHRC. The third part was to search the factors related to the initial choice of dialysis technique, PD or HD. This work was the subject of a targeted survey of patients and neurologists in a dialysis structure. The survival and the quality of life were similar between hemodialysis and peritoneal dialysis. Switching to HD may improve positively the survival compared to those who remained on PD, whereas, switching to PD was not. The DP is less expensive than HD. Medical contraindications to the PD were for 26.7%. In the absence of contraindications, patient preference and professional practices (information and practical center) are the two main factors related to the initial choice of dialysis technique, in particular to choice of PD. Better information could help to increase the choice of DP

This thesis deals with the profitability of sales of the dialysis care provider. The main aim of the work was to optimise the dialysis care in Jindrichuv Hradec hospital. Mentioned proposed solution concerns personnel and technical aspects and particular elimination methods. Another aim of the work was to clarify the reimbursement system of the particular dialysis methods, to compare economic results with the profitability of the dialysis care in the years 2006 and 2007. The author endeavoured to create possible ways of the development based on the knowledge of the number of patients and the insurance company reimbursement system. Necessary data and information were acquired from Jindrichuv Hradec hospital reports. This work is thought to contribute to enrich the practical usage and its results can be used by the hospital management or anybody interested in the dialysis care and its economic aspects.

Introduction: Restless Legs Syndrome (RLS) is more prevalent in chronic kidney disease patients in comparison to the general population, but its diagnosis is still delayed and predictors are unknown. Objectives: The goals of this study are to diagnose, determine the prevalence and severity of RLS and to identify independent variables associated with this disease among chronic dialysis patients. Methods: 326 chronic dialysis patients were launched in this observational and transversal study. International Study Group of Restless Legs Syndrome criterion was used to diagnosis RLS and International Scale of Degrees of Restless Legs Syndrome was used to determine its severity. Patients with and without RLS were compared using demographic and clinical characteristics, including dialysis modality. Statistical analysis was performed using Student t test and chi-square test (significance level p<0.05). Results: The median age was 50 years, 59% were men, 77% had time on dialysis >1 year and hypertension was the most common etiology (26%). RLS was diagnosed in 19.3% of patients and in 52.4% of them it was in severe forms. Patients with and without RLS were not different according to demographic, clinical and modalities characteristics. Conclusions: RLS is frequent in chronic dialysis patients and it happen in severe forms. Dialysis modality and other clinical characteristics analyzed in this sample may not have a significant effect on the diagnosis. Further studies are necessary to identify potentially predictors of RLS in this specific population. / Introdução: A Síndrome das Pernas Inquietas (SPI) possui maior prevalência em pacientes renais crônicos quando comparados à população geral, porém seu diagnóstico é tardio e seus preditores desconhecidos. Objetivos: Diagnosticar, determinar a frequência e avaliar a gravidade da SPI em renais crônicos em diálise, comparar prevalência e gravidade da SPI entre as modalidades dialíticas e identificar seus possíveis fatores preditores nesta população. Métodos: Estudo observacional e transversal com 326 pacientes em diálise, utilizando os critérios estabelecidos pelo Grupo Internacional de Estudo da SPI para o diagnóstico e a Escala de Graduação da SPI para determinação da sua gravidade. Compararam-se pacientes com e sem SPI no tocante a características clínico-demográficas e à modalidade dialítica. Realizou-se a análise estatística através dos testes t de Student e Qui-Quadrado, considerando p<0,05 para rejeição da hipótese nula. Resultados: Na amostra predominaram homens (59%), com média de idade de 50 anos, há mais de um ano em diálise (77%), tendo a nefrosclerose hipertensiva como principal etiologia (26,1%). Diagnosticou-se SPI em 19,3% dos pacientes e esta ocorreu em 52,4% deles nas formas grave ou muito grave. Pacientes com e sem SPI não diferiram no tocante às características clínico-demográficas e modalidade dialítica. Conclusões: A SPI é frequente em pacientes dialíticos e ocorre predominantemente nas suas formas mais graves, devendo ser pesquisada rotineiramente neles. Modalidade dialítica parece não exercer influência na sua ocorrência. Estudos adicionais são necessários na tentativa de identificar possíveis fatores preditores, já que as características analisadas nesta série não se associaram ao diagnóstico.

Bakgrund: Njursvikt innebär en nedsatt filtreringsförmåga och delas in i två tillstånd, akut och kronisk. Akut njursvikt utvecklas inom kort tid med kraftigt reducerad glomerulär filtration och leder till ett allvarligt tillstånd, medan vid kronisk njursvikt försämras kapaciteten långsamt under en längre tid och i det senare skedet krävs kontinuerlig dialysbehandling. Personer som drabbas av njursvikt behöver dialysbehandling för att uppehålla livet. Många väljer en behandlingsform med hembaserad dialys som innefattar både hemodialys (HD) och peritonealdialys (PD). Det krävs mycket självhantering vid utförandet av dialys i hemmet, och för att leva med sjukdomen behöver personen har förståelse för egenvård och samarbete med sjukvården.    Syfte: Att belysa personers upplevelser av att leva med hembaserad dialysbehandling vid kronisk njursvikt. Metod: Litteraturöversikten baserades på tio vetenskapliga artiklar med kvalitativa ansatser.  Artiklarna hämtades från databaserna CINAHL complete och PubMed med års begränsning 2009-2019. Resultat: Fyra teman framkom kring upplevelser att leva med dialys i hemmet: En förändrad livssituation påverkar självbild och kroppsuppfattning, Behov av stöd och hjälp vid egenvård, Upplevelser av begränsningar och anpassning och En känsla av frihet och ökad livskvalitet. Diskussion: I metoddiskussionen diskuteras styrkor och svagheter i hur studien har genomförts. Resultatet diskuteras mot Orems egenvårdteori, tidigare forskning och riktlinjer. En stor del av diskussionen understryker betydelsen av personers egenvårdsförmåga i samband med livsförändring och anpassningsprocess samt betydelsen av stöd och hjälp från sjukvården och närstående. / Background: Kidney failure includes reduced filtration ability and can be categorised into an acute and a chronic form. Acute renal failure develops within a short timeperiod and comes with a heavily reduced glomerular filtration whereas chronic kidney failure progresses slowly during a longer period of time and in the later stages, continuous dialysis treatment becomes necessary. Individuals afflicted by renal failure need dialysis treatment to survive. Many people choose a home-based dialysis including both haemodialysis and peritoneal dialysis. Home -based dialysis necessitates much individual efforts and to live with the disease there is a need for understanding selfcare as well as collaborating with national health care. Aim: To review individual experiences from living with home-based dialysis with chronic renal failure. Method: A literature review was based on ten scientific articles with qualitative methodology. The articles were obtained from the databases CINAHL complete and PUBMed covering 2009 to 2019. Results: Four themes associated with the experiences from living with home-dialysis emerged: A changed self - and body image, Need of support and help during selfcare, Experiences from limitations and adjustments, A sense of freedom and increased quality of life. Discussion: In the discussion on methodology, strength and weaknesses of the study is discussed. The results are discussed in the context of the self-care theory of Orem, previous research and guidelines.  A major part of the discussion underlines the importance of the self-care ability of the individual in the context of lifestyle changes and in the process of adjustment. Also the importance of support and help by the health-care system and relatives is emphasised.

published_or_final_version / Medicine / Doctoral / Doctor of Philosophy