Ces travaux de thèse ont débuté par la présentation des propriétés physico-chimiques du chrome, ses principaux domaines d'application. On a aussi indiqué les problèmes posés et les risques associés à l'emploi des dérivés chromiques qui s'expriment essentiellement au niveau cutané, respiratoire et même immunologique. Ensuite, on a cité les différents procédés d'élimination tels que les procédés membranaires, procédés chimiques, procédés biologiques et procédés physiques en précisant les avantages et inconvénients de chacun de ces procédés. Après, on a présenté le procédé d'adsorption sur alumine activée, en rappelant brièvement les différents adsorbants utilisés ainsi que les modèles thermodynamiques et cinétiques utilisés pour décrire ce phénomène. Enfin, on a rappelé quelques généralités sur les membranes échangeuses d'ions et sur le procédé de dialyse ionique croisée. Dans une seconde étape, on a étudié la validation de la technique analytique selon la norme Française XPT 90-120, ensuite une étude préliminaire de l'influence des différents paramètres selon le plan d'expérimentation factorielle afin de montrer l'influence de chaque paramètre indépendamment et leurs dépendances aussi. Ces facteurs sont les suivants : pH, quantité de l'adsorbant, concentration du métal initial et de la température. Cette étude a porté sur l'effet du pH mais aussi l'effet de la masse de l'alumine activée et l'effet de la concentration initiale du chrome afin d'optimiser ces paramètres, les résultats expérimentaux ont montré que l'adsorption du chrome dépend essentiellement du pH et de la concentration du chrome initiale. Dans les conditions optimales, les taux d'élimination du chrome VI peuvent attendre 98 % pour une concentration initiale de 10 mg/L en chrome. Les résultats expérimentaux ont été appliqués aux modèles de Freundlich, Langmuir, Dubinin-Redushkevich et Temkin. Des études cinétique et thermodynamiques suivront pour déterminer l'ordre de la réaction d'adsorption des métaux lourds et nature exothermique du mécanisme. La troisième partie a porté sur la Dialyse Ionique Croisée, dans un premier temps on a développé une étude préliminaire de l'influence des différents paramètres selon le plan d'expérimentation effectué afin d'identifier et d'évaluer l'influence de chaque paramètre sur les taux d'élimination de l'ion métallique. Ces facteurs sont la concentration initiale de l'ion métallique, la concentration initiale de l'ion de substitution, le type de la membrane et l'agitation magnétique. Cette démarche est nécessaire afin de fixer les paramètres optimaux et évaluer leurs interactions mutuelles. Cette étude a permis de montrer que le type de membrane échangeuse d'anions est le plus important paramètre influant sur l'élimination du chrome et ceci peut s'expliquer par les valeurs élevées de la capacité d'échange et de la teneur en eau de la membrane AFN. La modélisation du transfert des ions HCrO4- en dialyse ionique croisée a montré la présence de deux phases : la couche limite de diffusion du côté de l'alimentation (solution à traiter contant les ions HCrO4-) et la membrane. En deuxième étape, nous avons effectué une étude du vieillissement des membranes, qui consiste à faire un suivie de l'épaisseur membranaire, de la conductivité membranaire et de leur morphologie par MEB. Nous avons montré que les membranes AMV et AFN se dégradent peu à priori de la même manière. Finalement, nous avons effectué un nouveau montage qui couple les deux procédés et ceci dans le but d'améliorer le taux d'élimination. Ce couplage a permis d'augmenter l'efficacité et la cinétique d'échange de la dialyse, en plus une réduction considérable de la quantité d'alumine activée à régénérer et l'amélioration de la cinétique de transfert transmembranaire / The removal of chromium (VI) from aqueous solutions by activated alumina has been investigated as a function of solution pH, initial chromium concentration, adsorbent dose of activated alumina and temperature. The pH and the adsorbent dose of activated alumina are the most significant parameters affecting chromium (VI) adsorption. The chromium concentrations were analyzed by reaction with 1,5-diphenylcarbazide. This method has been validated according to the French standard XPT-90-210. In order to optimize the effect of the main parameters and their mutual interaction for the adsorption process, a full factor design of the type nk has been used. In this study the removal of chromium (VI) by adsorption on activated alumina was investigated and results were fitted to Langmuir, Freundlich, Dubinin-Redushkevich and Temkin adsorption models, at different temperatures. The constants of each model were evaluated depending on temperature. Thermodynamic parameters for the adsorption system were determined at 10, 25 and 40°C. The obtained values showed that Cr (VI) adsorption is a spontaneous and exothermic process. The kinetic process was evaluated by first–order, second–order and Elovich kinetic models. In second section, the removal of chromium (VI) from aqueous solutions by Donnan dialysis has been investigated. The tows AEMs: Selemion AMV and Neosepta AFN. The amount of chromium removed was determined on the basis of the following parameters: initial chromium concentration, type of anion exchange membranes, co-ion concentration and magnetic stirring. A 24 full factorial design analysis was performed to screen the parameters affecting Cr (VI) removal efficiency were examined. Using the experimental results, a linear mathematical model representing the influence of the different parameters and their interactions was obtained. Analysis of variance (ANOVA), F-test and student's t- test showed that the type of anion exchange membrane is the most significant parameter affecting chromium (VI) removal. The statistical analysis of experimental data assumes that the data come from normal distribution. Then, a modelisation of chromium removal by Donnan dialysis through anion exchange membrane, these results are compared with the theoretical predictions given by the resolution of the corrected Nernst–Planck's equation in the cases of the homogeneous models of ion-exchange membranes. This confrontation confirms the existence of three domains corresponding respectively to a complete diffusion boundary layers (DBLs) control, a mixed control and a complete membrane control of the inter-diffusion process. And finally, the Donnan dialysis and adsorption onto activated alumina has been coupled. The coupling DIC-AAA was successfully achieved with 90% of chromium removed

Title: Functional disorders of the musculoskeletal system on individuals after kindey transplantation Defining of the problem: Renal transplantation is a method to treat patients with renal failure,which is associated to a prolonged survival of patients compared to a dialysis method (Viklický et al., 2008). After a successful renal transplantation the renal function is restored and complications caused by dialysis treatment disappear . However, complications due to the transplant, not only in terms of surgical intervention, but also from the point of a lifelong immunosuppressive therapy remain at risk. Functional changes on the locomotor system can occur as a concequence of a long-term renal disease or kidney transplant. This could further reduce the quality of life on patients due to self-sufficiency, being the main role of the locomotor system. Objectives: The aim of this study is to valuate functional disorders of the musculoskeletal system on individuals after kindey transplantation up to one year after a transplant. Methods: This thesis is elaborated in the form of an analytical - experimental study in which 2 groups of selected individuals were tested. Testing was conducted by using suitable tests focused on functional disorders of the locomotor system and parameters in each group and time...

Title: The effect of selected exercise trends activating core stability system in dialysed patients - overview of the literature. Objective: Objective of this diploma thesis was to obtain and compare available studies dealing with exercise trends such as yoga, pilates, tai chi and balance training devices and to evaluate their effect on core stability system of dialysed patients. Methods: This diploma thesis has descriptively-analytical character and is structured in a form of literary review. Results: Issue of dialysis in connection with core stability system has not been sufficiently explored yet in literary sources. In conclusion, there were no studies found dealing with effects of particular exercise trends on core stability system of dialysed patients. In order to comprehend this issue an overview was written to define the effect of such trends on dialysed patients. Also, complications arising from renal failure and dialysis were mentioned such as hypertension, diabetes melitus and obesity. The effect of these trends on core stability system of healthy population as well as patients suffering from chronic back pain was described too. Conclusion: Some extent of coherence was found between strengthening core stability system and its effect on dialysed patients however further in- depth research...

Introduction : Le traitement de la dialyse entraîne de nombreux bouleversements dans la vie du patient et nécessite d’adhérer à nombreuses recommandations. L’éducation thérapeutique, prise en charge en plein essor dans la maladie chronique, consiste à accompagner les patients dans leur parcours de soin et à les aider à acquérir des connaissances et des compétences pour vivre au mieux leur vie avec leur maladie. Ainsi, l’objectif de cette étude était d’évaluer l’impact d’un programme d’éducation thérapeutique mis en place auprès de patients en auto-dialyse. Méthode : Le programme était composé de cinq interventions collectives (représentations et vécu de la dialyse, alimentation, protection de l’abord vasculaire, prise des médicaments et satisfaction). 125 patients ont participé à l’étude (64 dans le groupe expérimental et 61 dans le groupe contrôle). Plusieurs issues (adhésion thérapeutique, qualité de vie, état anxio-dépressif) et variables médiatrices ont été mesurées (connaissances, sentiment d’auto-efficacité, stratégies de coping, etc.) avant le programme, à la fin du programme éducatif et trois mois après. Résultats : Les résultats n’ont pas montré d’effet direct du programme sur l’adhésion thérapeutique, la qualité de vie et l’anxiété. Par contre, une augmentation des symptômes dépressifs a été observée dans le groupe expérimental, sans induire d’état dépressif. Des analyses de médiations ont précisé que l’augmentation des connaissances sur l’abord vasculaire expliquait l’effet de l’éducation thérapeutique sur les symptômes dépressifs. Les résultats ont également montré que le sentiment d’auto-efficacité vis-à-vis du suivi des recommandations alimentaires diminuait chez les patients du groupe expérimental à la fin du programme. Des analyses supplémentaires ont indiqué que ce changement prédisait d’autres évolutions comme la diminution de l’adhésion thérapeutique et une augmentation de l’anxiété. Conclusion : Ces principaux résultats montrent la nécessité d’améliorer les interventions d’éducation thérapeutique auprès des patients en dialyse en adaptant la transmission des connaissances au quotidien et en travaillant davantage sur l’amélioration du sentiment d’efficacité personnelle et aussi les stratégies de coping, c’est-à-dire d’avoir une action plus ciblée sur les variables médiatrices. / Introduction: Dialysis entails numerous alterations in the life of the patient and requires adhering to many recommendations. Therapeutic Patient Education helps patients acquire knowledge and skills to manage their life with a chronic disease in the best possible way. The objective of this study was to evaluate the impact of a therapeutic educational program for dialysis patients in an out-center. Methods: The program consisted of five group sessions concerning the representations and personal experience of the dialysis, dietary regimen, protection of vascular access, taking of medicines and satisfaction about the program. The study included 125 subjects (64 in the experimental group and 61 in the control group). Several criteria (adherence, quality of life, anxiety, depression) and mediating variables were measured (knowledge, self-efficacy, social support, coping strategies, etc.) before the program, at the end and three months after the end of the program. Results: The program had no effect on adherence, quality of life and anxiety. On the other hand, an increase in depressive symptoms was observed in the experimental group, without inferring a depressive state. Analyses of mediations showed that the increase in knowledge regarding vascular access explained the effect of therapeutic education on depressive symptoms. The results also showed that self-efficacy decreased in the experimental group after the five sessions. Additional analyses indicated that this change predicted other changes such as a decrease in dietary adherence and increased anxiety.Conclusion: These main results show the need for improving educational interventions with patients in dialysis by adapting the transmission of knowledge about everyday life, and especially by working more on improving the feeling of self-efficacy and the use of coping strategies.

Introdução: A dificuldade no controle da ingestão hídrica, refletida no ganho de peso interdialítico excessivo, e a dificuldade de se atingir a meta de perda de peso na sessão de hemodiálise são problemáticas, no cuidado aos pacientes com Doença Renal Crônica em tratamento hemodialítico. Muitos pacientes possuem dificuldades na adesão à prescrição de restrição de consumo de líquidos e vivenciam complicações decorrentes da sobrecarga hídrica. Objetivo: Analisar o efeito de uma intervenção educativa e motivacional no controle do consumo de líquidos no período interdialítico, de pacientes com doença renal crônica em tratamento hemodialítico. Métodos: Trata-se de um estudo quase experimental do tipo ensaio clínico não randomizado. Os participantes foram os pacientes com Doença Renal Crônica terminal em tratamento hemodialítico em um serviço de diálise, em um município do interior paulista. Os participantes foram inseridos em dois grupos: Controle (n=106) e Intervenção (n=86). Para os pacientes dos dois grupos, foram realizadas entrevistas, aplicando-se o instrumento de caracterização sociodemográfica e clínica, Escala de Autoeficácia Geral e Percebida (SOUZA; SOUZA, 2004), Inventário de Estratégias de Enfrentamento de Lazarus e Folkman (SAVÓIA; SANTANA; MEJIAS, 1996), Escala de Resiliência (PESCE et al., 2005) e Escala Hospitalar de Ansiedade e Depressão (BOTEGA et al., 1995), no início (T0) e ao final do estudo (T5). O estudo foi realizado em seis etapas, em um período de cinco semanas de seguimento, e a intervenção foi realizada por meio de dois encontros para as sessões de intervenção (T1 e T3) e dois para os reforços (T2 e T4). A intervenção constou da elaboração e aplicação de um vídeo educativo e motivacional para o controle do consumo de líquidos, apresentado aos pacientes. Ainda na intervenção, o reforço foi realizado em dois momentos, para acompanhamento das orientações. O percentual ideal de perda de peso foi a variável desfecho da pesquisa e caracterizou o padrão de consumo de líquidos, mensurado em 16 medidas de ganho de peso entre as sessões de hemodiálise no período da pesquisa, frente ao peso ideal. Os dados foram analisados por meio do software estatístico SAS 9.0 e o programa R versão 3.4.1. Realizaram-se análises descritivas e propuseram-se os modelos de regressão linear com efeitos mistos para comparações entre os grupos e os tempos para as variáveis independentes, e a regressão beta inflacionada para análise das associações entre as variáveis independentes e a variável desfecho. O projeto atendeu às recomendações da Resolução CNS 466/2012, tendo sido apreciado e aprovado por dois Comitês de Ética em Pesquisa com Seres Humanos, vinculados aos pesquisadores e ao serviço de diálise em estudo, bem como foi cadastrado no Registro Brasileiro de Ensaios Clínicos - ReBEC. Resultados: Os pacientes com doença renal crônica em tratamento hemodialítico participantes do estudo, ao final do estudo (T5), apresentaram bons níveis de autoeficácia, nos dois grupos (GC=39,2+6,2; GI=42,9+5,9). Com relação ao enfrentamento, no GC o fator com melhores escores foi a reavaliação positiva (2,09+0,56) e no GI foi a reavaliação positiva (1,67+0,44) e a resolução de problemas (1,81+0,42). Os pacientes dos dois grupos apresentaram boa resiliência (GC=143,01+16,86; GI=145,91+15,17), e observou-se presença de sintomas de ansiedade (GC=9,75+2,65; GI=8,91+2,69) e de depressão (GC=9,64+2,31; GI=8,58+2,50), nessa população. Os pacientes participantes do GI apresentaram, para todas as variáveis, mudanças nos escores avaliados após a implementação da intervenção educativa e motivacional. Na análise entre os grupos, para a resiliência, não houve significância estatística (p=0,23). Os pacientes que participaram da intervenção apresentaram diminuição no padrão de ganho de peso nos períodos interdialíticos, com 3,54 vezes mais chance de atingir a meta de 100% de perda de peso, comparados aos participantes do grupo controle. As variáveis autoeficácia, sintomas de ansiedade e de depressão e os fatores fuga-esquiva e reavaliação positiva do inventário de estratégias de enfrentamento apresentaram relação negativa com o percentual ideal de perda de peso, enquanto a resiliência e os fatores confronto e resolução de problemas do inventário de estratégias de enfrentamento tiveram relação positiva com o percentual ideal de perda de peso. Conclusão: A intervenção educativa e motivacional para o controle do consumo de líquidos, nos períodos interdialíticos de pacientes com Doença Renal Crônica em tratamento hemodialítico, apresentou um impacto positivo, avaliado por meio do percentual ideal de perda de peso / Introduction: The difficulty in controlling water intake reflected in the excessive interdialytic weight gain, and difficulty to achieve the goal of weight loss on hemodialysis session, is a problem in the care of patients with Chronic Kidney Disease who are undergoing hemodialysis therapy. Many patients have difficulties on comply with the prescription of liquids restriction and experience complications arising from water overload. Objective: To analyze the effect of an educational and motivational intervention to control liquids during the interdialytic period in chronic kidney disease patients who are undergoing hemodialysis therapy. Methods: This is a non-randomized quasi-experimental clinical study. The participants were the terminal Chronic Kidney Disease patients who are undergoing hemodialysis therapy in a dialysis service in a city in the countryside of the State São Paulo. The participants have been enrolled into two groups: Control (n = 106) and Intervention (n = 86). For both groups, the patients had been interviewed by applying the clinical and sociodemographic characterization instrument, General and Perceived Self-Efficacy Scale (SOUZA; SOUZA, 2004), Confront Strategies Inventory of Lazarus and Folkman (SAVÓIA; SANTANA; MEJIAS, 1996), Resiliency Scale (PESCE et al., 2005) and Hospital Anxiety and Depression Scale (BOTEGA et al., 1995), at the beginning (T0) and at the end of study (T5). The study was conducted in six stages during five weeks of follow-up, and the intervention was performed by means of two meetings for the intervention sessions (T1 e T3) and two support meetings (T2 e T4). The intervention consisted of developing and implementing an educational and motivational video for liquids control, presented to patients. Also in the intervention, the support was carried out in two moments later for the guidelines follow-up. The percentage of weight lost was the variable research endpoint and featured the standard liquids consumption, measured on 16 measures of weight gain between dialysis sessions in the survey period, compared to ideal weight. Data have been analyzed through the statistical SAS 9.0 software and R program, version 3.4.1. Descriptive analysis had been conducted and linear regression templates have been proposed with mixed effects for comparisons between the groups and the times for the independent variables, and the inflated beta regression for analysis of associations between the independent variables and the endpoint variable. The project met the recommendations of CNS Resolution 466/2012, having been assessed and approved by two Research Ethics Committees with Human Beings, bound to the researchers and to the dialysis service under study, as well as registered in the Brazilian Clinical Trials Registration - ReBEC. Results: The study participants who are the patients with chronic kidney disease undergoing hemodialysis therapy at the end of study (T5), showed high levels of self-efficacy in both groups (GC = 39.2?6.2; GI = 42.9?5.9). With respect to confront, in GC the factor with best scores was the positive re-evaluation (2.09?0.56), and in GI was the positive re-evaluation (1.67?0.44) and the problem solving (1.81?0.42). Patients of both groups showed good resilience (GC = 143.01?16.86; GI = 145.91?15.17) and noted the presence of anxiety symptoms (GC = 9.75?2.65; GI = 8.91?2.69) and depression (GC = 9.64?2.31; GI = 8.58?2.50) in this population. Patients participating in GI showed, for all variables, changes in scores assessed after implementation of the educational and motivational intervention. In the analysis between the groups, no statistical significance was found for resilience (p=0.23). Patients who participated in the intervention presented a decrease in weight gain standard during interdialytic periods, with 3.54 folds more likely to achieve the goal of 100% loss of weight compared to the control group. The self-efficacy variables, anxiety and depression symptoms, escape-avoidance factors and positive re-evaluation of the confront strategies inventory showed a negative relationship with the weight loss percentage, while resilience and confront factors and problem-solving of confront strategies inventory had positive relationship with the percentage of weight loss. Conclusion: Educational and motivational intervention for liquids control in interdialytic periods with Chronic Kidney Disease patients who are undergoing hemodialysis treatment showed a positive impact, assessed through percentage of weight loss

Introdução: Diálise peritoneal (DP) é a modalidade de diálise mais utilizada em pacientes pediátricos portadores de doença renal crônica (DRC) em todo o mundo. Peritonites e infecções de óstio e túnel do cateter de diálise peritoneal constituem as duas primeiras causas de morbidade e falha de tratamento em pacientes em programa de diálise peritoneal. Objetivo: Caracterizar o perfil dos episódios de peritonites e infecções de óstio e túnel nos pacientes em programa de diálise peritoneal crônica na Unidade de Nefrologia Pediátrica do Instituto da Criança do HC FMUSP. Métodos: Avaliou-se o período compreendido entre janeiro de 1994, quando foi iniciado o programa de diálise peritoneal crônica nessa unidade, e dezembro de 2005. Foram incluídos todos os pacientes que estiveram em programa de diálise peritoneal crônica no período, cujos prontuários estivessem acessíveis para análise. Realizou-se revisão dos prontuários quanto aos dados demográficos dos pacientes, peso e estatura ao início e ao final do programa de diálise, etiologia e evolução clinica de cada episódio infeccioso, e presença de fatores de risco para peritonites e infecções relacionadas ao cateter de DP. Realizou-se análise descritiva dos dados gerais, cálculo da incidência de episódios infecciosos no período estudado e freqüência de fatores de risco para infecção. Analisaram-se descritivamente os perfis de todos os episódios infecciosos. Resultados: Cinqüenta e três pacientes foram estudados, sendo 32 (60,4%) do sexo masculino, com mediana de idade de 9,5 (0,3 a 18,2) anos. A etiologia da DRC foi má-formação urológica em 32 (60,4%) pacientes, glomerulopatias em 15 (28,3%), tubulopatias em 4 (7,5%) e outras causas em 2 (3,8%). A mediana do tempo em diálise foi de 20,5 (3,9 a 87,1) meses. Houve 132 episódios infecciosos no período observado, em 42 (79%) pacientes, sendo 65 peritonites, 54 infecções de óstio e túnel e 13 infecções de óstio e túnel associadas a peritonite, num total de 1329,3 paciente-mês. Assim sendo, houve 0,49 infecções de óstio e túnel/ paciente-ano, 0,59 peritonites/ paciente-ano e 0,12 infecções de óstio e túnel associadas a peritonite/ paciente-ano. Os agentes mais encontrados nas infecções de óstio e túnel foram S. aureus, isolado em 23 culturas (43% das culturas de óstio positivas), Staphylococcus coagulase negativo em 7 (13%) e Pseudomonas aeruginosa em 7 (13%). Nas peritonites, os agentes mais encontrados foram S. aureus, isolado em 15 culturas (27% das culturas de líquido peritoneal positivas), Staphylococcus coagulase negativo em 13 (24%) e Acinetobacter baumanii em 4 (7%). Nos casos de peritonite associada a infecção de óstio e túnel, S. aureus foi isolado em 6 culturas (67% das culturas de secreção de óstio) e Staphylococcus coagulase negativo em 2 (22%). Staphylococcus sp, Pseudomonas aeruginosa e fungos foram os agentes mais relacionados a complicações como colonização do óstio, evolução para peritonite, necessidade de troca do cateter e perda funcional peritoneal. Devido ao reduzido número de pacientes que não apresentaram infecções, não foi possível identificar fatores de risco na casuística estudada. Conclusões: As taxas encontradas de peritonites e infecções de óstio e túnel são elevadas. Staphylococcus sp foram os agentes mais encontrados e um dos mais relacionados a complicações. Medidas profiláticas no sentido de diminuir a contaminação por esse agente podem constituir uma intervenção eficaz para a redução das taxas de infecção diálise-relacionadas. / Introduction: Peritoneal dialysis (PD) is one of the most frequently used modality of chronic dialysis in children presenting with end stage renal disease (ESRD) worldwide. Peritonitis and exit site and/or tunnel infections (ESI/TI) are the major causes of morbidity and treatment failure in patients undergoing peritoneal dialysis. Objective: To study the episodes of peritonitis and ESI/TI in patients undergoing maintenance peritoneal dialysis in the Pediatric Nephrology Unit of Instituto da Criança - HC FMUSP. Methods: All patients whose files were available for analysis were included. Data was collected from January 1994, at the beginning of the program of chronic peritoneal dialysis in this unit, until December 2005. Demographic data, weight and height at the start and at the end of the period of study, etiology and clinical outcome of each infectious episode and risk factors for peritonitis and catheter related infections, were analyzed. Descriptive analysis of demographic data was performed. Incidence rates of peritonitis and ESI/TI and frequency of possible risk factors rates were calculated. Results: Fifty three patients were studied, 32 (60.4%) male, with median age of 9.5 (0.3 to 18.2) years. Primary renal disease was urological malformation in 32 (60.4%) patients, glomerular diseases in 15 (28.3%), tubular diseases in 4 (7.5%) and other causes in 2 (3.8%). Median time on dialysis was 20.5 (3.9 a 87.1) months. In 1329.3 patient-month, 132 episodes of peritonitis and/or ESI/TI occurred in 42 (79%) patients, including 54 episodes of ESI/TI, 65 episodes of peritonitis and 13 episodes of peritonitis associated with ESI/TI, yielding an annualized rate of 0.49, 0.59 and 0.12 episodes/patientyear, respectively. The most frequent etiologic agents in the ESI/TI group were S. aureus, isolated in 23 exit site cultures (43% of positive cultures), Staphylococcus coagulase negative in 7 (13%) and Pseudomonas aeruginosa in 7 (13%). In the peritonitis group, the most frequent agents were S. aureus, isolated in 15 peritoneal fluid cultures (27% of positive cultures), Staphylococcus coagulase negative in 13 (24%) and Acinetobacter baumanii in 4 (7%). In the episodes of peritonitis associated with ESI/TI, S. aureus was isolated in 6 (67%) exit site cultures and Staphylococcus coagulase negative in 2 (22%). Complications such as exit site colonization, evolution to peritonitis, catheter removal and peritoneal failure were mostly associated with Staphylococcus sp, Pseudomonas aeruginosa and fungi infections. No risk factors could be identified due to the reduced number of patients not affected by infections. Conclusion: Peritonitis and ESI/TI rates in this population were high. Staphylococcus sp was the most frequently recovered agent. Infections caused by this agent presented a high rate of complications. Prophylactic measures to decrease contamination with this microorganism could be an efficient intervention to reduce dialysis associated infection rates.

É sabido que o paciente com doença renal crônica que tem um acompanhamento nefrológico precoce apresenta melhores condições clínicas e melhor prognóstico ao entrar em diálise. Porém o acompanhamento precoce pelo nefrologista melhora também o enfrentamento psíquico da doença e do tratamento? Foram estudados 39 pacientes com insuficiência renal estágio 5 no momento em que entravam em hemodiálise: 19 pacientes com acompanhamento por nefrologista 6 meses (Grupo 1) e 20 pacientes sem qualquer acompanhamento nefrológico prévio (Grupo 2). Todos os pacientes participaram de entrevista semiestruturada, composta por 17 questões abordando informações, crenças, expectativas e fantasias relacionadas à doença e ao tratamento. As respostas foram decompostas em categorias através da técnica da Análise de Conteúdo. Os dados demográficos e laboratoriais também foram coletados. A classe socioeconômica foi avaliada e classificada como baixa, média ou alta. Na análise estatística foram utilizados o teste de Fisher, do Quiquadrado, t de Student ou de Wilcoxon como apropriado e os resultados apresentados como média ± DP. O grupo 1 foi seguido por 26 ± 20 meses. Em ambos os grupos a maioria dos pacientes pertencia à classe baixa e era do sexo masculino. Os pacientes do grupo 2 eram mais jovens e apresentavam piores parâmetros laboratoriais (p <0,05). Também os aspectos psicológicos foram semelhantes nos 2 grupos: 63% dos pacientes do grupo 1 e 55% do grupo 2, disseram que tinham informações anteriores sobre a diálise; 42% no grupo 1 e 40% no grupo 2, disseram pouco entender o que o médico falava; 74% no grupo 1 e 85% no grupo 2 acreditam que seus rins voltariam a funcionar. Em ambos os grupos, 25% tinham expectativas ruins sobre voltar a trabalhar, e 60% sentiam atitudes negativas da família. O acompanhamento com o nefrologista minimiza as complicações clínicas e laboratoriais dos pacientes com insuficiência renal estágio 5, porém não é suficiente para minorar o impacto psicológico da entrada em hemodiálise. A atenção do nefrologista deve ir além dos aspectos clínicos. É necessário que o paciente seja adequadamente informado sobre sua doença e tratamento. Principalmente os pertencentes a uma classe social baixa como os estudados o apoio de uma equipe interdisciplinar pode ser de grande valia. / It is well known that patients with chronic renal failure (CRF) who are early on referred to a nephrologist have less clinical complications of the disease and a better outcome on chronic dialysis. But can early referral also improve the psychological burden of starting chronic dialysis? Thirty-nine ESRD patients initiating dialysis were studied: 19 patients had a Nephrology followup 6 months and 20 patients had no referral to nephrologist, starting dialysis on emergency situation. All patients participated in a semi-structured interview with 17 questions covering the perceived knowledge, beliefs, expectations and fantasies related to the disease and dialysis. The answers were decomposed in categories through the technique of content analysis. Demographic and laboratorial data at dialysis initiation were also collected. The socioeconomic position was evaluated and the patient was classified in one of 3 categories: low, middle or high. Categorical data were analyzed by Fishers or Chisquare statistical tests and continuous data by t or Wilcoxon tests as appropriate. The results are presented as mean ± SD. Group1 had been followed for 26 ± 20 months. In both groups the majority of patients were classified as low socioeconomic position and were males. Group 2 was younger and had worse laboratorial parameters (p<0.05). Also regarding the psychological aspects both groups were similar: 63% patients of group 1 and 55% of group 2 said they had no previous information about dialysis, and 42% in group 1 and 40% in group 2 said they didn\'t completely understand what the doctor said; 74% in group 1 and 85% in group 2 believed that their kidneys would work again; 25% in both groups had bad expectations about being able to work again , and 60% in both groups felt there was a negative attitude of the family toward them. Nephrology care of CRF patients mitigates clinical complications. However, on its own, it is not enough to minimize the psychological impact of the entering dialysis. Nephrology care must go beyond clinical care. The patients need to be well informed about the disease and treatment, especially patients like ours who came from low socioeconomic position. This kind of patients should be supported by an interdisciplinary team.

A Insuficiência Renal Crônica Terminal (IRCT) é uma doença crônica nãotransmissível e um problema de saúde pública, constituindo uma das principais causas de morte e incapacitação no mundo. A condição crônica de saúde é uma situação estressante e fonte de novos estressores que são enfrentados, de acordo com o significado que têm para os envolvidos. Os modos de enfrentamento podem amenizar os efeitos do estresse, favorecendo o processo adaptativo. Objetivos: Analisar os modos de enfrentamento das pessoas com IRCT frente à situação de doença e ao tratamento por hemodiálise, segundo variáveis sociodemográficas, clínicas e hábitos de vida. Material e método: Trata-se de um estudo descritivo, transversal e populacional, que utiliza análise quantitativa, desenvolvido no Instituto de Urologia e Nefrologia de São José do Rio Preto (IUN), onde foram entrevistados 107 pacientes acometidos por IRCT em tratamento hemodialítico há seis meses ou mais, adultos (pacientes com 18 anos ou mais), orientados, tendo condições de responder aos questionários propostos sem prejuízo nas respostas; que concordaram em participar do estudo, assinando o termo de consentimento livre e esclarecido. Os instrumentos utilizados foram o Inventário de Estratégias de Enfrentamento de Folkman e Lazarus (1985) e um roteiro de entrevista semi-estruturada para caracterização da população elaborado para este estudo. Resultados: A maioria das pessoas entrevistadas era do sexo masculino, de idade adulta (idade entre 18 e 59 anos), branca, tinha companheiro (a), morava com a família, tinha escolaridade entre zero e oito anos de estudo, era aposentada, não trabalhava, tinha atividade de lazer, não praticava atividades físicas e tinha religião. As principais causas da IRCT foram GNC, diabetes mellitus, causa indeterminada e hipertensão arterial. Os modos de enfrentamento que obtiveram maiores escores médios foram relacionados aos fatores reavaliação positiva, resolução de problemas e fuga-esquiva, evidenciando o uso mais freqüente dos modos de enfrentamento focados no problema. As mulheres apresentaram escores médios mais elevados para todos os fatores; idosos tiveram escores médios mais elevados nos fatores confronto, afastamento e fuga-esquiva; pessoas com 12 ou mais anos de estudo apresentaram escores médios mais elevados que pessoas com menos anos de estudo para os fatores autocontrole, suporte social, fuga-esquiva, resolução de problemas e reavaliação positiva; pessoas que referiram trabalhar apresentaram escores médios mais elevados para os fatores autocontrole, suporte social, resolução de problemas e reavaliação positiva; pessoas que realizaram transplante obtiveram escores mais elevados nos fatores autocontrole, suporte social, aceitação de responsabilidades, fuga-esquiva, resolução de problemas e reavaliação positiva; pessoas que não tinham religião obtiveram os menores escores médios para todos os fatores. Conclusão: a identificação dos modos de enfrentamento das pessoas, em tratamento hemodialítico, pode facilitar o planejamento da assistência, favorecendo a adaptação das pessoas aos estressores associados à IRCT e ao tratamento hemodialítico. / Terminal Chronic Renal Failure (TCRF) is a non-transmissible chronic disease and one problem of public health, constituting one of the main causes of death and disabilities in the world. The chronic condition of health is a stressful situation and source of new stressors, that are cope in accordance with the meaning that has for the involved ones. The ways of coping can brighten up the effect of the stress it favoring the adaptation. Aims: To analyze the ways of coping of the people with TCRF front the situation of disease and the hemodialysis treatment, according to social, demography, clinical variables and habits of life. Material and method: One is about a descriptive, transversal and population study, that uses quantitative analysis, developed in the Institute of Urology and Nephrology of São Jose do Rio Preto (IUN), where 107 patients with TCRF in hemodialysis treatment had been interviewed, they have six months or more , adults (patient with 18 years or more), guided, having conditions to answer to the questionnaires considered without damage in the answers; that they had agreed to participating of the study signing the term of free and clarified assent. The instruments had been used was Ways of coping of Folkman and Lazarus (1985) and a half-structuralized script of interview for characterization of the people, made for this study. Results: The majority of the interviewed people was mans, adults (age between 18 and 59 years), white, had study between 0 and 8 years and it had religion. The main causes of the TCRF had been GNC, diabetes mellitus, indetermined cause and arterial hipertension. The ways of coping that had the hight medium scores had been related to the factors positive reappraisal, planful problem-solving and escape-avoidance, evidencing the most frequent use in the problem-focuse coping. The women had higher médium score for all the factors; old had had higher medium scores in the factors confrontive coping, distancing and escapeavoidance; people that not work higher médium scores for the factors self-control, seeking social support, planful problem-solving and positive reppraisal; people who had carried through transplant, had gotten higher médium scores in the factors self-control, seeking social support, accepting responsibility, escape-avoidance, planful problem-solving and positive reppraisal; people who did not have religion had gotten the minors medium scores for all the factors. Conclusion: the identification in the ways of coping of the people in hemodialysis treatment, can facilitate to the planning of the assistance, favoring the adaptation of the people to the stressors associates to the TCRF and the hemodialysis treatment.

As complicações de pacientes com insuficiência renal crônica submetidos ao tratamento hemodialítico representam desafios para os profissionais de saúde. A variabilidade de fatores de risco que predispõem a essas complicações têm sido, freqüentemente, investigada na literatura científica. Nesse sentido, objetivou-se descrever as complicações locais e sistêmicas dos pacientes com insuficiência renal crônica a partir da implantação do cateter temporário de duplo lúmen para hemodiálise até sua retirada definitiva. Trata-se de um estudo de segmento que avaliou prospectivamente os pacientes da implantação do cateter até sua retirada definitiva. Para o estabelecimento do grupo estudado foi considerado um período de seis meses consecutivos de julho a dezembro de 2003. Assim, após a aprovação do Comitê de Ética em pesquisa procedeu-se a coleta dos dados. Para análise dos resultados realizou-se a codificação das variáveis no banco de dados do programa Microsoft Excel mediante dupla digitação, e, utilizou-se o programa Software Statistical Package for Social Sciences, versão 10.0 na análise estatística. Dos 64 pacientes avaliados 38 (59,4%) eram do sexo masculino, 20 (31,2%) tinham como causa provável da insuficiência renal a nefroesclerose hipertensiva, e, 35 (54,7%) implantaram o cateter devido à necessidade do tratamento hemodialítico imediato. Totalizou-se no período 145 cateteres implantados, 29 (45,3%) dos pacientes tiveram implantes únicos, 98 (67,6%) dos acessos foram a veia jugular interna direita, 40 (27,6%) das trocas dos cateteres foram devido a febre. O tempo médio de permanência dos cateteres foi de 30 dias. A complicação local mais freqüente em 41 (64%) dos pacientes foi o funcionamento inadequado do cateter com 26 dias de média para a ocorrência, e, a complicação sistêmica mais freqüente em 24 (37,5%) foi a febre com 34 dias de média para sua ocorrência, 27 (42,2%) dos pacientes apresentaram infecção do sítio de inserção, e, 30 (47%) infecção da corrente sanguínea. O Staphylococcus aureus foi o microrganismo mais isolado em 10 (33,4%) das hemoculturas. Observou-se que 45 (70,4%) dos pacientes retiraram definitivamente o cateter devido à punção da fístula arteriovenosa. O estudo apontou aspectos preocupantes, dentre eles, o tempo de permanência do cateter, que expõe sobremaneira o paciente a diferentes complicações, em especial, a infecção. A confecção da fístula arteriovenosa representa uma importante alternativa que contrapõe o uso do cateter temporário. / Complications in chronic renal insufficiency patients under dialysis treatment represent important challenges to health professionals. The variety of risk factors predisposing towards these complications have frequently been discussed in scientific literature. Thus, this study aimed to describe the local and systemic complications of chronic renal insufficiency patients who were using a temporary double-lumen catheter for hemodialysis treatment, until its final withdrawal. A segment research prospectively studied patients from the moment the catheter was inserted until its final withdrawal. A period of six consecutive months, from July to December 2003, was considered to determine the group of patients ti be studied. Thus, after ethical approval, data were collected through interviews, clinical exams and patient record evaluation. For the result analysis, the variables were coded in a database through double data entry in Microsoft Excel and Software Statistical Package Social Sciences, version 10.0 was used for statistical analysis. 38 (59.4%) of the 64 patients were men, 20 (31.2%) showed hypertensive nephrosclerosis as the probable cause of insufficiency renal and 35 (54.7%) inserted the catheter due to the need for immediate hemodialysis treatment. 145 catheters were inserted during the period, 29 (45.3%) of which were single implants and the right internal jugular vein was the access in 98 cases (67.6%). Average catheter permanence time was 30 days. Catheters were substituted in 40 cases (27.6%) due to fever. The most frequent local complication was inadequate functioning in 41 (64%) cases, with an average occurrence of 26 days, while the most frequent systemic complication was fever in 24 cases (37.5%), with an average occurrence of 34 days. Infection of the insertion site occurred in 27 (42.2%) cases and infection of the blood flow associated with the catheter in 30 (49%) cases. Sthaphylococos aureus was the most frequently isolated microorganism in 10 (33.4%) blood cultures. 45 (70.4%) final catheter withdrawals were due to arterio-venous fistula puncture. This analysis revealed various preoccupying aspects, including the catheter permanence time, which highly exposes the patient to different complications, particularly infection.

Made available in DSpace on 2016-04-04T18:28:14Z (GMT). No. of bitstreams: 1 MARCIA CALIXTO DOS SANTOS.pdf: 1003356 bytes, checksum: c4b5e00e909e2559f64ab1568facdc7b (MD5) Previous issue date: 2013-12-11 / Chronic renal failure (CRF) is the gradual and progressive loss of kidney functions, which can promote severe restrictions and psychosocial impact into the individual?s life, even risking to lead her or him to death. Its high prevalence in the current context defines it as a worldwide public health problem. The present study aimed to evaluate the degree of association between adaptive efficacy, psychopathological symptoms and stress levels in chronic renal failure patients and verify whether these variables could predict their adaptive efficacy. We adopted the concept of adaptive efficacy, by Ryad Simon, a measure of the quality of the individual's responses to situations of their day-by-day. The sample was composed of 50 patients with chronic renal failure, of both sexes, attended hemodialysis unit of a general hospital inland city of S?o Paulo. The assessment instruments used were: EDAO-AR - Self-Report Scale of Adaptation, designed to evaluate the quality of the adaptation of the sector Affective-Relational (AR) and Productivity (Pr); EAS- 40 - Assessment Symptoms Scale-40, which assesses the severity of psychopathological symptoms according to four dimensions: psychoticism, obsessiveness-compulsiveness, somatization and anxiety; ISSL Lipp Stress Symptoms Inventory, which assesses the symptoms of stress in the psychological and physical, besides the person?s stress phase. The results suggested that the participants were divided into effectively adapted (76%) and poorly ineffectively adapted (24%). Regarding psychopathological symptoms, the average score was 0,41 (? 0,33) (cutoff 1[E1]); 56% showed no stress and 44 % had stress, in the Resistance Phase (34%) with predominant psychological symptoms of stress (73%). The values of the Spearman Rank Correlation (?) confirmed the initial hypotheses as they pointed to significant and negative associations between psychopathological symptoms and adaptive efficacy and between stress and adaptive efficacy; significant positive association between psychopathological symptoms and stress. The structural equations modeling (SEM) suggested that psychopathological symptoms predict psychological stress and adaptive efficacy, however physical stress and phases of stress are not depicted as predictors of adaptive efficacy. / A insufici?ncia renal cr?nica (IRC) consiste na perda gradativa e progressiva das fun??es dos rins, o que pode causar restri??es severas e impacto psicossocial ao indiv?duo, ou at? mesmo lev?-lo ? morte. Sua alta preval?ncia no contexto atual a define como um problema de sa?de p?blica em n?vel mundial. O presente estudo teve como objetivo avaliar o grau de associa??o entre a efic?cia adaptativa, os sintomas psicopatol?gicos e os n?veis de stress de pacientes renais cr?nicos e verificar se estas vari?veis poderiam predizer a sua efic?cia adaptativa. Adotou-se o conceito de efic?cia adaptativa, de Ryad Simon, uma medida da qualidade das respostas do indiv?duo ?s situa??es de seu dia-a-dia. A amostra ficou constitu?da por 50 pacientes com insufici?ncia renal cr?nica, de ambos os sexos, atendidos na unidade de hemodi?lise de um hospital geral do interior de S?o Paulo. Os instrumentos de avalia??o utilizados foram: EDAO-AR - Escala Diagn?stica Adaptativa Operacionalizada de Autorrelato, que permite avaliar a qualidade da efic?cia adaptativa do setor Afetivo-Relacional (A-R) e Produtividade (Pr); EAS-40 - Escala de Avalia??o de Sintomas 40, que avalia a severidade de sintomas psicopatol?gicos segundo quatro dimens?es: psicoticismo, obsessividade-compulsividade, somatiza??o e ansiedade; ISSL Invent?rio de Sintomas de Stress para Adultos de Lipp, que avalia a presen?a de sintomas de stress nos ?mbitos psicol?gico e f?sico, al?m da fase do stress em que a pessoa se encontra. Os resultados apontaram que os participantes ficaram distribu?dos em adapta??o eficaz (76%) e adapta??o ineficaz leve (24%). Quanto aos sintomas psicopatol?gicos, o escore m?dio foi de 0,41 (? 0,33) (ponto de corte 1[E1]); 56% n?o apresentaram stress e 44% apresentaram stress, dos quais 34% na Fase de Resist?ncia e com predom?nio de sintomas psicol?gicos do stress (73%). As correla??es por postos de Spearman (?) confirmaram as hip?teses iniciais, indicando associa??es significantes e negativas entre sintomas psicopatol?gicos e efic?cia adaptativa e entre stress e efic?cia adaptativa; associa??o significante positiva entre sintomas psicopatol?gicos e stress. A modelagem de equa??es estruturais (MEE) indicou que sintomas psicopatol?gicos predizem o stress psicol?gico e a efic?cia adaptativa, entretanto o stress f?sico e as fases do stress n?o se configuram como preditores da efic?cia adaptativa.