FundaÃÃo de Amparo à Pesquisa do Estado do Cearà / O elevado nÃmero de pacientes renais crÃnicos em hemodiÃlise no Brasil e a escassez de dados acerca de sua sobrevida justificam a necessidade da realizaÃÃo de estudos nesse campo. Conhecer o perfil de morbidades dessa populaÃÃo e verificar as taxas de sobrevivÃncia desses indivÃduos. Estudo observacional longitudinal retrospectivo, de seguimento de pacientes renais crÃnicos em hemodiÃlise por mais de trÃs meses, em cinco unidades de diÃlise de Fortaleza (CE). Pacientes de 18-88 anos de idade foram incluÃdos no estudo no perÃodo de janeiro/1998 a dezembro/2000 e acompanhados atà dezembro/2004. Os dados foram obtidos mediante registros em arquivos nos respectivos centros de tratamento, atravÃs de formulÃrio padronizado com informaÃÃes acerca de dados sÃcio-demogrÃficos, histÃria clÃnica, uso de medicamentos e parÃmetros laboratoriais. Na anÃlise estatÃstica foram utilizados o teste exato de Fisher, Student (t) e Wilcoxon; considerando-se o nÃvel de significÃncia p < 0,05. As curvas de sobrevida foram construÃdas pelo mÃtodo de Kaplan-meier e com teste de diferenÃa por log rank. Foram acompanhados 239 pacientes com uma mÃdia de idade de 45  16,6 anos; a maioria pertencia ao sexo masculino e era casada (56,9% e 54,0%, respectivamente). Os principais diagnÃsticos de base da doenÃa renal crÃnica em fase terminal foram: o diabetes mellitus, a hipertensÃo arterial, as glomerulonefrites e as causas indeterminadas (19,7%, 19,2%, 13,4% e 28,0%). Dentre as comorbidades, as mais freqÃentes foram: hipertensÃo arterial (64,0%), infecÃÃes (55,2%), diabetes mellitus (20,1%) e doenÃa cardÃaca (20,1%). Ao tÃrmino do estudo, 49 pacientes foram a Ãbito (20,5%). Os medicamentos mais utilizados foram os relacionados ao sistema cardiovascular (50,3%), sendo os agentes com aÃÃo no sistema renina-angiontensina (21,8%) e outros anti-hipertensivos (10,0%) os mais usados. Dos pacientes acompanhados, 81,2% usaram ferro endovenoso e 89,1%, eritropoetina recombinante humana. A sobrevida atuarial foi de 94,3%, 88,9%, 84,4%, 78,7% e 75,5%, aos 12, 24, 36, 48 e 60 meses, respectivamente. Os pacientes diabÃticos apresentaram sobrevida significantemente inferior aos nÃo-diabÃticos (p<0,001). Pacientes brancos (p=0,004), aqueles com mais de 60 anos (p<0,001) e, os que usaram uma dose de ferro inferior a 8000mg (p=0,002) tambÃm apresentaram sobrevida significantemente menor. A sobrevida atuarial foi de 94,3%, 88,9%, 84,4%, 78,7% e 75,5%, aos 12, 24, 36, 48 e 60 meses, respectivamente.

Η τελικού σταδίου χρόνια νεφρική ανεπάρκεια (ΤΣΧΝΑ) είναι η αμετάκλητη απώλεια της νεφρικής λειτουργίας. Όταν η απώλεια της νεφρικής λειτουργίας φτάσει στο σημείο όπου οι νεφροί δεν μπορούν να συντηρήσουν τον ασθενή στην ζωή, τότε απαιτείται θεραπεία υποκατάστασης της νεφρικής λειτουργίας (ΘΥΝΛ). που είναι η αιμοκάθαρση (ΑΜΚ), η περιτοναϊκή κάθαρση, ή η μεταμόσχευση νεφρού. Η ενδονοσοκομειακή ΑΜΚ πραγματοποιείται 3 φορές την εβδομάδα και διαρκεί 3-5 ώρες. Η κατ' οίκον ΑΜΚ λαμβάνει χώρα στο σπίτι του ασθενούς, προσφέροντας ευελιξία στην επιλογή της συχνότητας (3-7 οορές εβδομάδα) και της διάρκειας της συνεδρίας ΑΜΚ (4-10 ώρες). Ειδικότερα η καθημερινή νυχτερινή κατ' οίκον ΑΜΚ, που πραγματοποιείται κατά την διάρκεια του ύπνου, προσφέρει σημαντικά κλινικά οφέλη, δυνατότητα κοινωνικής και επαγγελματικής αποκατάστασης, μείωση της φαρμακοληψίας, ελευθερία στην διατροφή και την πόση, καθώς και βελτίωση στην ποιότητα ζωής των ασθενών. Σύμφωνα με πρόσφατα στοιχεία, περισσότεροι από 10.000 Έλληνες ασθενείς υποφέρουν από ΤΣΧΝΑ και το 74% χρησιμοποιεί την ΑΜΚ ως θεραπεία υποκατάστασης, ενώ παράλληλα υπάρχει αυξανόμενη πίεση στις μονάδες ΑΜΚ, εξαιτίας της μεγάλης προσαύξησης του αριθμού των ασθενών τους. Για το 2004, η Ελλάδα παρουσίασε την μεγαλύτερη συχνότητα νεοεισαχθέντων ασθενών ανά εκατομμύριο πληθυσμού στην ΑΜΚ σε σύγκριση με 24 Ευρωπαϊκές χώρες και κατείχε την 3η θέση παγκοσμίως στην αντίστοιχη συχνότητα σε ΘΥΝΛ, μετά τις ΗΠΑ και την Ιαπωνία. Η κατάταξη της Ελλάδας στην 8η θέση, στην παγκόσμια σύγκριση του επιπολασμού σε ΘΥΝΛ, παρόλο που είναι ευνοϊκότερη, παραμένει πολύ υψηλή, υποδεικνύοντας το μέγεθος του αυξημένου αριθμού ΤΣΧΝΑ στην χώρα μας. Στους παράγοντες που συντελούν στην ύπαρξη του φαινομένου, είναι ο πολύ χαμηλός αριθμός μεταμοσχεύσεων νεφρού στην Ελλάδα, η οποία κατέχει την 20η θέση ανάμεσα σε 24 Ευρωπαϊκές χώρες, για το 2004, καθώς και η αύξηση της επιβίωσης των ασθενών σε ΘΥΝΛ. Η παρούσα διδακτορική διατριβή εστιάζεται στην αποτίμηση τεχνολογίας υγείας της κατ' οίκον αιμοκάθαρσης, στην μελέτη των παραγόντων που επιδρούν την υιοθέτηση της και στην αξιολόγηση της ποιότητας ζωής των αιμοκαθαιρομένων στην Ελλάδα. Συγκεκριμένοι στόχοι της είναι: i) Να εκτιμηθεί, πέρα από την ποιότητα ζωής, η προθυμία των Ελλήνων αιμοκαθαιρομένων να συμμετάσχουν σε πρόγραμμα κατ' οίκον ΑΜΚ και ii) Να διεξαχθεί βιβλιογραφική ανασκόπηση για να αποτιμηθεί αν η κατ' οίκον αιμοκάθαρση είναι πιο αποτελεσματική και με καλύτερο δείκτη κόστους -χρησιμότητας από την ενδονοσοκομειακή, καθώς και να συγκεντρωθούν και να αναλυθούν δεδομένα από την ερευνητική επίσκεψη σε έμπειρα κέντρα κατ' οίκον αιμοκάθαρσης του εξωτερικού. Η συγκέντρωση δεδομένων για την σχετιζόμενη με την υγεία ποιότητα ζωής 146 Ελλήνων αιμοκαθαιρομένων, πραγματοποιήθηκε σε 10 κέντρα ΑΜΚ της Ελλάδας, με ποσοστό απόκρισης 84%. Χρησιμοποιήθηκε το εξειδικευμένο στη νεφροπάθεια εργαλείο KDQOL-SF (που ενσωματώνει το εργαλείο γενικής υγείας SF-36) και ένα συμπληρωματικό ερωτηματολόγιο που συνοδευόταν από ενημερωτικό κείμενο για την* νυχτερινή κατ' οίκον ΑΜΚ, ώστε να συλλεχθούν δημογραφικά δεδομένα και να εκτιμηθεί η προθυμία συμμετοχής σε πρόγραμμα κατ' οίκον ΑΜΚ. Η συμπλήρωση των ερωτηματολογίων έγινε με επιτόπου συνέντευξη. Στην έρευνα συμμετείχαν 99 άνδρες και 47 γυναίκες, με μέση ηλικία 57 +/- 15,7 έτη. Παρόλο που το 61% των ερωτηθέντων ήταν σε παραγωγική ηλικία, μόνο το 23% είχαν παραμείνει στην εργασία τους και οι υπόλοιποι ήταν είτε άνεργοι, είτε σε άδεια ασθενείας, είτε είχαν συνταξιοδοτηθεί λόγω μερικής αναπηρίας, ενώ το 62% των ασθενών δήλωσε ετήσιο εισόδημα μικρότερο από 10.000€. Ο σακχαρώδης διαβήτης ήταν η πιο συχνά εμφανιζόμενη πρωτογενής αιτία νεφρικής ανεπάρκειας (20%) και η πλειοψηφία των ασθενών (73%) τελούν ΑΜΚ για λιγότερα από πέντε χρόνια. Τρεις ασθενείς αναγκάστηκαν να αλλάξουν τόπο διαμονής για να βρίσκονται πιο κοντά στην μονάδα ΑΜΚ, ενώ περίπου το 45% των αιμοκαθαιρομένων διανύουν συνολικά περισσότερα από 40km, 3 φορές την εβδομάδα, για κάθε συνεδρία ΑΜΚ. Από τις κλίμακες του KDQOL-SF, χαμηλότερες τιμές καταγράφηκαν στην εργασία, την σεξουαλική λειτουργία και τον φόρτο της νεοροπάθειας. Η σύγκριση των κλιμάκων SF-36 του δείγματος με τον Ελληνικό γενικό πληθυσμό παρουσίασε στατιστικά σημαντικές διαφορές (p<0,01) σε όλες τις κλίμακες, πλην του σωματικού πόνου. Επίσης, η σύνοψη συνιστωσών ψυχικής υγείας του δείγματος των αιμοκαθαιρουμένων ήταν ελαφρώς χαμηλότερη από του γενικού πληθυσμού, ενώ η σύνοψη συνιστωσών σωματικής υγείας ήταν αρκετά χαμηλότερη. Τα αποτελέσματα του δείγματος της παρούσας έρευνας (Ν=146) συγκρίθηκαν με αντίστοιχο δείγμα Ισπανών ασθενών ΤΣΧΝΑ (Ν=194) που συμπλήρωσαν το ίδιο ερωτηματολόγιο. Το γεγονός ότι και σ" αυτή την σύγκριση δεν εμφανίστηκε στατιστικά σημαντική διαφορά στην κλίμακα του σωματικού πόνου, ενδυναμώνει την εγκυρότητα της μέτρησης και υποδεικνύει ότι οι ασθενείς ΤΣΧΝΑ δεν υπέφεραν σημαντικά από σωματικό πόνο εξαιτίας της ασθένειας τους, σε σημείο τέτοιο, που να έχει αρνητική απήχηση στην αντίληψη τους για την σχετιζόμενη με την υγεία ποιότητα ζωής τους. Διάθεση συμμετοχής στην νυχτερινή κατ’ οίκον ΑΜΚ εξέφρασε το 84% των ασθενών και το 75% για την κατ΄ οίκον ΑΜΚ. Έντονη προθυμία σημειώθηκε στο 53% και το 38% των 146 ερωτηθέντων αντίστοιχα, ενώ διατεθειμένοι να δαπανήσουν κάποιο χρηματικό ποσό για να συμμετάσχουν ήταν το 38%. Στην ερευνητική επίσκεψη σε δύο μεγάλα και έμπειρα κέντρα κατ’ οίκον αιμοκάθαρσης του εξωτερικού, στο Lund και το Helsinki. συγκεντρώθηκαν πολύτιμα δεδομένα που αφορούν στην οργάνωση, την διεξαγωγή, την εμπειρία και την τεχνογνωσία τους. και τα οποία σχετίζονται με την δομή του προγράμματος, οικονομικές εκτιμήσεις, ιατρικά δεδομένα, στατιστικά αποτελέσματα, μεθόδους εκπαίδευσης και τα πιθανά ρίσκα ή προβλήματα που ενδέχεται να ανακύψουν, μαζί με τους τρόπους αποφυγής ή επίλυσης τους. Τα δημογραφικά δεδομένα σε συνδυασμό με το υψηλό κόστος, καθιστούν την ενδονοσοκομειακή αιμοκάθαρση μια από τις πιο δαπανηρές υγειονομικές παρεμβάσεις και διαπιστωμένα την πιο δαπανηρή μεταξύ των υπολοίπων μεθόδων ΘΥΝΛ. Το κόστος της στην Ελλάδα ξεπερνά το 2% των δαπανών της υγείας. Από την ανασκόπηση της παγκόσμιας βιβλιογραφίας, αλλά και από την μελέτη των κέντρων ΑΜΚ της Σκανδιναβίας, επιβεβαιώνεται ότι η κατ’ οίκον και η δορυφορική ΑΜΚ στοιχίζουν λιγότερο και έχουν καλύτερο δείκτη κόστους-αποτελεσματικότητας από την ενδονοσοκομειακή ΑΜΚ. ενώ παράλληλα εμφανίζουν αυξημένη επιβίωση και καλύτερη ποιότητα ζωής. Κατά συνέπεια, η ανάπτυξη αυτών των εναλλακτικών μεθόδων στην Ελλάδα θα μπορούσε να αμβλύνει την αύξηση του προβλεπόμενου συνολικού κόστους των μεθόδων ΘΥΝΛ στο υγειονομικό σύστημα, συμβάλλοντας και στην ανακούφιση από το πρόβλημα της αυξανόμενης πίεσης στις νοσοκομειακές μονάδες ΑΜΚ. αλλά και της έλλειψης του νοσηλευτικού προσωπικού, με την ταυτόχρονη βελτίωση της ποιότητας ζωής των αιμοκαθαιρομένων. Με την κατάλληλη οργάνωση και στελέχωση, η κατ* οίκον ΑΜΚ θα μπορούσε να γίνει εφικτή και στην Ελλάδα, αφού μεγάλη μερίδα ασθενών δηλώνουν πρόθυμοι να συμμετάσχουν, γεγονός που αποτελεί και την βασικότερη προϋπόθεση επιτυχίας ενός τέτοιου προγράμματος. Επιπρόσθετα, με δεδομένο ότι η Ελλάδα παρουσιάζει πολύ υψηλή συχνότητα νεοεισαχθέντων ασθενών ΤΣΧΝΑ, πρέπει να ενταθούν οι προσπάθειες για την συγκράτηση και τον περιορισμό αυτού του φαινομένου, μέσω προγραμμάτων ενημέρωσης και πρόληψης, που μαζί με την μεταμόσχευση παραμένουν οι αποτελεσματικότεροι τρόποι αντιμετώπισης του προβλήματος. / End stage renal failure is the irreversible loss of kidney function. When loss of kidney function reaches the point at which die kidneys fail to support life, then renal replacement therapy (RRT) is required, that is hemodialysis (HD), peritoneal dialysis or renal transplantation. Hospital hemodialysis is conducted 3 times per week and lasts 3-5 hours. Home hemodialysis takes places at patient’s home, offering flexibility in choosing the frequency (3-7 times Week) and the length of the hemodialysis session (4-10 hours). Daily nocturnal home hemodialysis in particular, which is conducted while the patient is asleep, offers significant clinical benefits, the opportunity of social and professional rehabilitation, reduction of drugs, freedom in diet and drinking intake, as well as improvement in patients' quality of life. According to recent records, more than 10.000 Greek patients suffer from end stage renal disease (ESRD) and 74% of them use hemodialysis as replacement therapy, while at die same time there is increasing pressure on hemodialysis units because of the growing number of patients who are receding hemodialysis. In 2004, Greece appeared to have the highest incidence per million population in hemodialysis, in comparison with 24 European countries and the 31 place in die world in the incidence per million population in RRT, after USA and Japan. The rating of Greece in the 8th place of global comparison in prevalence in RRT, although more propitious, remains very high suggesting die extent of the increasing number of ESRD m Greece. Among the factors that contribute to the existence of this phenomenon are the very low numbers of renal transplantation in Greece, which holds the 20th place among 24 European countries m 2004 and the increase of survival of patients on RRT. This doctoral thesis focuses on technology assessment of home HD, the study of the factors that affect its adoption and finally die evaluation of Greek hemodialysis patients' quality of life. The specific objectives are: i) To evaluate the quality of life of Greek hemodialysis patients, as well as their willingness to participate in a home HD program and ii) To conduct a review of the literature in order to assess whether home hemodialysis is more effective and with better cost-utility than hospital hemodialysis and to gather and analyze data taken from the inquiring visit in experienced home hemodialysis units of foreign countries. Data concerning die health related quality of life of 146 Greek hemodialysis patients were gathered from 10 HD units in Greece and the response rate was 84%. The renal disease specific instrument KDQOL-SF was used (which incorporates the general health instrument SF-36), accompanied with an additional questionnaire and an informative leaflet on nocturnal home hemodialysis, in order to gather demographic data and to evaluate the willingness of participation m a home hemodialysis progρam. Questionnaires were completed with on site interview. This study included 99 men and 47 women, with mean age 57 +/- 15,7 years. Although 61% of the participants were in productive age, only 23% were employed and the rest were either unemployed, on sick leave or receiving a disability pension, while 62% of the patients reported annual income less than l0.000 Euros. Diabetes mellitus was the most common primary kidney disease (20%) and the majority of patients were on hemodialysis for less than five years. Three patients were obliged to change place of residence so as to be closer to the hemodialysis unit, while almost 45% of the patients had to navel more than 40km, 3 times per week, for every HD session. The lowest scores in KDQOL-SF scales were found in work status, in sexual functioning and m the burden of kidney disease. The comparison of the SF-36 scales of die study sample with the Greek general population identified statistically significant differences (p<0.01) in all scales, except of the bodily pain scale. Moreover, the Mental Component Summary was slightly worse compared with the general population's, while the Physical Component Summary was quite lower. The results of the present study sample (N=146) were compared with an equivalent sample of Spanish ESRD patients (N=194) who completed the same questionnaire. The fact that m this comparison no statistically significant difference was found in the scale of bodily pain, strengthens the validity of the measurement and suggests that ESRD patients did not experience severe suffering from pain due to their disease that could worsen their perception of health related quality of life. Inclination to participate in nocturnal home HD was expressed by 84% of the patients and by 75% of the patients for home hemodialysis. Strong willingness was reported in 53% of the patients for nocturnal home HD and in the 38% for home HD respectively, while the 38% of the patients were also willing to contribute financially in order to participate. The inquiring visit in two experienced home hemodialysis units in Lund and Helsinki, provided valuable information concerning their organization, their waging, their experience and their know-how. which are related with the structure of the program, economical evaluations, medical data, statistical outcomes, methods of training and potential risks or problems that might emerge, together with advices on how to avoid or solve them. The demographical data in combination with the high cost renders hospital hemodialysis one of the most expensive medical interventions and certainly the most expensive among the other RRT methods. Hemodialysis cost in Greece absorbs more than 2% of total health expenditure. The review of the global literature and the study on the Scandinavian home HD units verified that both home and satellite hemodialysis are less costly and more cost-effective than hospital hemodialysis, while at the same time they present increased survival and better quality of life. Hence, the development of these alternative modalities of dialysis in Greece could mitigate the anticipated net cost increases of RRT to the health system. This could contribute to the alleviation of the increasing pressure on hospital HD units and the nursing shortage, with the simultaneous improvement of hemodialysis patients' quality of life. With the appropriate organization and staff, home hemodialysis could be feasible also in Greece, since big part of the patients are reporting willingness to participate and this fulfils the basic requirement for such a program to succeed. In addition, considering that Greece reports very high incidence, efforts must be intensified in order to restrain and reduce this phenomenon, through informing and prevention programs, which next to renal transplantation are the most effective ways to confront the problem.

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Η εργασία αυτή αποτελεί μία από τις πρώτες που ασχολήθηκαν με τη διερεύνηση του τρόπου ζωής των ασθενών με χρόνια νεφρική ανεπάρκεια τελικού σταδίου, οι οποίοι υποβάλλονται σε μέθοδο υποκατάστασης της νεφρικής λειτουργίας με αιμοκάθαρση ή περιτοναϊκή κάθαρση ή έχουν υποβληθεί σε επιτυχή μεταμόσχευση νεφρού στον Ελλαδικό χώρο και συγκρίνει τα αποτελέσματα με τα υπάρχοντα από ανάλογες εργασίες που έχουν επιτελεστεί στην Ευρώπη και στη Βόρειο Αμερική. Στο πρώτο μέρος της διατριβής έγινε αναφορά: α) στους νεφρούς και στη λειτουργία τους και β) στη διαχρονική εξέλιξη των μεθόδων υποκατάστασης της νεφρικής λειτουργίας. Στο δεύτερο μέρος αναφέρθηκαν τα γενικά χαρακτηριστικά των ασθενών σε υποκατάσταση και στη συνέχεια τα ιδιαίτερα χαρακτηριστικά ανάλογα με την μέθοδο υποκατάστασης της νεφρικής λειτουργίας, αιμοκάθαρση ,περιτοναϊκή κάθαρση ή μεταμόσχευση Στη συνέχεια για κάθε ομάδα ασθενών προσδιορίστηκαν: α) δημογραφικά χαρακτηριστικά (ηλικία, οικογενειακή κατάσταση, τόπος κατοικίας, γραμματικές γνώσεις, χρονικό διάστημα σε υποκατάσταση) β) επαγγελματική κατάσταση γ) δραστηριότητες και φυσική κατάσταση δ) κοινωνική κατάσταση (σεξουαλική ζωή, συμμετοχή στις κοινωνικές εκδηλώσεις, ικανοποίηση από τη ζωή, τις κοινωνικές παροχές, την ιατρική και νοσηλευτική φροντίδα, σχέσεις με οικογενειακό και φιλικό περιβάλλον ) ε) ψυχολογική κατάσταση ως προς το άγχος και την κατάθλιψη και ζ) έγινε σύγκριση των αποτελεσμάτων με αυτά από ανάλογες εργασίες που έχουν επιτελεστεί στον Ευρωπαϊκό και στον βόρειο-αμερικανικό χώρο. Από τα αποτελέσματα της διατριβής προκύπτει ότι από τις διάφορες μεθόδους αντιμετώπισης της ΧΝΝ τελικού σταδίου, η νεφρική μεταμόσχευση φαίνεται να υπερέχει, συμβάλλοντας σε καλύτερο βαθμό συνολικής αποκατάστασης, αφού εξασφαλίζει βελτιωμένη φυσική κατάσταση, καλύτερη επαγγελματική αποκατάσταση και κοινωνική ευεξία. Ακολουθούν οι ασθενείς υπό ΣΦΠΚ οι οποίοι φαίνεται να έχουν καλύτερη ψυχολογική προσαρμογή με λιγότερο stress, άγχος και κατάθλιψη, μεγαλύτερη αυτονομία και ανεξαρτησία. Αυτό τους διευκολύνει για καλύτερη κοινωνική προσαρμογή με μεγαλύτερες δυνατότητες και ευκαιρίες απασχόλησης και κοινωνικής δραστηριοποίησης. Αντίστοιχα η ζωή των ασθενών υπό ΑΚ επηρεάζεται ιδιαίτερα, ο τρόπος ζωής αλλάζει δραματικά σε όλους τους παραπάνω τομείς, αν και δείχνουν να προσαρμόζονται καλύτερα στις αντίξοες συνθήκες που βιώνουν έναντι των ασθενών άλλων χωρών. Πιο αναλυτικά τα αποτελέσματα της διατριβής ήταν τα παρακάτω: - Οι ασθενείς των ομάδων ΑΚ και ΣΦΠΚ είναι κυρίως ηλικιωμένα άτομα, ενώ οι μεταμοσχευμένοι ασθενείς είναι άτομα νεαρής ηλικίας. Ως προς την οικογενειακή κατάσταση και τον τόπο κατοικίας και οι τρεις ομάδες ακολουθούν την κατανομή του γενικού πληθυσμού. Οι γραμματικές γνώσεις των ασθενών των ομάδων ΑΚ και ΣΦΠΚ είναι κυρίως επιπέδου δημοτικού σχολείου, ενώ των μεταμοσχευμένων ασθενών επιπέδου γυμνασίου. Μεγαλύτερο χρονικό διάστημα σε θεραπεία υποκατάστασης παρουσιάζουν οι μεταμοσχευμένοι ασθενείς. - Οι μεταμοσχευμένοι ασθενείς παρουσιάζουν καλύτερη επαγγελματική αποκατάσταση και ακολουθούν οι ασθενείς υπό ΣΦΠΚ, ενώ το ποσοστό των ασθενών υπό Α/Κ που εργάζεται είναι πολύ μικρό. - Προβάδισμα στις δραστηριότητες, φυσική κατάσταση έχουν και πάλι οι μεταμοσχευμένοι ασθενείς έναντι των άλλων ομάδων και ακολουθούν οι ασθενείς υπό ΣΦΠΚ. - Οι μεταμοσχευμένοι ασθενείς παρουσιάζουν καλύτερο επίπεδο κοινωνικής κατάστασης. - Σε καλύτερη ψυχολογική κατάσταση βρίσκονται οι ασθενείς υπό ΣΦΠΚ και ακολουθούν με μικρή διαφορά οι μεταμοσχευμένοι. - Αντίστοιχα αποτελέσματα δίνουν έρευνες που έχουν γίνει σε ασθενείς σε άλλες Ευρωπαϊκές και Βόρειο-Αμερικανικές χώρες αν και οι ασθενείς της παρούσας έρευνας και των τριών ομάδων δείχνουν να έχουν καλύτερους δείκτες αναφορικά με τις παραπάνω παραμέτρους και να προσαρμόζονται καλύτερα στις αντίξοες συνθήκες που βιώνουν, έναντι των ασθενών άλλων χωρών. / The present work is one of the first dealing with the study of the lifestyle of patients with end stage renal failure, under renal function substitution with haemodialysis or peritoneal dialysis or successful kidney transplantation, in Greece, and compares this data with existing results from Europe and North America. In the first part of the thesis there is a presentation of: a) the kidneys and their function and b) the evolution of renal function substitution methods through time. In the second part, the general characteristics of the included patients are reported, followed by the specific characteristics due to the renal substitution methods, haemodialysis, peritoneal dialysis or transplantation. In every group of patients the following parameters were determined: α) demographic data (age, family status, place of living, education, time in renal substitution) β) job status γ) activities and physical status δ) social status (sex life, participation in social events, satisfaction due to life, social benefits, medical and nursery care, relations with friends and relatives) ε) psychology due to stress and depression ζ) comparison of these results with other from Europe and North America. The results of this work reveal that renal transplantation preponderates all other substitution methods for renal function, since it guarantees improved physical status, better job rehabilitation and social welfare. Patients in peritoneal dialysis come next in adaptation, with lesser stress anxiety and depression, bigger autonomy and independence. They have more possibilities and opportunities to work and participate in social activities. On the contrary, the lifestyle of renal patients under dialysis is more negatively affected and their lives changes dramatically in all of the above sections; even though they seem to adapt better in the adverse conditions they are dealing with. In detail, the results of this work are: - Patients under haemodialysis (HD) or peritoneal dialysis (PD) are older people, while transplanted patients are younger. All patients follow the general population distribution, as for family status and place of living. The education level of the HD and PD patients is mostly elementary, while, most transplanted patients have a high school degree. These patients have spent longer periods under renal substitution. - Transplanted patients present better job rehabilitation, followed by patients in PD, while the percentage of working patients in HD is too small. - Transplanted patients have a better physical condition, followed by PD patents. - Transplanted patients are in a better level of social status compared with other renal patients. - Patients in PD seem to have a better psychological profile slightly higher than transplanted patients. - Similar results are presented in other studies from Europe and North America, although patients of all groups, in the present work, show better indices as for the above parameters and adapt better in adverse living conditions, compared with patients of other countries.

The thesis examines the relationship of birthweight to risk factors and markers, such as proteinuria and glomerular filtration rate, for chronic disease in postnatal life. It made use of the Australian Diabetes, Obesity and Lifestyle Study (AusDiab). The AusDiab study is a cross sectional study where baseline data on 11,247 participants were collected in 1999-2000. Participants were recruited from a stratified sample of Australians aged ≥ 25 years, residing in 42 randomly selected urban and non-urban areas (Census Collector Districts) of the six states of Australia and the Northern Territory. The AusDiab study collected an enormous amount of clinical and laboratory data. During the 2004-05 follow-up AusDiab survey, questions about birthweight were included. Participants were asked to state their birthweight, the likely accuracy of the stated birthweight and the source of their stated birthweight. Four hundred and twelve chronic kidney disease (CKD) patients were approached, and 339 agreed to participate in the study. The patients completed the same questionnaire. Medical records were reviewed to check the diagnoses, causes of kidney trouble and SCr levels. Two control subjects, matched for gender and age, were selected for each CKD patient from participants in the AusDiab study who reported their birthweight. Among 7,157 AusDiab participants who responded to the questionnaire, 4,502 reported their birthweights, with a mean (standard deviation) of 3.4 (0.7) kg. The benefit and disadvantages of these data are discussed in chapter three. The data were analysed for the relationship between birthweight and adult body size and composition, disorders of glucose regulation, blood pressure, lipid abnormalities, cardiovascular diseases and glomerular filtration rate. Low birthweight was associated with smaller body build and lower lean mass and total body water in both females and males. In addition low birthweight was associated with central obesity and higher body fat percentage in females, even after taking into account current physical activity and socioeconomic status. Fasting plasma glucose, post load glucose and glycosylated haemoglobin were strongly and inversely correlated with birthweight. In those with low birthweight (< 2.5 kg), the risks for having impaired fasting glucose, impaired glucose tolerance, diabetes and all abnormalities combined were increased by 1.75, 2.22, 2.76 and 2.28 for females and by 1.40, 1.32, 1.98 and 1.49 for males compared to those with normal birthweight (≥ 2.5 kg), respectively. Low birthweight individuals were at higher risk for having high blood pressure ≥ 140/90 mmHg and ≥ 130/85 mmHg compared to those with normal birthweight. People with low birthweight showed a trend towards increased risk for high cholesterol (≥ 5.5 mmol/l) compared to those of normal birthweight. Females with low birthweight had increased risk for high low density lipoprotein cholesterol (≥ 3.5 mmol/l) and triglyceride levels (≥ 1.7 mmol/l) when compared to those with normal birthweight. Males with low birthweight exhibited increased risk for low levels of high density lipoprotein cholesterol (<0.9 mmol/l) than those with normal birthweight. Females with low birthweight were at least 1.39, 1.40, 2.30 and 1.47 times more likely to have angina, coronary artery disease, stroke and overall cardiovascular diseases respectively, compared to those ≥ 2.5 kg. Similarly, males with low birthweight were 1.76, 1.48, 3.34 and 1.70 times more likely to have angina, coronary artery disease, stroke and overall cardiovascular diseases compared to those ≥ 2.5 kg, respectively. The estimated glomerular filtration rate was strongly and positively associated with birthweight, with a predicted increase of 2.6 ml/min (CI 2.1, 3.2) and 3.8 (3.0, 4.5) for each kg of birthweight for females and males, respectively. The odd ratio (95% confidence interval) for low glomerular filtration rate (<61.0 ml/min for female and < 87.4 male) in people of low birthweight compared with those of normal birthweight was 2.04 (1.45, 2.88) for female and 3.4 (2.11, 5.36) for male. One hundred and eighty-nineCKD patients reported their birthweight; 106 were male. Their age was 60.3(15) years. Their birthweight was 3.27 (0.62) kg, vs 3.46 (0.6) kg for their AusDiab controls, p<0.001 and the proportions with birthweight<2.5 kg were 12.17% and 4.44%, p<0.001. Among CKD patients, 22.8%, 21.7%, 18% and 37.6% were in CKD stages 2, 3, 4 and 5 respectively. Birthweights by CKD stage and their AusDiab controls were as follows: 3.38 (0.52) vs 3.49 (0.52), p=0.251 for CKD2; 3.28 (0.54) vs 3.44 (0.54), p=0.121 for CKD3; 3.19 (0.72) vs 3.43 (0.56), p= 0.112 for CKD4 and 3.09 (0.65) vs 3.47 (0.67), p<0.001 for CKD5. The results demonstrate that in an affluent Western country with a good adult health profile, low birthweight people were predisposed to higher rates of glycaemic dysregulation, high blood pressure, dyslipidaemia, cardiovascular diseases and lower glomerular filtration rate in adult life. In all instances it would be prudent to adopt policies of intensified whole of life surveillance of lower birthweight people, anticipating this risk. The general public awareness of the effect of low birthweight on development of chronic diseases in later life is of vital importance. The general public, in addition to the awareness of people in medical practice of the role of low birthweight, will lead to a better management of this group of our population that is increasingly surviving into adulthood.

The thesis examines the relationship of birthweight to risk factors and markers, such as proteinuria and glomerular filtration rate, for chronic disease in postnatal life. It made use of the Australian Diabetes, Obesity and Lifestyle Study (AusDiab). The AusDiab study is a cross sectional study where baseline data on 11,247 participants were collected in 1999-2000. Participants were recruited from a stratified sample of Australians aged ≥ 25 years, residing in 42 randomly selected urban and non-urban areas (Census Collector Districts) of the six states of Australia and the Northern Territory. The AusDiab study collected an enormous amount of clinical and laboratory data. During the 2004-05 follow-up AusDiab survey, questions about birthweight were included. Participants were asked to state their birthweight, the likely accuracy of the stated birthweight and the source of their stated birthweight. Four hundred and twelve chronic kidney disease (CKD) patients were approached, and 339 agreed to participate in the study. The patients completed the same questionnaire. Medical records were reviewed to check the diagnoses, causes of kidney trouble and SCr levels. Two control subjects, matched for gender and age, were selected for each CKD patient from participants in the AusDiab study who reported their birthweight. Among 7,157 AusDiab participants who responded to the questionnaire, 4,502 reported their birthweights, with a mean (standard deviation) of 3.4 (0.7) kg. The benefit and disadvantages of these data are discussed in chapter three. The data were analysed for the relationship between birthweight and adult body size and composition, disorders of glucose regulation, blood pressure, lipid abnormalities, cardiovascular diseases and glomerular filtration rate. Low birthweight was associated with smaller body build and lower lean mass and total body water in both females and males. In addition low birthweight was associated with central obesity and higher body fat percentage in females, even after taking into account current physical activity and socioeconomic status. Fasting plasma glucose, post load glucose and glycosylated haemoglobin were strongly and inversely correlated with birthweight. In those with low birthweight (< 2.5 kg), the risks for having impaired fasting glucose, impaired glucose tolerance, diabetes and all abnormalities combined were increased by 1.75, 2.22, 2.76 and 2.28 for females and by 1.40, 1.32, 1.98 and 1.49 for males compared to those with normal birthweight (≥ 2.5 kg), respectively. Low birthweight individuals were at higher risk for having high blood pressure ≥ 140/90 mmHg and ≥ 130/85 mmHg compared to those with normal birthweight. People with low birthweight showed a trend towards increased risk for high cholesterol (≥ 5.5 mmol/l) compared to those of normal birthweight. Females with low birthweight had increased risk for high low density lipoprotein cholesterol (≥ 3.5 mmol/l) and triglyceride levels (≥ 1.7 mmol/l) when compared to those with normal birthweight. Males with low birthweight exhibited increased risk for low levels of high density lipoprotein cholesterol (<0.9 mmol/l) than those with normal birthweight. Females with low birthweight were at least 1.39, 1.40, 2.30 and 1.47 times more likely to have angina, coronary artery disease, stroke and overall cardiovascular diseases respectively, compared to those ≥ 2.5 kg. Similarly, males with low birthweight were 1.76, 1.48, 3.34 and 1.70 times more likely to have angina, coronary artery disease, stroke and overall cardiovascular diseases compared to those ≥ 2.5 kg, respectively. The estimated glomerular filtration rate was strongly and positively associated with birthweight, with a predicted increase of 2.6 ml/min (CI 2.1, 3.2) and 3.8 (3.0, 4.5) for each kg of birthweight for females and males, respectively. The odd ratio (95% confidence interval) for low glomerular filtration rate (<61.0 ml/min for female and < 87.4 male) in people of low birthweight compared with those of normal birthweight was 2.04 (1.45, 2.88) for female and 3.4 (2.11, 5.36) for male. One hundred and eighty-nineCKD patients reported their birthweight; 106 were male. Their age was 60.3(15) years. Their birthweight was 3.27 (0.62) kg, vs 3.46 (0.6) kg for their AusDiab controls, p<0.001 and the proportions with birthweight<2.5 kg were 12.17% and 4.44%, p<0.001. Among CKD patients, 22.8%, 21.7%, 18% and 37.6% were in CKD stages 2, 3, 4 and 5 respectively. Birthweights by CKD stage and their AusDiab controls were as follows: 3.38 (0.52) vs 3.49 (0.52), p=0.251 for CKD2; 3.28 (0.54) vs 3.44 (0.54), p=0.121 for CKD3; 3.19 (0.72) vs 3.43 (0.56), p= 0.112 for CKD4 and 3.09 (0.65) vs 3.47 (0.67), p<0.001 for CKD5. The results demonstrate that in an affluent Western country with a good adult health profile, low birthweight people were predisposed to higher rates of glycaemic dysregulation, high blood pressure, dyslipidaemia, cardiovascular diseases and lower glomerular filtration rate in adult life. In all instances it would be prudent to adopt policies of intensified whole of life surveillance of lower birthweight people, anticipating this risk. The general public awareness of the effect of low birthweight on development of chronic diseases in later life is of vital importance. The general public, in addition to the awareness of people in medical practice of the role of low birthweight, will lead to a better management of this group of our population that is increasingly surviving into adulthood.

The thesis examines the relationship of birthweight to risk factors and markers, such as proteinuria and glomerular filtration rate, for chronic disease in postnatal life. It made use of the Australian Diabetes, Obesity and Lifestyle Study (AusDiab). The AusDiab study is a cross sectional study where baseline data on 11,247 participants were collected in 1999-2000. Participants were recruited from a stratified sample of Australians aged ≥ 25 years, residing in 42 randomly selected urban and non-urban areas (Census Collector Districts) of the six states of Australia and the Northern Territory. The AusDiab study collected an enormous amount of clinical and laboratory data. During the 2004-05 follow-up AusDiab survey, questions about birthweight were included. Participants were asked to state their birthweight, the likely accuracy of the stated birthweight and the source of their stated birthweight. Four hundred and twelve chronic kidney disease (CKD) patients were approached, and 339 agreed to participate in the study. The patients completed the same questionnaire. Medical records were reviewed to check the diagnoses, causes of kidney trouble and SCr levels. Two control subjects, matched for gender and age, were selected for each CKD patient from participants in the AusDiab study who reported their birthweight. Among 7,157 AusDiab participants who responded to the questionnaire, 4,502 reported their birthweights, with a mean (standard deviation) of 3.4 (0.7) kg. The benefit and disadvantages of these data are discussed in chapter three. The data were analysed for the relationship between birthweight and adult body size and composition, disorders of glucose regulation, blood pressure, lipid abnormalities, cardiovascular diseases and glomerular filtration rate. Low birthweight was associated with smaller body build and lower lean mass and total body water in both females and males. In addition low birthweight was associated with central obesity and higher body fat percentage in females, even after taking into account current physical activity and socioeconomic status. Fasting plasma glucose, post load glucose and glycosylated haemoglobin were strongly and inversely correlated with birthweight. In those with low birthweight (< 2.5 kg), the risks for having impaired fasting glucose, impaired glucose tolerance, diabetes and all abnormalities combined were increased by 1.75, 2.22, 2.76 and 2.28 for females and by 1.40, 1.32, 1.98 and 1.49 for males compared to those with normal birthweight (≥ 2.5 kg), respectively. Low birthweight individuals were at higher risk for having high blood pressure ≥ 140/90 mmHg and ≥ 130/85 mmHg compared to those with normal birthweight. People with low birthweight showed a trend towards increased risk for high cholesterol (≥ 5.5 mmol/l) compared to those of normal birthweight. Females with low birthweight had increased risk for high low density lipoprotein cholesterol (≥ 3.5 mmol/l) and triglyceride levels (≥ 1.7 mmol/l) when compared to those with normal birthweight. Males with low birthweight exhibited increased risk for low levels of high density lipoprotein cholesterol (<0.9 mmol/l) than those with normal birthweight. Females with low birthweight were at least 1.39, 1.40, 2.30 and 1.47 times more likely to have angina, coronary artery disease, stroke and overall cardiovascular diseases respectively, compared to those ≥ 2.5 kg. Similarly, males with low birthweight were 1.76, 1.48, 3.34 and 1.70 times more likely to have angina, coronary artery disease, stroke and overall cardiovascular diseases compared to those ≥ 2.5 kg, respectively. The estimated glomerular filtration rate was strongly and positively associated with birthweight, with a predicted increase of 2.6 ml/min (CI 2.1, 3.2) and 3.8 (3.0, 4.5) for each kg of birthweight for females and males, respectively. The odd ratio (95% confidence interval) for low glomerular filtration rate (<61.0 ml/min for female and < 87.4 male) in people of low birthweight compared with those of normal birthweight was 2.04 (1.45, 2.88) for female and 3.4 (2.11, 5.36) for male. One hundred and eighty-nineCKD patients reported their birthweight; 106 were male. Their age was 60.3(15) years. Their birthweight was 3.27 (0.62) kg, vs 3.46 (0.6) kg for their AusDiab controls, p<0.001 and the proportions with birthweight<2.5 kg were 12.17% and 4.44%, p<0.001. Among CKD patients, 22.8%, 21.7%, 18% and 37.6% were in CKD stages 2, 3, 4 and 5 respectively. Birthweights by CKD stage and their AusDiab controls were as follows: 3.38 (0.52) vs 3.49 (0.52), p=0.251 for CKD2; 3.28 (0.54) vs 3.44 (0.54), p=0.121 for CKD3; 3.19 (0.72) vs 3.43 (0.56), p= 0.112 for CKD4 and 3.09 (0.65) vs 3.47 (0.67), p<0.001 for CKD5. The results demonstrate that in an affluent Western country with a good adult health profile, low birthweight people were predisposed to higher rates of glycaemic dysregulation, high blood pressure, dyslipidaemia, cardiovascular diseases and lower glomerular filtration rate in adult life. In all instances it would be prudent to adopt policies of intensified whole of life surveillance of lower birthweight people, anticipating this risk. The general public awareness of the effect of low birthweight on development of chronic diseases in later life is of vital importance. The general public, in addition to the awareness of people in medical practice of the role of low birthweight, will lead to a better management of this group of our population that is increasingly surviving into adulthood.