Submitted in partial fulfillment of the requirements for the degree of Doctor In Technology (Clinical Technology), Durban University of Technology, Durban, South Africa, 2016. / Erythropoietin (EPO) is widely used in patients with chronic renal failure and is a necessity. However, due to the cost implications and the medical complications in our population it is imperative to review the factors affecting the process of erythropoiesis and the analysis of cell proliferation and cell viability in the bioassay. Complications such as hypertension and risk of worsening a malignancy cannot be ignored. We had previously analysed variations of erythropoietin levels in haemodialysis patients over a six month period. This study aims to evaluate erythropoiesis in conjunction with various laboratory, demographic, clinical parameters and inflammatory markers, in the population of haemodialysis patients. EPO, antibody level and antibody activity were analysed in the population groups as EPO responsive and EPO sensitive patients. This is a prospective, experimental and controlled study. Fifty nine patients were randomly selected from haemodialysis units of Addington and King Edward VIII Hospitals following an informed consent and 15 healthy individuals were also selected as controls. Demographic parameters (age, sex), clinical parameters (weight, height, skin folding, EPO doses and blood pressures (BP) were recorded. Pre-dialysis serum was used to measure laboratory markers (haemoglobin, transferrin, ferritin, albumin, ESR, C reactive protein, creatinine and urea). EPO levels and antibody levels were measured by ELISA, the optical density of each well was determined within fifteen minutes using the microplate reader set at 450 nm. All results were statistically analysed using SPSS statistical package version 21 (IBMR). Patients requiring very high doses of EPO to reach Hb of 11g/dL, and they remained anaemic after at least three months of adequate EPO doses were considered to be EPO resistant. Those who responded to the usual EPO doses were labelled EPO sensitive. The bioassay was used to quantify cell proliferation and cell viability in the presence of EPO. The UT 7 cells were cultured in medium, in the presence of serum from the EPO resistant, EPO sensitive patients and the healthy, control subjects. Luminescence was read with the Glorunner Microplate Luminometer and was recorded in relative light units (RLU). The analysis revealed: a non-significant positive correlation between haemoglobin and erythropoietin levels. However, a strong negative correlation was found between CRP and albumin level (R= -0.591; (p=0.001), which was not significant. No correlation was found between haemoglobin or erythropoietin levels and CRP or albumin. There was a positive correlation with systolic and diastolic blood pressures and mean arterial pressures which was statistically significant (p <0.05). EPO dosages and Hb levels were correlated significantly (p < 0.05). No correlation of EPO levels and Hb; age and Hb was found to be significant (p = 0.08). The UT 7 cells cultured in serum in medium alone with RHuEPO containing cells were statistically significant (p <0.01)). Reduction of ATP stimulation between medium and serum was observed. However, mean arterial pressures had a significant association with EPO resistance (p = 0.041) odd ratio- 1.066. In conclusion, EPO level is not a useful tool for the monitoring of its use as it does not correlate with EPO goal of red blood production in our patients. The neutralizing antibodies did not correlate with any of our variables contributing to erythropoiesis, and are therefore not confirmed as playing a major role in erythropoiesis. From the analysis of our results the key contributing factors of EPO doses, malnutrition and age were more significant in erythropoiesis. However the higher doses of EPO significantly increased the blood pressures and the mean arterial pressures (MAP). The analysis of the bioassay showed lack of difference between EPO responsive and EPO sensitive patients. This observation warrants further studies to clarify the role of serum of haemodialysis patients in erythropoiesis. / D

The effects of 18 milligrams elemental zinc as zinc sulfate were investigated in 24 hemodialysis patients during a double blind study. The study was conducted at two different dialysis centers in Utah. Each patient was evaluated for a 12 week period. The effects of zinc supplementation were evaluated using the parameters of serum zinc, hair zinc, dialysate zinc, and objective and subjective taste evaluation procedures. To possibly clearify the above determination in zinc status, copper determination were made of the same parameters. In addition, determinations of serum ferritin, transferrin and iron levels were made. A three day diet record was used to document the dietary intakes of calories, protein, and zinc as well as indicate the balance of food groups in the diets. Patients were evaluated biweekly throughout the study period. There were a total of six evaluations made on each participant during the investigation. Complete data were collected on six patients in the treatment group, and on ten patients in the control group. Even though the sample size was small, results were very steady and values fell within narrow ranges for most parameters examined. The mean baseline serum zinc value (n = 24) was 56 micrograms per deciliter. Patients, by this value would be classified as zinc deficient. However, the hair zinc levels were within the normal range, and no other signs or symptoms of zinc deficiency were evident in any patient, other than altered taste. There were no differences between pre and post dialysis serum zinc levels, nor were there any consistent increases in zinc levels cleared from the plasma during dialysis. There were no increases seen in the serum zinc or hair levels in response to zinc supplementation. Furthermore, there was no significant improvement in the taste acuities of the treatment group patients compared to the controls. The low serum levels maintained were probably due to the redistribution of body zinc known to occur in uremia. Most patients improved their taste test scores. This displayed the learning phenomena that was inherent in the taste testing technique. Furthermore, hemodialysis patients and the failure of many subjects to identify all four tastants (sweet, sour, bitter, and salt) correctly. Daily dietary intakes of high bioglogical value protein and zinc by the patients were less than the amounts recommended by the National Dietary Counsil and the physicians. However, the daily intakes of protein (55 grams) and zinc (7.9 milligrams) were not limited to the level where deficiency signs or symptoms of either nutrient were seen. Copper serum levels were all within the normal range. The mean baseline level for all patients was 113 micrograms per deciliter. Copper status appeared unaffected by uremia or hemodialysis. Body stores of iron, determined by serum ferritin levels, ranged from possibly indicating iron deficiency to iron overload. The body iron stores did not correlate with patients’ responses to the oral zinc supplementation.

published_or_final_version / abstract / Medicine / Master / Doctor of Medicine

The present study investigated whether vitamin E supplementation reduced oxidative stress in erythrocytes and improved vitamin E status in patients undergoing hemodialysis (HD). Plasma and erythrocyte α-tocopherol, plasma ascorbic acid, and iron status were determined in 11 regular HD patients prior to and post-dialysis, before and during oral supplementation of vitamin E, 400 IU daily for two months. HD patients were categorized into two groups according to their plasma ascorbic acid levels. We found that only the vitamin C sufficient group (>40 μM, Group I) had reliable measurements of erythrocyte α-tocopherol concentrations before vitamin E supplementation. In Group I prior to dialysis, erythrocyte α-tocopherol concentrations increased in response to vitamin E supplementation from 6.7 ± 0.7 μmol/L packed cells to 9.8 ± 0.6 (μmol/L packed cells (p<0.04). Moreover, there was a positive correlation (p<O.001) between plasma and erythrocyte α-tocopherol levels in Group I subjects. Additionally, vitamin E supplementation significantly increased hematocrits (39.9% ± 1.9% to 42.3% ±1.6%, p<0.004) post-dialysis only in Group I subjects. On the contrary, there was no change in hematocrits during vitamin E supplementation in the vitamin C deficient group (<40 μM, Group II). With respect to measures of iron status and recombinant human erythropoietin (rHuEPO) dose, no differences between before and during vitamin E supplementation were observed in two groups ofpatients. In summary, our data suggest that oral vitamin E supplementation protected erythrocytes from oxidative stress and improved vitamin E status in HD patients, but only in patients with adequate vitamin C status. / Graduation date: 2003

No description available.

This study investigated the hypothesis that dietary compliance among hemodialysis patients is related to their health locus of control orientation, as well as other factors. Fifty chronic hemodialysis patients were studied over a 3-month period. Among women interdialytic weight gain as a percentage of body weight (%BWG) was positively correlated with the number of weekly hemodialysis sessions and negatively related to ease of fluid compliance. Among men %BWG was positively correlated with powerful others health locus of control, family support, and hemodialysis tenure, and negatively correlated with employment. The best fitting multiple regression equation explained 26% of the variance for %BWG using ease of fluid compliance, frequency of urination, and powerful others orientation, with sex effects seen for the latter two variables. Staff perceptions of patient dietary compliance were also highly correlated with %BWG, though they never tabulated fluid gain controlled for body weight.

Hemodializuojamų ligonių skaičius pasaulyje kasmet auga, dializuojama vis daugiau vyresnio amžiaus ligonių, turinčių sunkią gretutinę patologiją. Todėl tenka dažniau juos stacionarizuoti, didėja finansinė šių ligonių gydymo našta visuomenei. Daugelis pasaulyje atliekamų hemodializuojamų ligonių stacionarizavimą vertinančių tyrimų apima atskiras būkles, kaip anemijos, kaulų ir mineralų metabolizmo sutrikimų reikšmę, gretutines ligas ir kitus veiksnius. Mes savo tyrime sujungėme dažniausias hemodializuojamiems ligoniams aprašomas komplikacijas, kad įvertintume bendrą suminę jų reikšmę stacionarizavimui. Tai pirmasis tyrimas, nagrinėjantis Lietuvos hemodializuojamų ligonių stacionarizavimo priežastis ir sąlygojančius veiksnius. Taip pat pirmą kartą nustatytos Lietuvos hemodializuojamų ligonių gydymo išlaidos. Perspektyvusis tyrimas atliktas Kauno Medicinos universiteto Nefrologijos klinikoje. Į tyrimą įtraukti visi galutinės stadijos inkstų nepakankamumu sergantys ligoniai, kurie buvo hemodializuoti visuose Kauno krašto hemodializės centruose 5 metų laikotarpiu (2002-2006 metais). Nustatėme, kad hospitalizavimui svarbūs tiek demografiniai veiksniai, tiek gretutinės ligos, tiek kai kurių laboratorinių rodiklių pokyčiai, tiek ir režimo pažeidimai. / Increasing numbers of hemodialysis patients is influenced by growing life expectancy. increasing burden of diabetes and hypertension. Dialysis population becomes older with heavy comorbidities and high risk for hospitalization. Treatment of those patients is a big financial burden for society. So it is necessary to evaluate the predisposing factors for hospitalization and to assess possibilities of ambulatory treatment optimization and reduction of hospitalization rates in hemodialysis patients. Most of the studies in hemodialysis patients investigate hospitalization risk according to separate conditions, like influence of anemia, bone-mineral metabolism, comorbidities and other factors. In our study we tested together most common complications of end stage renal disease in order to evaluate a combined value of various different factors on hospitalization risk and to discriminate the most important ones. This is the first study which examined hospitalizations rates and factors related to hospitalization in Lithuanian hemodialysis population. Also for the first time treatment expenditures of Lithuanian hemodialysis patients were estimated. Prospective study was performed in the Nephrology department of Kaunas University of Medicine. We enrolled all end stage renal disease patients dialysed in the years 2002-2006 in all centers in Kaunas region. In order to reduce hospitalization risk, a contribution of the doctor and the patient is needed as both treatment failure and... [to full text]

Submitted in fulfillment of the requirements for the degree of Master of Clinical Technology (Nephrology), Durban University of Technology, Durban, South Africa, 2013. / Diabetic nephropathy is a serious complication of diabetes that can lead to end stage renal failure (ESRF). It is now the most common cause of ESRF in patients accepted onto renal replacement therapy (RRT) programmes. Kidney disease is common in South Africa. 60-65% is due to inherited hypertension and 20-25% due to Type 2 diabetes (National Kidney Foundation of South Africa, 2002). The renal replacement therapies include haemodialysis, peritoneal dialysis and transplantation. Successful long-term haemodialysis in patients with end stage renal disease (ESRD) depends to a large extent upon a trouble- free vascular access. Achieving a successful vascular access remains a challenge especially in the diabetic population. Current Kidney Dialysis Outcome Quality Initiative (KDOQI) guidelines encourage placing Arterio-Venous Fistula (AVF) in more haemodialysis patients. While the upper limb is the preferred site for AVF creation, researchers are undecided on which is the ideal location (distal or proximal arm) in the diabetic population. Many new fistulae fail to mature sufficiently to be usable for haemodialysis. Pre-insertion work-up with regard to haemodialysis access is important in maintaining the most appropriate access in the growing diabetic population requiring haemodialysis. Pre-operative vascular mapping to identify suitable vessels has been reported to improve vascular access outcomes . In South Africa, duplex scanning is not routinely done, and a clinical judgement by the surgeon remains in most instances the deciding factor on the site of the AVF. Whilst conducting this research, it has been found that while diabetic patients may have AVF created, the maturation time is of a much extended period, and a challenge to achieve the desired dose of dialysis. This is a prospective, quantitative and qualitative study of 21 diabetic patients. These included patients that were starting on the chronic haemodialysis program and limited to patients that were having first attempt of AVF creation and aims to establish if sonogram testing provides a more accurate measure of the ideal location for the AVF, or if a clinical evaluation alone by the surgeon is sufficient. Surgical techniques are different amongst surgeons and clinical evaluation is more a subjective decision. By limiting the surgeons performing the AVF, a standardized surgical procedure was established. If an ideal AVF access for the patient is created, haemodialysis efficiency is increased and ultimately patient outcome improved. The AVF was created according to the clinical evaluation as is the current process, and the surgeons were not aware of the duplex sonogram results. Failure and success of AVF were analysed according to primary patency and functional success. A primary patency success of the AVF does not guarantee functional success. If an AVF is not able to complete an entire haemodialysis session trouble free at the prescribed dialysis dose, the AVF is considered a failure irrespective of primary patency success. This was evident with 10% of patients who had primary patency but functional success was not achieved. With a 55% functional success in this study with AVF created on clinical evaluation, there was no significance difference (p=0.795) if AVFs were based on duplex sonogram findings. However, there was evidence of increased AVF success in 33% of the failed AVFs when the new AVFs were created at the duplex sonogram site. 95% of patients in this study had commenced haemodialysis with a Central Venous Catheter (CVC). AVF success could be increased if early referral of diabetic patients for permanent access to the surgeon occurred. Maturation rate of AVF differed from KDOQI guidelines with AVF first cannulation only after 17 weeks, and not after the recommended time of 6 weeks. Blood flow rates on dialysis also varied with international standards, with only maximum of 400mls/min reached after one year. With distal arm AVF, diameter of radial artery of less than 2mm and cephalic vein less than 3mm was associated with AVF failure. This research study represents the first of its kind in Kwazulu Natal looking at vascular access sites in diabetic patients with End Stage Renal Disease on haemodialysis. / PDF Full-text unavailable. Please refer to hard copy for Full-text / M

BACKGROUND: Patients receiving haemodialysis (HD) treatment experience a significant symptom burden and their needs are multifaceted. In HD unit, patients receive treatment in a diverse cultural and open ward setting. However, patients‟ experiences of receiving HD treatment in an open ward setting are not known. OBJECTIVES: The central aim of this study was to explore and describe the experiences of patients receiving HD treatment in an open setting environment at an academic hospital in Johannesburg. DESIGN: A qualitative, exploratory and descriptive study was conducted at a public, tertiary level academic hospital in Johannesburg after obtaining ethical approval from Wits University and relevant authorities. SETTING: The research setting for this study was an adult Chronic Renal Dialysis Unit. POPULATION: Sixteen adult (age 18 and above) patients receiving chronic HD treatment were recruited purposively in this study. INTERVENTIONS: An in-depth semi-structured interview was conducted either before or after receiving HD treatment, which was audio-recorded, transcribed then analysed by using Giorgi Phenomenological method. FINDINGS: A mood enhancer appeared a major theme as participants positively valued the open setting environment for their overall and psychological well-being. Participants expressed by being with others and sharing experiences, a sense of community likened to a family developed. Common to all participants‟ language was the use of the “we” in relation to being in the open setting environment. This expression of the “we” by participants was interpreted as a community concept. The use of “we” associated with the concept of community described as a space to which every patient receiving HD belonged. They described their experiences in a collective manner. This was evident in repetitive reference to their common space, being together, sharing experiences, and finding identity from one another, being understood and a sense of being protected with personal relations that extend beyond 10 years for some. This open space contributed to shaping their perception of body image and illness. The nurse‟s role in timeously providing HD care was appreciated by many. However, being exposed to multiple situations of chronic illness and treatment a sense of fear developed. Any negative event experienced, watched, observed, or heard in the HD unit triggered fear in the patients. Two common fears were of HD complications and the constant threat of death. Complications such as clotting, muscle cramps and collapsing because of hypotension as well as watching somebody dying on the machine were all reported in this study and so psychological counselling was felt to be very important. CONCLUSION The recommendations proposed in this study hopefully will assist HD staff to intervene and make adjustments to support patients‟ holistic needs. Further studies into patients receiving HD in open settings and mixed-gender space are required for diversity of experiences and knowledge from different settings. Keywords: Haemodialysis, hospital environment, open setting, patient experiences

A contaminação por metais e agentes microbiológicos na água de hemodiálise pode ocasionar manifestações clínicas nos pacientes em tratamento, como anemia, dor óssea, picos hipertensivos, distúrbios neurológicos, episódios de hipotensão, náuseas e vômitos. Avaliar e garantir níveis mínimos de contaminação por metais e micro-organismos na água de hemodiálise pode, assim, aumentar a segurança do paciente. O objetivo deste estudo foi avaliar a relação entre a qualidade da água tratada para hemodiálise e as intercorrências clínicas apresentadas pelos pacientes. Foi utilizado um questionário para a coleta de informações referentes aos aspectos demográficos e hábitos de consumo, e um instrumento de registro mensal de intercorrências clínicas e parâmetros clínico-laboratoriais; tais informações foram obtidas por meio de entrevista e no prontuário do paciente, respectivamente. As dosagens de metais em sangue foram realizadas por EAA (Chama/ Forno de Grafite) no Setor de Metais do HCFMRP/USP, e em água por ICP/MS no Laboratório de Toxicologia e Saúde Ambiental da Universidade Rovira i Virgili, Espanha. A quantificação de bactérias heterotróficas foi realizada pelo Método \"Pour Plate\", a de Coliformes totais e E. coli por Tubos Múltiplos e a detecção de fungos filamentosos por Membrana Filtrante no Laboratório de Ecotoxicologia e Parasitologia Ambiental da EERP/USP. A quantificação de endotoxina foi realizada pela técnica cromogênica do lisado de Limulus Amebocyte, no Laboratório de Vacinas Gênicas da FMRP/USP. Para a análise dos dados foi aplicado o teste Wilcoxon- Mann Whitney bilateral ou Teste t bilateral no software R®, o teste de Kruskal-Wallis no software GraphPad Prism 6®, e ajustados modelos de regressão no software SAS/STAT®. Verificou-se que a concentração de Pb sérico entre os pacientes que exercem/exerciam atividades relacionadas à maior exposição a metais foi significativamente maior (p-valor = 0,0208) que aqueles que nunca realizaram tais atividades. A concentração média de Cu, Pb e Zn na água após filtração por osmose reversa (AFOR) foi inferior ao preconizado na RDC nº 154/2004 e RDC nº 11/2014 da ANVISA, somente o Al (15,35 ± 14,53 µg/L) apresentou concentração média superior a tais normativas. Não foi detectado presença, durante todo o período do estudo, de Cd, coliformes totais, E. coli e endotoxina na água AFOR. A contagem de bactérias heterotróficas foi significativamente maior (p-valor <0,0001) na água após a pré- filtração (APF) do que na água potável (AP) e na água AFOR. As concentrações de cloro total e nitrato foram significativamente maiores (p-valor <0,0001) na AP em relação à água APF e na água AFOR. A contagem de bactérias heterotróficas e a concentração de nitrato na água AFOR foi inferior ao preconizado nas normativas, o cloro total apresentou concentração média superior ao estabelecido na RDC nº 11/2014, mas dentro do limite preconizado pela RDC nº 154/2004. Foi verificado presença de fungos filamentosos em todos os pontos de coleta. Constatou-se que a diminuição da concentração de Cu e nitrato em água de hemodiálise foram significativos (p-valor = 0,001 e 0,0354, respectivamente) para explicar o aumento da concentração de hemoglobina em sangue. Embora a água utilizada no preparo do dialisato tenha apresentado excelente qualidade microbiológica e físico-química é importante o monitoramento contínuo para garantia dos parâmetros de qualidade e prevenção de intercorrências clínicas / The contamination by metals and microbiological agents in hemodialysis water can cause clinical manifestations in hemodialysis patients, such as anemia, bone pain, hypertensive peaks, neurological disturbances, hypotension episodes, nausea and vomiting. Evaluating and assuring minimum levels of contamination by metals and microorganisms in hemodialysis water can improve patient safety. The aim of the study was assess the relationship between the quality of treated water for hemodialysis and the clinical intercurrences presented by patients. A questionnaire was used to collect information about demographic characteristics and consumer habits, and an instrument was applied for monthly recording of clinical intercurrences and clinical laboratorial parameters. The data were obtained by interviews and from clinical records, respectively. Concentrations of metals in blood were determined by AAS (flame/graphite furnace) in the Metals Sector of HCFMRP/USP, and in water by ICP/MS in the Laboratory of Toxicology and Environmental Health of University Rovira i Virgili, Spain. The quantification of heterotrophic bacteria was performed by the pour plate method, the total coliforms and E. coli by multiple tubes, and filamentous fungi by the membrane filter at the Laboratory of Ecotoxicology and Environmental Parasitology of the EERP/USP. The quantification of endotoxin was performed by the chromogenic technique of Limulus Amebocyte lysate, at the Gene Vaccine Laboratory of the FMRP/USP. For data analysis, the bilateral Wilcoxon-Mann-Whitney or bilateral t-test was applied using the R® software, the Kruskal-Wallis test using GraphPad Prism 6®, and adjusted regression models with SAS/STAT®. The results showed that patients who reported having or having had job activities with high exposure to metals showed serum concentrations of Pb significantly higher (p-value = 0.0208) than patients without job exposure to metals. The mean concentrations of Cu, Pb and Zn in the water after reverse osmosis (ARO) were below the threshold limits set by RDC nº 154/2004 and RDC nº 11/2014 from the ANVISA; only Al (15.35 ± 14.53 µg/L) was present in average concentration higher than resolutions. The presence of Cd, total coliforms, E. coli and endotoxins in the water ARO during the study was not detected. The counting of heterotrophic bacteria was significantly higher (p-value <0.0001) in the water after the pre-filtration (APF) than the potable water (PW) and the wate ARO. The concentrations of total chlorine and nitrate were significantly higher (p-value <0.0001) in the PW than the water APF and the water ARO. The counting of heterotrophic bacteria and concentration of nitrate in the water ARO were below the reference limits, while the total chlorine was present in higher concentration than the established in RDC nº 11/2014 but lower than that in RDC nº 154/2004. Filamentous fungi were detected at all sampling points. The decrease in the levels of Cu and nitrate in hemodialysis water were significant (p value = 0.001 and 0.0354, respectively) to explaining the increase of hemoglobin concentration in the blood samples. Although the water used for dialysis showed excellen microbiological and physicochemical quality, it is important to monitor it regularly to assure the quality parameters and prevent clinical intercurrences