Intra-dialytic hypotension (IDH) is the most common complication in haemodialysis (HD) treatment and has been linked with increased mortality in HD patients. Despite various approaches towards understanding the underlying physiological mechanisms giving rise to IDH, the causes of IDH are poorly understood. Heart Rate Variability (HRV) has previously been suggested as a predictive measure of IDH. In contrast to conventional spectral HRV measures in which the frequency bands are defined by fixed limits, a new spectral measure of HRV is introduced in which the breathing rate is used to identify and measure the physiologically-relevant peaks of the frequency spectrum. The ratio of peaks leading up to the IDH event was assessed as a possible measure for IDH prediction. Changes in the proposed measure correlate well with the magnitude of abrupt changes in blood pressure in patients with autonomic dysfunction, but there is no such correlation in patients without autonomic dysfunction. At present, routine clinical vital sign monitoring beyond simple weight and blood pressure measurements at the start and end of each session has not established itself in clinical practice. To investigate the benefits of continuous vital sign monitoring in HD patients with regard to detecting and predicting IDH, different population-based and patient-specific models of normality were devised and tested on data from an observational study at the Oxford Renal Unit in which vital signs were recorded during HD sessions. Patient-specific models of normality performed better in distinguishing between IDH and non-IDH data, primarily due to the wide range of vital sign data included as part of the training data in the population-based models. Further, a patient-specific data fusion model was constructed using Parzen windows to estimate a probability density function from the training data consisting of vital signs from IDH-free sessions. Although the model was constructed using four vital sign inputs, novelty detection was found to be primarily driven by blood pressure decreases.

L’objet de cette thèse est de considérer les coûts et la qualité comme les doubles produits de l’organisation mise en œuvre dans la production de soins. Les soins dispensés que l’on peut mesurer par leur qualité et leurs coûts dépendent directement de cette combinatoire. De ce considérant découle la question de recherche que l’on peut formuler de la façon suivante: « les coûts ne peuvent-ils être dans certaines conditions les sentinelles de la qualité ? ».Le mot « sentinelle » a une double référence, celle donnée par le dictionnaire au sens de personne qui a la charge de faire le guet et de prévenir en cas de risque d’intrusion mais aussi celle de l’image du ganglion sentinelle, premier ganglion pouvant être touché par le cancer qu'il est donc important d'analyser pour évaluer l'extension du cancer.Par un parallélisme des formes, c’est cette image qui dit le mieux notre hypothèse. Les coûts sont la face visible de la qualité. La recherche bibliographique sur le sujet montre l’émergence de cette question dans la littérature hospitalière. Le champ d’application de la thèse concerne l’hémodialyse. La vérification empirique a été réalisée auprès d’un échantillon multicentrique.La méthode de recherche a consisté à repérer à partir de l’analyse du méta processus de prise en charge d’un patient dialysé les processus majeurs représentant 80% des coûts et à décomposer chaque processus sous la forme d’un vecteur à trois dimensions exprimé par des indicateurs de coûts, des inducteurs de qualité et des indicateurs de qualité. Les mesures des indicateurs de qualité ont été confrontées aux données des bases nationales et aux référentiels formulés par les praticiens.Des mesures réalisées tout au long du processus de prise en charge évaluent la relation Coût/Qualité.Les résultats empiriques valident l’hypothèse dans certaines limites / The purpose of this PhD dissertation is to demonstrate that costs and quality stem from the organization of healthcare production. The measured quality and costs of medical care directly depend on this. From then on, under which conditions costs are to be considered as quality sentries? « Sentry » refers both to the dictionary definition (a sentry being in charge of keeping watch and of warning in case there is an intrusion) and to a « sentinel node », which is the first ganglion that is contaminated when getting a cancer. This last image particularly fits our thesis: costs are the visible face of quality. This Phd thesis deals with haemodialysis. Empirical verification was conducted with a polycentric sample. The research methodology consists in identifying the main processes dealing with the treatment of a dialysed patient. Those processes represent 80% of the overall costs; they are decomposed into a three dimensional vector (costs indicators, quality inductors and quality indicators). The measures associated with the quality indicators are confronted with national databases and with the reference documents, which are designed by the practitioners. Measures have been implemented during the whole caring process so as to evaluate the relation costs/quality. Empirical results confirm the generic hypothesis to a certain extent.

<p>Kidney dysfunction increases cardiovascular disease (CVD) risk. The mechanisms for the risk increase seem to involve a combination of traditional and non-traditional CVD risk factors.</p><p>We studied renal dysfunction as CVD and mortality risk factor in middle-aged men free from diabetes and CVD. The risk for myocardial infarction (MI) and CVD mortality was increased by ~40% in the 16.5% of men with worse renal function, independent of other CVD risk factors.</p><p>Renal transplant dysfunction as CVD and mortality risk factor was also studied. Renal transplant dysfunction was a risk factor for mortality and for combined CVD endpoint. The risk by renal transplant dysfunction was independent of traditional CVD risk factors as well as transplantation-specific risk factors. Only moderate increase in serum creatinine resulted in mortality and CVD risk comparable to diabetes, older age and higher low density lipoprotein levels.</p><p>In haemodialysis patients, the effects of a dialysis session on non-traditional CVD risk factors were studied. A HD session reduced asymmetric dimethylarginine (ADMA) and homocysteine levels, as well as augmentation index (AIx). The change in AIx was related to ADMA plasma level change.</p><p>In patients with stage 3-5 chronic kidney disease (CKD), endothelium dependent vasodilation (EDV) was studied together with markers of oxidative stress and C-reactive protein (CRP). CRP was related to lipid peroxidation, while EDV was related to intracellular antioxidative capacity measured by reduced glutathione levels.</p><p>These studies demonstrate that mild to moderate renal dysfunction is independently associated with increased CVD risk in apparently healthy people, as well as in renal transplant recipients. The mechanisms by which renal dysfunction increases CVD risk are yet to be elucidated. We suggest that arterial stiffness could be reduced in haemodialysis patients by increasing nitric oxide bioavailability. In stage 3-5 CKD patients, improving intracellular antioxidative capacity may result in endothelial function improvement.</p>

Kidney dysfunction increases cardiovascular disease (CVD) risk. The mechanisms for the risk increase seem to involve a combination of traditional and non-traditional CVD risk factors. We studied renal dysfunction as CVD and mortality risk factor in middle-aged men free from diabetes and CVD. The risk for myocardial infarction (MI) and CVD mortality was increased by ~40% in the 16.5% of men with worse renal function, independent of other CVD risk factors. Renal transplant dysfunction as CVD and mortality risk factor was also studied. Renal transplant dysfunction was a risk factor for mortality and for combined CVD endpoint. The risk by renal transplant dysfunction was independent of traditional CVD risk factors as well as transplantation-specific risk factors. Only moderate increase in serum creatinine resulted in mortality and CVD risk comparable to diabetes, older age and higher low density lipoprotein levels. In haemodialysis patients, the effects of a dialysis session on non-traditional CVD risk factors were studied. A HD session reduced asymmetric dimethylarginine (ADMA) and homocysteine levels, as well as augmentation index (AIx). The change in AIx was related to ADMA plasma level change. In patients with stage 3-5 chronic kidney disease (CKD), endothelium dependent vasodilation (EDV) was studied together with markers of oxidative stress and C-reactive protein (CRP). CRP was related to lipid peroxidation, while EDV was related to intracellular antioxidative capacity measured by reduced glutathione levels. These studies demonstrate that mild to moderate renal dysfunction is independently associated with increased CVD risk in apparently healthy people, as well as in renal transplant recipients. The mechanisms by which renal dysfunction increases CVD risk are yet to be elucidated. We suggest that arterial stiffness could be reduced in haemodialysis patients by increasing nitric oxide bioavailability. In stage 3-5 CKD patients, improving intracellular antioxidative capacity may result in endothelial function improvement.

This study aimed to examine the quality of life (QOL) and well-being of haemodialysis patients and the relationship of two components of perceived expressed emotion (criticism/hostility and emotional over-involvement) and other psychosocial resources within the Conservation of Resources Model. Demographic variables and haemodialysis related information of patients, classified as resources, were also included in the study. One hundred and six haemodialysis patients voluntarily participated in the study. Before the main study, for evaluating the psychometric properties of the Symptom Distress Scale (SDS), Coping Self-Efficacy Scale (CSES), and Perceived Expressed Emotion Scale (PEES) a pilot study was conducted with the fifty-three haemodialysis patients. Results of the pilot study provided support for the reliability and validity of scales. For the main study, optimism, self-esteem, and perceived social support were taken as resources and were also included as measures. In order to test the main hypothesis of the studies a series of regression analyses were conducted. The results of the analysis revealed that predictors of well-being were age, self esteem, criticism/hostility factor of perceived expressed emotion and coping self-efficacy / predictors of physical health component of QOL were age, education, presence of additional diagnosis, and coping self-efficacy. Moreover, it was found that predictors of mental health component of QOL were the presence of additional diagnosis and coping self-efficacy / and predictors of the mean score of QOL were age, presence of additional diagnosis, self-esteem, and coping self-efficacy. Directions of the relationship between age, education, presence of additional diagnosis, and criticism/hostility were negative with the outcome variables, whereas, directions of the relationship between self-esteem and coping self-efficacy were positive with the outcome variables. The mediational role of coping self-efficacy in the association between resources and outcome variables were also investigated. Mediator effect of coping self-efficacy was found only for two variables. Firstly, the effect of duration of haemodialysis treatment was mediated by the coping self-efficacy for the well being measure. Second, coping self-efficacy carries the influence of the family income to the mean score of QOL. After discussing the findings of the present study in the light of the literature, the limitations and the clinical implications of the results and directions for the future studies were suggested.

<p>Diss. (sammanfattning) Umeå : Umeå universitet, 1994, härtill 5 uppsatser.</p> / digitalisering@umu

Computed tomography is one of the most evolving fields of modern radiology. The current CT applications permit among other things angiography, 3D image reconstructions, material decomposition and tissue characterization. CT is an important tool in the assessment of specific patient populations prior to an invasive or surgical procedure. The aim of this dissertation was to demonstrate the decisive role of CT with 3D-image reconstructions in haemodialysis patients scheduled to undergo fistulography, in patients undergoing surgical breast reconstructions with a perforator flap and in patients with complicated renal calculi scheduled to undergo percutaneous nephrolithotomy. CT Angiography with 3D image reconstructions was performed in 31 patients with failing arteriovenous fistulas and grafts, illustrating the vascular anatomy in a comprehensive manner in 93.5% of the evaluated segments and demonstrating a sensitivity of 95% compared to fistulography. In 59 mastectomy patients scheduled to undergo reconstructive breast surgery with a deep inferior epigastric perforator flap, the preoperative planning with CT Angiography with 3D image reconstructions of the anterior abdominal wall providing details of its vascular supply, reduced surgery time significantly (p&lt; 0.001) and resulted in fewer complications. Dual Energy CT Urography with advanced image reconstructions in 31 patients with complicated renal calculi scheduled to undergo PNL, resulted in a new method of material characterisation (depicting renal calculi within excreted contrast) and in the possibility of reducing radiation dose by 28% by omitting the nonenhanced scanning phase. Detailed analysis of the changes renal calculi undergo when virtually reconstructed was performed and a comparison of renal calculi number, volume, height and attenuation between virtual nonenhanced and true nonenhanced images was undertaken. All parameters were significantly underestimated in the virtual nonenhanced images. CT with 3D-reconstructions is more than just “flashy images”. It is crucial in preoperative planning, optimizes various procedures and can reduce radiation dose.

Depression is common in haemodialysis (HD) patients and is often unrecognised and undertreated, though associated with excess morbidity and mortality. Diagnosis is challenging due to symptom overlap with kidney failure, with fatigue being the most common overlapping symptom. Research on the effectiveness of antidepressant medication in this setting is sparse. A recent systematic review advocated well-designed Randomised Controlled Trials (RCTs) in this setting. The studies reported in this thesis had a number of aims. The main aim was to undertake a multicentre feasibility randomised, double blind, placebo-controlled trial of sertraline in patients on HD with Major Depressive Disorder (MDD). To identify suitable patients for this, a screening phase was required, which also allowed determination of the prevalence of depression in this setting and of the relative effectiveness of screening tools Patient Health Questionnaire-2 (PHQ-2), Patient Health Questionnaire-9 (PHQ-9), and Beck Depression Inventory-II (BDI-II). It also allowed examination of the relationships of fatigue in this setting (assessed mainly by the Multidimensional Fatigue Inventory (MFI), including those with a diagnosis, and management of depression. The finding, during screening, that a large proportion of the HD cohort was already on antidepressant treatment, presented the opportunity to study 'real-life' practice patterns in the management of antidepressant treatment in this setting. Recruitment into the RCT was difficult. 1,355 patients in five HD centres were considered for screening, but 243 of these were excluded, mainly because of their inability to read and understand English. Of the remaining 1,110 patients, 709 consented to screening. 231 of these screened positive for high depression symptoms but 130 were not considered for the trial phase, mainly because of concurrent treatment for depression (68 patients), and other contraindicated conditions and medication. In addition, 38 patients declined to take part in the psychiatric interview necessary for diagnosis of MDD. Of the 63 who underwent the diagnostic interview, 37 (58.7%) were diagnosed with MDD and 30 consented to enter the RCT and were randomised into sertraline or placebo groups. This was half of the anticipated recruitment into the RCT. Twenty-one patients (70%) completed the six-month study, eight of 15 in the sertraline group and 13 of 15 in the placebo group (p < 0.05). Drop out was mainly due to adverse or serious adverse events. Depression scores (BDI-II and Montgomery-Åsberg Depression Rating Scale (MADRS)) improved significantly in both the sertraline and placebo groups over six months but there were no significant differences between the treatment groups. There was a slight suggestion of more rapid improvement over the first two months on sertraline, but this was not significant. Fatigue scores were high in all sub-domains - with only a weak relationship with age and comorbidity. Mental fatigue was the strongest independent predictor of high depressive symptoms (BDI-II ≥16, PHQ-9 ≥8), while physical fatigue had the strongest relationship with dialysis recovery time, and survival. Distinguishing between these components of fatigue may have a role in refining the diagnosis and management of MDD. Forty-one of the 76 patients on antidepressant medication at screening were followed up for a mean of 14±5 months. Ten different antidepressant agents were being taken - the most common being Citalopram (39%). Most had been prescribed by GPs. Two-thirds of patients either deteriorated or failed to improve in terms of BDI-II scores during follow-up, many of whom had had no adjustment of medication during this time. Diagnostic evaluation at follow-up showed 37% to be suffering from current or recurrent major depressive episodes (MDE), 48% to have evidence of past MDE, and 15% to have no evidence of ever having been depressed. These empirical studies confirm that depression is very common in HD patients. Its diagnosis is complicated due to symptom overlap with the uraemic syndrome. Fatigue seems to be a key area of overlap with symptoms of depression with a complex relationship. There was no obvious benefit from antidepressants in this feasibility RCT and there was a high drop-out rate due to adverse events, particularly in the sertraline group. These findings raise concerns about the benefits and risks of antidepressants in patients on HD. Current practice patterns may be subjecting patients to substantial risk for little or no benefit. Identifying whether antidepressant medication is effective in this context is a major clinical need, hence the requirement for a definitive study. There is no doubt that to undertake a definitive study would pose considerable recruitment challenges. The findings presented here emphasise the importance of finding ways to overcome these challenges that might include efforts to incorporate patients already taking antidepressants.

The diploma work surveys the social impacts of ill people in dependence on dialysis treatment. The whole dialysis team?s interest is the effort to take care of the ill people in a way for them to feel at their best and for the chronic illness to have the least impacts on their common life. The aim of the treatment is not only their stabilized health condition, mental satisfaction and sanity but also the help with solving the social impacts that are brought with by the chronic kidney disease. Work of medical social worker in the dialysis team contributes not only to better understanding the dialysed people?s needs but it also influences mutually cooperation between clients and medical staff and thereby contributes to efficiency of the treatment.

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No. of bitstreams: 1 josemunizpazelijunior.pdf: 868943 bytes, checksum: 7c1afb9837b6e1d73d18f7ea10b1401f (MD5) Previous issue date: 2012-11-29 / CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / A Doença Renal Crônica (DRC) é um problema de saúde pública mundial e o número de pacientes inscritos em programas de terapia de substituição de função renal vem crescendo progressivamente. A morbimortalidade dos pacientes com DRC é impressionante e se deve principalmente a doença cardiovascular. A remoção inadequada de líquidos durante a hemodiálise é um dos principais fatores responsáveis por esta evolução desfavorável. A hipervolemia crônica leva a hipertensão, hipertrofia ventricular esquerda, congestão pulmonar e aumenta as taxas de hospitalização e mortalidade. A hipovolemia, por outro lado, se associa com náuseas, vômitos, diminuição da qualidade de vida, perda da função renal residual, trombose do acesso venoso e redução da adequação da diálise, devido às frequentes interrupções das sessões de diálise. O peso seco, definido como o menor peso atingido pelo paciente no final das sessões, quando a maior parte do excesso de líquido acumulado tenha sido removido, ainda é avaliado clinicamente, mas tem fraca correlação com a verdadeira volemia. Apesar de não podermos contar com método que seja “padrão-ouro”, devido às limitações na acurácia e aplicabilidade, várias exames complementares tem sido estudados e validados para a determinação mais precisa da volemia em pacientes dialíticos, incluindo a avaliação ultrassonográfica da veia cava inferior (VCI). O alto custo dos ecocardiógrafos e a necessidade de um ecocardiografista para operá-los têm impedido a disseminação da ultrassonografia para avaliar a VCI e, consequentemente, a volemia. Nós hipotetizamos que a classificação volêmica baseada na determinação do diâmetro expiratório da VCI indexado pela superfície corpórea (DVCIi) e o índice de colabamento inspiratório da VCI (ICVCI) realizada por médico nefrologista, sem especialização em ultrassonografia, é similar àquela obtida no mesmo exame realizado por médico especialista em ecocardiografia utilizando um ecocardiógrafo padrão (ECO) ou um equipamento de ultrassom convencional (US). Neste estudo transversal, um ecocardiografista experiente e um nefrologista sem especialização formal em ultrassonografia avaliaram consecutivamente o DVCIi e o ICVCI de 52 pacientes, durante as sessões de hemodiálise. No protocolo I, o nefrologista usou o US e o cardiologista usou o ECO; no protocolo II os aparelhos foram invertidos entre os pesquisadores. Em ambos os protocolos, os coeficientes de Pearson e kappa foram utilizados para avaliar a correlação entre as variáveis contínuas e categóricas, respectivamente. A concordância entre os examinadores foi avaliada pelo Bland-Altman. Obtivemos imagens de boa qualidade da VCI em 96% dos pacientes. As avaliações do DVCIi apresentaram forte correlação em ambos os protocolos (r= 0,88 e 0,84, nos protocolos I e II, respectivamente). A correlação entre as classificações volêmicas foi excelente no protocolo I (kappa = 0,82 e 0,93 pelo DVCIi e ICVCI, respectivamente) e substancial no protocolo II (kappa = 0,77 e 0,75 pelo DVCIi e ICVCI, respectivamente). A concordância entre os examinadores pelo gráfico de Bland-Altman das avaliações de DVCIi foi também muito boa em ambos os protocolos. Nefrologistas sem especialização formal em ultrassonografia usando um US podem avaliar a volemia de pacientes dialíticos através da ultrassonografia de VCI. O mesmo equipamento que já equipa as clínicas de diálise e é utilizado para diversas outras finalidades, como biópsia renal guiada, acesso venoso guiado, avaliação do trato urinário, mapeamento vascular e estudo das fístulas e enxertos, pode ser utilizado para determinação do peso seco. Esperamos assim, reduzir custos e melhorar a qualidade do atendimento dos pacientes dialíticos, através da disseminação da avaliação ultrassonográfica da VCI. / Chronic kidney disease has emerged as a public health problem of substantial proportions, and the number of patients who require renal replacement therapy has been growing over the years. The mortality rate of patients with ESRD remains amazing, and a large part of this mortality is due to cardiovascular disease. The inadequate fluid removal during hemodialysis is a major factor responsible for this unfavorable development. The hypervolemia leads to chronic hypertension, left ventricular hypertrophy, pulmonary congestion and increased rates of hospitalization and mortality. The hypovolemia, moreover, is associated with nausea, vomiting, diminished quality of life, loss of residual renal function, access thrombosis and reduction of dialysis adequacy, due to frequent interruptions of dialysis sessions. Clinically estimated dry weight, defined as the lowest post-dialysis weight at which most excess body fluid will have been removed, is widely used but is poorly predictive of volemic status. Despite the lack of gold standards, related to limitations in accuracy and feasibility, fluid volume has been assessed by using various tools, including ultrasonographic evaluation of the inferior vena cava (IVC). We sought to determine whether a nephrologist with limited ultrasound training can accurately assess the IVC in patients undergoing haemodialysis compared with a cardiologist by using a regular ultrasound system (RUS) or a full cardiovascular ultrasound system (CVUS). In a cross-sectional study, an experienced cardiologist and a nephrologist without formal ultrasound training consecutively measured the indexed IVC expiratory diameter (VCDi) and IVC collapsibility index (IVCCI) of 52 patients during haemodialysis sessions. In protocol I, the nephrologist used an RUS and the cardiologist used a CVUS; in protocol II, the machines were interchanged. In both protocols, Pearson and kappa correlation coefficients were used to evaluate the 11 interobserver correlation of continuous and categorical data, respectively. The interexaminer agreement was determined by the Bland–Altman method. High-quality IVC images were obtained in 96% of the patients. The VCDi measurements showed strong correlation in both protocols (r = 0.88 and 0.84 in protocols I and II, respectively). The volaemic classifications were excellent in protocol I (kappa = 0.82 and 0.93 by the VCDi and IVCCI, respectively) and substantial in protocol II (kappa = 0.77 and 0.75 by the VCDi and IVCCI, respectively). The interexaminer agreement on the VCDi measurements was also very good in both protocols. Ultrasound evaluation of the IVC can be performed by nephrologists without formal training using an RUS to assess volaemic status in patients undergoing haemodialysis. The same equipment that is already being used in dialysis clinics for several other purposes, such as guided renal biopsy, guided venous access, evaluation of the urinary tract, vascular mapping and study of fistulas and grafts can be used to determine the dry weight. We hope reduce costs and improve the quality of care for dialysis patients, through the spread of ultrasound evaluation of the IVC.