京都大学 / 新制・課程博士 / 博士(医学) / 甲第25005号 / 医博第5039号 / 新制||医||1070(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 羽賀 博典, 教授 竹内 理, 教授 小林 恭 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

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Orientador: Daniela Ponce / Resumo: Introdução: Poucos trabalhos avaliaram a viabilidade e os resultados entre diálise peritoneal (DP) e hemodiálise (HD) no início urgente de terapia renal substitutiva (TRS). Objetivo: Comparar DP e HD como opções de início urgente de TRS, quanto à evolução, desfechos e complicações dos pacientes. Método: Estudo quasi experimental com pacientes incidentes em DP e HD em hospital universitário brasileiro, no período de julho/2014 a dezembro/2016. Incluídos indivíduos DRC estádio final que necessitaram de TRS imediata, ou seja, HD por meio de CVC ou DP cujo cateter foi implantado por nefrologista e utilizado em 72 horas, sem treinamento prévio. Pacientes em DP foram submetidos, inicialmente, a DP de alto volume (DPAV) para compensação metabólica. Após alta hospitalar, permaneciam em DP intermitente na unidade de diálise até efetivação do treinamento. Foram comparados: complicações mecânicas e infecciosas, recuperação de função renal e sobrevida. Resultados: Foram incluídos 93 pacientes em DP (G1) e 91, em HD (G2). Os grupos G1 e G2 foram semelhantes quanto à idade (58+17 vs 60+15; p=0,49), frequência de diabetes mellitus (37,6 vs 50,5%; p=0,10), outras comorbidades (74,1 vs 71,4%; p=0,67) e parâmetros bioquímicos ao início da TRS – creatinina (9,1+4,1 vs 8,0+2,8; p=0,09), albumina sérica (3,1+0,6 vs 3,3+0,6; p=0,06) e hemoglobina (9,5+1,8 vs 9,8+2,0; p=0,44). Após seguimento mínimo de 180 dias e máximo de dois anos, não houve diferença quanto a complicações mecânicas (24,7 vs 37,4... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Background: Few studies have evaluated the feasibility and results of peritoneal dialysis (PD) and hemodialysis (HD) at the urgent-start of renal replacement therapy (RRT). Objective: We compared PD and HD as options for urgent-start of RRT regarding the evolution, complications and outcomes of patients. Method: End-stage renal disease (ESRD) patients who initiated dialysis urgently without a pre-established functional vascular acess or PD catheter were included in a period between July/2014 to December/2016, from a Brazilian single centre. In urgent-start PD, nephrologists performed the Tenckhoff catheter insertions. It was used high volume PD (HVPD) right after 72 hours PD catheter placement, and it was kept until metabolic and fluid control. After hospital discharge, patients were treated with intermittent PD on alternate days at the dialysis unit, until family training. Results: Ninety-three patients in PD (G1) and 91 in HD (G2) were included. Comparing the G1 group with G2, they were similar in age (58±17 vs 60±15; p= 0.49), frequency of diabetes mellitus (37.6 vs 50.5%; p= 0.10), others comorbidities (74.1 vs 71.4%; p= 0.67) and biochemical parameters to early RRT - creatinine (9.1+4.1 vs 8.0+2.8; p= 0.09), serum albumin (3.1+0.6 vs 3.3+0.6; p= 0.06) and hemoglobin (9.5+1.8 vs 9.8+2.0; p= 0.44). There was no difference between the groups in mechanical complications (24.7 vs 37.4%; p= 0.06) and bacteremia (15 vs 24%; p= 0.11). Exit site infection (ESI) (25.8 vs 39.5%; p ... (Complete abstract click electronic access below) / Doutor

This thesis deals with the processing of a business plan in the health sector . This is a draft business plan strategy for the introduction of outreach services for ambulatory peritoneal dialysis patients in the private health care facilities . The theoretical part is devoted to the characteristics of the services provided, including a description of the current situation and possibilities in the treatment of peritoneal dialysis patients in the home environment in the Czech Republic and abroad. It is also described the concept of strategic management and planning, of which I have in this thesis was based on creating your own business plan. In the practical part , which includes the characteristics of an organization that will provide the service , I made a concrete proposal for a business plan based on identified strategic analysis of the findings . The conclusion is presented feedback from stakeholders, which I used in finalizing the business plan. The aim of the work was to present the methodology of the business plan , which will form the basis for strategic management of development organizations to expand services for patients through the introduction of outreach services for ambulatory peritoneal patients. Key words: business strategy, business plan, dialysis, peritoneal dialysis, assisted...

Thesis (M.Sc. (Statistics)) -- University of Limpopo, 2020 / Peritoneal Dialysis (PD) is a process of replacing kidney function which cleans waste from the blood and remove extra fluid from the body. In most cases, the process of PD is slowed down by a peritoneal membrane infection called peritonitis. Despite recent advancements in treatments and prevention, peritonitis still remains the leading complication which results in high morbidity and technique failure among PD patients. Using a prospective peritonitis dataset of 159 kidney patients who were on PD from 2008 to 2015 in Pietersburg Provincial Hospital, the aim of this study was to identify potential social, demographic and biological risk factors that contribute to the first episode of peritonitis. Both semi-parametric (Cox PH) and parametric (Accelerated Failure Time: Weibull, exponential, loglogistic, and gamma) survival models were fitted to the peritonitis dataset. Akaike Information Criterion (AIC) was applied to select models which best fit to the peritonitis data. Accordingly, log-logistic Accelerated Failure Time (AFT) model was found to be a working model that best fit to the data. A total of 96 (60.38%) peritonitis cases were recorded over the follow-up period with majority of peritonitis infection coming from females (65.4%) and rural dwellers (65.7%) with (62.6%) of black Africans showing higher risk of developing peritonitis. The multivariate log-logistic AFT model revealed that availability of water (p-value=0.018), electricity (p-value=0.018), dwelling (p-value=0.008), haemoglobin status (p-value=0.002) and duration on PD (p-value=0.001) are significant risk factors for the development of peritonitis. Therefore, patients with no water and electricity, coming from rural background with low level of haemoglobin and shorter duration on PD are associii ated with high risk or hazard of developing peritonitis for the first time.

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

published_or_final_version / Medicine / Doctoral / Doctor of Philosophy

published_or_final_version / Mental Health / Master / Master of Social Sciences

Este estudo teve como objetivo geral analisar a evolução clínica e a QVRS de pacientes em Diálise Peritoneal (DP), dois anos após a primeira avaliação. Trata-se de uma pesquisa observacional, descritiva e analítica de delineamento longitudinal, realizada nos serviços de Diálise Peritoneal, no município de Ribeirão Preto, Estado de São Paulo, entre 2010 e 2012, tendo sido aprovada pelo Comitê de Ética em Pesquisa sob número 1451/201. A primeira e a segunda etapas de coleta de dados foram realizadas pela pesquisadora, por meio de entrevistas, utilizando os instrumentos: Miniexame do Estado Mental, questionário de caracterização sociodemográfica, econômica, clínica e laboratorial e o Kidney Disease and Quality of Life. Foi realizada a análise descritiva dos dados sociodemográficos, clínicos, laboratoriais e de QVRS. Na análise da evolução da QVRS, foi utilizado o teste t pareado. Na determinação das variáveis preditoras de QVRS, foram empregados o teste t de Student e o Mann-Whitney, bem como o coeficiente de Correlação de Pearson. Na análise de sobrevivência, foram calculados o risco relativo não ajustado e o seu intervalo de confiança. Para estimar o risco de óbito, foram obtidas, também, as curvas de sobrevida pelo método de Kaplan-Meier, e na análise multivadiada, foram determinados os preditores de óbito, utilizando o modelo de riscos proporcionais de Cox. O nível de significância adotado foi de 5%. Dos 82 participantes da primeira etapa do estudo em 2010, na etapa de 2012 houve perda de seguimento de sete pacientes, 18 foram excluídos da avaliação da QVRS, e 23 tiveram como desfecho o óbito. Portanto 34 pacientes tiveram a QVRS reavaliada, em 2012. A maioria era mulher 21; (61,8%), idosa 19 (55,9%), com cor da pele branca 25 (73,5%), morava com o companheiro 25 (73,5%), aposentada 25 (73,5%), hipertensa 33 (97,1%), estavam em Díalise Peritoneal Ambulatorial Contínua (DPAC) 18 (52,9%), apresentavam níveis de hemoglobina 25; (73,5%) e produto cálcio/fósforo 29 (85,3%) normais e de paratormônio 24 (70,6%) alterados. O número de comorbidades e de complicações aumentou de 2,8 e 4,3 para 3,2 e 5,1, respectivamente. No período, o número médio de peritonites foi de 1,0 episódio, e a média de internações foi de 1,6 vez. Em relação à QVRS, após dois anos da primeira avaliação, os pacientes que permaneceram em DP apresentaram piora, nos escores médios do Funcionamento físico e Dor e melhora no Bem-estar emocional. As variáveis preditoras de piora da QVRS no Funcionamento físico foram a idade avançada e os maiores números de comorbidades e de complicações; esta última também foi preditora de piora da QVRS na dimensão Dor, enquanto o menor número de peritonite foi preditor de melhora na dimensão Bem-estar emocional. Sobre a análise de sobrevivência, o risco aumentado para o desfecho óbito e/ou menor sobrevida se relacionou com ter diabetes, ter quatro comorbidades ou mais, estar em DPAC, ter escore de QVRS na dimensão Funcionamento físico menor que 50. Conclui-se que a QVRS piorou nas dimensões Funcionamento físico e Dor e melhorou para o Bem-estar emocional, dois anos após a primeira avaliação. A pior QVRS, especificamente na dimensão Funcionamento físico, pôde ser considerada preditora de óbito / This study aimed to analyze the clinical evolution and HRQoL of patients under peritoneal dialysis (PD) two years after the first assessment. This is a longitudinal observational descriptive and analytical study performed in the Peritoneal Dialysis services in Ribeirão Preto, São Paulo state, between 2010 and 2012, previously approved by the Research Ethics Committee under number 1451/201. The first and second stages of data collection were performed by the researcher through interviews, using the following instruments: Mini Mental State Examination a questionnaire with sociodemographic, economic, clinical and laboratory data and the Kidney Disease and Quality of Life .A descriptive analysis of demographic, clinical, laboratory, and HRQoL data was performed. The paired t test was used for the analyzis of the HRQoL evolution. In order to determine the predictors of HRQoL, the Student\'s t test, the Mann-Whitney\'s test, and the Pearson\'s correlation coefficient were used. For the survival analysis, the unadjusted relative risk and its confidence interval were calculated. The risk of death was estimated through the Kaplan-Meier\'s survival curves. The predictors of death were determined by multivariate analysis through Cox proportional hazards model. The level of significance adopted was 5%. Out of the 82 participants in the first stage of the study in 2010, seven had been lost to follow in the 2012 step, 18 were excluded from the assessment of HRQoL and 23 had died. Therefore, 34 patients had HRQoL reassessed in 2012. Most were women 21 (61.8%), elderly 19 (55.9%), caucasian 25, (73.5%) lived with a partner 25, (73.5%), retired 25 (73.5%), hypertensive 33 (97.1%), under Continuous Ambulatory Peritoneal Dialysis (CAPD) 18 (52.9%), with normal hemoglobin 25 (73.5%) and calcium-P product levels 29 (85.3%) and altered parathyroid hormone levels 24 (70.6%). The number of comorbidities and complications increased from 2.8 and 4.3 to 3.2 and 5.1, respectively. During the follow-up period, the average number of peritonitis episodes was 1.0, and the average number of hospitalizations was 1.6. Regarding HRQoL, two years after initial assessment, patients who remained on PD had worse mean scores of Physical functioning and Pain and better Emotional well- being. The predictors of worsening HRQoL Physical functioning were older age and greater numbers of comorbidities and complications. A greater number of complications was also a predictor of worsening HRQoL Pain, whereas a lower number of peritonitis episodes was predictive of improvement in the Emotional well- being dimension. On the survival analysis, the increased risk for the outcome of death and/or shorter survival was associated with having diabetes, having four or more comorbidities, being under CAPD and having a HRQoL score smaller than 50 in the Physical functioning dimension. It was concluded that HRQoL was worse in the Physical functioning and Pain dimensions and improved in the Emotional well-being dimension two years after the first assessment. Worse HRQoL, specifically in the Physical functioning dimension, was a predictor of death