Diss. (sammanfattning) Stockholm : Karol. inst. / Härtill 7 uppsatser.

Thesis (M. Res.(Med.))--University of Hong Kong, 2008. / Includes bibliographical references (p. 106-130)

Thesis (M.S.)--Virginia Commonwealth University, School of Nursing. / Includes bibliographical references (leaves 48-52). Also available online.

The management of people on dialysis is complex and requires a multi-disciplinary multi-professional approach. Observational studies in dialysis care have demonstrated a correlation between key clinical indicators and survival. However, achieving change in such a complex setting is difficult, with limited evidence from controlled studies of the effectiveness of interventions to improve these indicators. There is little evaluation of how best to implement and sustain known best practice into clinical care. UK renal registry data shows that whilst overall standards have improved, variation between units remains unchanged. This variation demonstrates that feedback alone is not enough to implement best practise, and that it is also necessary to understand cultural, structural, organisational and process factors. Quality Improvement (QI) is the process by which change can be implemented in systems. Methodologies vary, and highlight the need for bespoke approaches tailored to fit the clinical context. In 2010 the Salford Royal renal network introduced a two-year programme of QI to improve clinical indicators in dialysis care. Results were followed up on completion of the programme to establish whether outcomes were sustained. This thesis starts with a literature review summarising the evidence to date on modifiable factors affecting outcomes in renal replacement therapy and the rationale for addressing these factors in our chronic dialysis population, the development of QI in healthcare, and the evidence for its use to improve outcomes in renal replacement therapy. The first aim of this thesis was to analyse the outcomes of the Salford quality improvement programme. This found that the programme was successful in improving attainment of clinical indicators, and there was evidence of a reduction in hospitalisation and its associated costs. The second aim was to analyse in more detail one aspect of the programme- reduction in peritonitis. Key themes that emerged from this were the role of audit and continuous measurement, the importance of local leadership, learning from best practice elsewhere, and a patient-centred approach to reducing avoidable harm. The last question centred on the sustainability of results. Review of two years' follow up data on urea reduction ratio and bacteraemia identified that whilst not all changes to practice were sustained, both improved clinical outcomes were broadly sustained. However, additional themes emerged from the analyses, highlighting the need to embed ongoing continuous review into practice. Finally, I have described potential future work arising from this thesis.

Background: Tuberculosis (TB) now ranks as the leading cause of death from a single infectious agent worldwide. Patients on dialysis are particularly vulnerable to TB infection due to immune dysfunction. Despite this, there is a paucity of incidence data on TB in dialysis patients in high burden settings such as South Africa. The aim of this study was to determine the incidence of TB in chronic kidney disease stage 5 patients on dialysis (CKD-5D) at a single centre in the Eastern Cape, South Africa and to identify risk factors associated with TB infection. Methods: We conducted a retrospective cohort study of all consenting prevalent CKD-5D patients between April 2010 and March 2014 at the Livingstone Tertiary Hospital Renal Unit in the Eastern Cape, South Africa. TB was defined as “definite” or “probable” according to WHO criteria. Results: One hundred and eleven patients were enrolled: they were predominantly black African (73%) and female (53%); mean age was 42 years (SD ±9years). The prevalence of HIV infection was 11%: all were on antiretroviral treatment and all had suppressed viral loads. Sixty eight patients were on haemodialysis (HD) and 43 patients were on peritoneal dialysis (PD). Nineteen patients were diagnosed with 20 episodes of TB; 14 cases were pulmonary and 6 cases extrapulmonary. Of the patients with TB, 2 were HIV infected. Of the 20 TB cases, 7 (35%) were definite TB cases and 13 (65%) had probable TB. The calculated incidence rate was 4505 per 100 000 patient years. Only informal housing and a history of hospitalization were significantly associated with a diagnosis of TB. Conclusion: Dialysis patients in the Eastern Cape region of South Africa are at extremely high risk for the acquisition of TB with an incidence rate that is 4.1 times that of the local Nelson Mandela Bay population and over 5 times that reported in the general population for the country as a whole. Only informal housing and a history of hospitalization were identified as positive risk factors in this young population with a low HIV prevalence. Isoniazid prophylaxis in this high risk group might be of benefit but further studies are required to inform such treatment.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, in partial fulfilment of the requirements for the degree of Master of Medicine in Anaesthesia Johannesburg, 2015 / Patients with chronic renal failure are considered to be at risk of perioperative pulmonary aspiration and consequently the recommendation is to perform a rapid sequence induction on such patients. Rapid sequence induction is not without its risks and may not be necessary. The aim of this study was to determine whether patients who are on a chronic haemodialysis program have sufficient residual gastric contents after an overnight fast, to place them at risk of pulmonary aspiration of gastric contents during anaesthesia. The presence and volume of gastric content was ascertained by ultrasound examination of the stomachs of twenty patients. Patients were asked to fast overnight and an ultrasound was scheduled for a morning on which the patient was due to come in for a dialysis session. The appearance of the stomach and the contents were graded by the radiologist and the diameters of the gastric antrum were then measured so that the cross sectional area could be calculated. Once the cross sectional area was known the gastric volume was calculated using a validated equation. The risk of perioperative pulmonary aspiration was then assessed according to the graded appearance as well as calculated gastric volumes. If the stomach was found to contain fluid a cut off value of 0.8ml/kg was used as a relative gastric volume that would place the patient at increased risk of perioperative pulmonary aspiration. Any patient with a gastric antrum found to be distended with fluid in both the supine and lateral positions or seen to contain solid contents was assessed as being at increased risk of perioperative pulmonary aspiration. Gastrointestinal symptoms were assessed and compared to residual gastric volumes. Urea and creatinine concentrations were also correlated to residual gastric volumes. In this study none of the patients with chronic renal failure on a chronic haemodialysis program were considered to be increased risk of perioperative pulmonary aspiration, after an overnight fast. Gastrointestinal symptoms were found in 60% of patients. There was no association between gastrointestinal symptoms and residual gastric volumes. There was no correlation between either urea or creatinine levels and residual gastric volumes.

A research report submitted in partial fulfilment of the requirements of the Master of Medicine at the University of Witwatersrand. Johannesburg, 16 April 2018. / Background: Chronic kidney disease and end stage kidney disease are becoming a huge health challenge. The optimal treatment is renal transplantation but due to low rates of transplantation most patients who are enrolled in the chronic renal replacement programme are on dialysis. This study aimed at investigating demographic and social factors that are associated with the outcomes of peritoneal dialysis (PD). The study also investigates how co-morbidity contributed to the outcomes of PD. Methods: The study makes use of retrospective analysis of demographic data (age, marital status, residential area, race) and socioeconomic status, level of education, family support, poor access to health care system as well as co-morbidities and underlying cause of ESKD, obtained from 167 patients who were enrolled on continuous ambulatory peritoneal dialysis (CAPD) over the period of 2008 - 2012 at the Charlotte Maxeke Academic Johannesburg Hospital (CMJAH). The data analysis for the present study was conducted using STATA version 14.0. To describe the demographic characteristics of the patients, frequency tables were computed for all categorical variables. For continuous variables, the Shapiro Wilk test for normality was used to assess the distribution of the data to report the appropriate central tendency measure i.e. mean±SD or median (IQR). To assess the contribution of demographic factors to the overall outcome of CAPD, a Fisher’s exact test of comparison was used to assess the difference between the proportions for each demographic factor and CAPD outcome. The Fisher exact test was used because the proportions for each frequency table included a proportion below five (<5). To assess how the relationship of demographic and co-morbid disease affects the outcome of the treatment, a multivariate logistic regression model was fitted adjusting for co-morbid disease for each of the demographic factors. Findings and interpretation: Of 167 patients enrolled, the majority were black with low levels of education, living in townships and 56% were on subsisting on disability grants. PD failure occurred in 53.3% of patients over the study period and 46.7% were successful on PD. Of the variables tested, age was statistically significant for CAPD outcomes [Fisher exact test (p= 0.004)], indicating a significant difference in the proportion of CAPD outcomes among different age categories). The univariate and multivariate logistic regression analysis did not show significant association with CAPD outcomes. Adherence also significantly impacted on outcomes in both univariate and multivariate analyses, showing that non-compliant patients were less likely to have successful outcomes on PD. In addition, the Fisher exact test showed no significant difference in the distribution of CAPD outcome with marital status while the multivariate analysis showed that single patients were three times more likely to succeed with PD compared to married patients. These could be due to chance, because of the small sample size, and require further investigation. Conclusions: Prospective studies are needed to fully understand the extent that demographic and socioeconomic factors impact on the outcomes of PD. This will assist in formulating comprehensive recommendations and ways to improve PD utilization and outcomes. / LG2018

published_or_final_version / Chemistry / Master / Master of Philosophy

by Wing-cheung Pang. / Thesis (M.Sc.)--Chinese University of Hong Kong, 1988. / Bibliography: leaves 45-56.

Introducción: En pacientes con Enfermedad Renal Crónica Terminal (ERCT), la mortalidad cardiovascular está asociada a la presencia de calcificaciones vasculares. Nuestro objetivo fue determinar la asociación entre la modalidad de diálisis y la presencia de calcificación en aorta abdominal en pacientes con ERCT. Métodos: Realizamos un estudio transversal mediante el censo de los pacientes de la unidad renal del Hospital Nacional Edgardo Rebagliati Martins (HNERM), Lima-Perú. Las calcificaciones se evaluaron con radiografías simples de abdomen lateral. Comparamos la proporción de sujetos con calcificaciones según modalidad de diálisis. Calculamos razones de prevalencia mediante la regresión log-binomial. Resultados: Enrolamos 224 pacientes de los cuales 75,4% (169/224) estaban en hemodiálisis y 24.6% (55/224) en diálisis peritoneal. La edad mediana fue 57 años y el 49.1% (110-224) eran mujeres. El 31.3% (70/224) tuvo calcificaciones en aorta abdominal. La modalidad de diálisis no presentó asociación significativa con la presencia de calcificaciones. Sin embargo, la significancia presento valores límites. Los niveles altos de paratohormona estuvieron asociados en forma independiente con las calcificaciones. Conclusiones: Nuestro estudio sugiere que la diálisis peritoneal podría asociarse a una mayor presencia de calcificaciones vasculares a comparación de la hemodiálisis por ser la significancia límite debido al pequeño tamaño muestral. La evaluación rutinaria de calcificaciones a lo largo del tratamiento de soporte dialítico debe ser promovida en esta población. / Background: Presence of vascular calcifications is associated to cardiovascular mortality in patients with terminal chronic renal disease (ESRD). The aim of the present study is to determine the association between dialysis modality and the presence of vascular calcification. Methods: Vascular calcification was detected by plain lateral abdominal radiograph. We calculated the proportion of vascular calcification associated whit dialysis modality obtaining adjusted prevalence ratios from logistic regression models in this cross- sectional study. Results: We studied a total of 224 patients, 75.4 % (169/224) were on hemodialysis and 24.6% (55/224) on continuous ambulatory peritoneal dialysis. The median age was 57 years –old and 49.1% (110-224) were female. Abdominal aortic calcification was detected in 31.3% (70/224). Higher parathyroid hormone level (PTH) was an independent factor associated whit vascular calcification. Conclusions: Our study suggests that peritoneal dialysis could be associated a higher presence of vascular calcification but we did not find a significance result due to small sample. The continuous evaluation in this group of patients must be encouraged to prevent further complications. / Tesis