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A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg in partial fulfilment of the requirements for the degree of Master of Science in Nursing Johannesburg, 2016 / The purpose of the study was to determine knowledge of nephrology nurses’ on evidence based guidelines for the prevention of haemodialysis catheter related infections. The study was done in 5 haemodialysis units from two university-affiliated, public sector and tertiary level hospitals in Gauteng which are: “Baragwanath Hospital and Charlotte Maxeke Academic Hospital”. Face and content validation of the research instrument “Evaluation questionnaire concerning nurses’ knowledge of interventions for prevention of haemodialysis catheterrelated bloodstream infections” was done by a panel of experts to ensure applicability of the instrument to the South African context. Prior to commencement of the study, ethical clearance and permission to conduct the study was obtained from the relevant authorities and the university committee. A non-experimental, descriptive, prospective study design was utilised in order to meet the objectives of the study. Descriptive and comparative statistics were used to analyse the data which was done in consultation with a statistician. Knowledge was reorganised as poor (0-50%), average (50-70%) and good (71% and above). Overall, participants performed well in the second part of the questionnaire where their knowledge was tested regarding evidence based guidelines in prevention of vascular access infection; the majority 72.50% (n=58) scored more than 71%, indicating they have knowledge of evidence based guidelines on prevention of vascular access infection, 20% of participants scored between 51 and 70%, whilst only 2% scored below 50%. A positive correlation (with moderate strength) between age and experience (r=0.563) was established indicating that as age increases the experience will also increase moderately. A slight negative correlation, which was very weak (null correlation) was also established between years of experience and performance as most respondents were above and below the regression line. Therefore years of experience has no influence over performance. / MT2016

Left ventricular hypertrophy (LVH) and increases in large artery stiffness predict cardiovascular outcomes in patients with renal failure. What determines left ventricular mass index (LVMI) and large artery stiffness and the contribution toward LVH and large artery dysfunction is not entirely clear. Consequently, this cross sectional study was aimed at assessing the various factors impacting on LVH in haemodialysis (HD), to contribute toward our understanding of the pathophysiology of LVH and large artery dysfunction in 94 adult HD patients. Pre- and post-dialysis blood pressures (BPs) were determined over 12 sessions of dialysis and averaged. Pulse wave analysis performed at the carotid, femoral and radial arteries was employed to determine pulse wave velocity (PWV) and central augmentation index (AIc). Echocardiography was performed to determine left ventricular mass (LVM) indexed to body surface area (LVMI). Natriuretic peptides, procollagen type I c-peptide (PIP), c-terminal telopeptide of type I collagen (ICTP), matrix metalloproteinases and their inhibitors were studied. The prevalence of LVH was 72.8 % (67/92) .On multivariate analysis pre- (p≤ 0.005), post- (p<0.05) and averaged dialysis (p < 0.015) systolic BP were associated with LVMI and PWV. 24 hour (r = 0.260, p = 0.026), day (r = 0.247, p = 0.036), and night (r= 0.241, p = 0.042) systolic BP were not more closely associated with LVMI than the averaged dialysis systolic BP (r = 0.272, p = 0.010). Similarly 24 hour (r = 0.41, p = 0.0003), day (r=0.400, p = 0.0005), and night (r =0.416, p = 0.0003) systolic BP were not more closely associated with PWV than the post-dialysis systolic BP (r=0.39, p=0.0001) indicating that these BP measurements are as effective as 24-hour ambulatory BP in predicting cardiovascular target organ changes. No relationship between either PWV (r=-0.08), or AIc (r=-0.10) and LVMI, between PWV (r=-0.11), or AIc (r=0.03) and LV MWT was noted. IVCD was independently associated with LVMI (partial r adjusted for average dialysis SBP=0.27, p=0.014; partial r adjusted for 24-hour SBP=0.29, p=0.013), and LV mean wall thickness (p<0.01), but not with LV relative wall thickness (p=0.18), or LV end diastolic diameter (p=0.88). An association between IVCD and AIc (partial r adjusted for average dialysis SBP=0.21, p<0.05), but not PWV was noted. NT-proANP and NT-proBNP were independently associated with LVMI (p<0.0001) but neither were associated with IVCD independent of LVMI suggesting a close association with LVMI in HD. Serum concentrations of matrix metalloproteinases 1, 2 and 9, and their tissue inhibitors (1 and 2) were not associated with LVMI, remodelling or PWV and neither procollagen I nor the C-terminal telopeptide of type I collagen (ICTP) were associated with LVMI. Thus, factors impacting on LVH in this study were systolic BP, NT-proANP, NT-proBNP and IVCD.

Background: Direct patient care is a term being used within nursing and healthcare. The term is used to explain what the nursing and clinical support staff are doing during a rostered shift. One particular area in which patients attend regularly and require a large amount of nursing support is the haemodialysis unit. Patients attend this department usually for three to six hours, with treatment lasting from three hours to over five hours. Patients require to attend three times a week to receive long but lifesaving treatment through one form of renal replacement therapy. Aim: This doctoral research was designed to explore the idea of ‘direct patient care’ within one specific context, where patients spend a great deal of time in a healthcare setting- the haemodialysis out-patient unit. This study aimed to explore nursing staff’s and patients’ experiences and perceptions of direct patient care in this area. Methods: The research used an ethnographic approach, using an insider as the researcher, due to holding an existing nursing position in the area, and was conducted between December 2013 - August 2014. The research considered both registered nurses and healthcare support workers, as well as patients, as participants. Data was initially collected using participant observation; using fieldnotes, informal questioning and photographs. Observation sessions lasted between 4-6 hours covering the different days and shifts. 27 Semi-structured interviews were also used in a small purposive sample of all participant groups. This variety of methods allowed for the views and experiences of haemodialysis patients, registered nurses and clinical support workers to be gained. Results/Findings: The analysis uncovered that direct patient care was the provision of safe, comfortable and individualised care. Direct patient Care was then identified to be delivered in two ways- actively or passively. Active care follows the more traditional understanding of time together, through engagement or interaction. Passive care identifies that staff being visible and available for patients, despite not being in close proximity or directly caring for patients, still allows a patient to be cared for, and in turn, staff feel they are caring for the patients during their time in this environment. Underpinning both of these ways of direct patient care delivery is the individual connection between the member of staff and the patient. The connections within the haemodialysis unit are part of this ability to deliver active and passive care. The individual connection between a patient and either a registered nurse or support worker facilitates this. The familiarity of each of these groups to each other, rapport, trust and being interested allow for this individual connection. Conclusion: Direct patient care in the haemodialysis unit can be understood using a conceptual model, where the process of delivering this direct patient care is either by active or passive care, with both allowing the provision of safe, comfort and individualised as part of direct patient care.

Die Hämodialyse ist das am weitesten verbreitete Verfahren zur Nierenersatztherapie in Deutschland. In Verbindung mit der Nierentransplantation gelingt es damit heute, das Leben junger betroffener Patienten bei guter Lebensqualität um Jahrzehnte zu verlängern. Die überwiegende Mehrzahl der jährlich neu hinzukommenden Patienten ist jedoch über 65 Jahre alt, weist eine hohe Komorbidität auf und toleriert Standard-Hämodialysebehandlungen weit weniger gut. Daraus resultieren höhere Anforderungen an eine Individualisierung der Dialysetherapie. Neue technische Verfahren bieten dafür vielversprechende Ansätze, die hier näher vorgestellt werden sollen. Dies betrifft zum einen die exakte Messung der Flüssigkeitskompartimente des Körpers mittels Bioimpedanz-Spektroskopie. Andererseits kann durch die Implementierung geschlossener Regelkreise zwischen Patient und Maschine die individuelle Behandlungstoleranz signifikant erhöht werden. / Haemodialysis is the most significant method in renal replacement therapy in Germany. In alliance with kidney transplantation, it offers survival over decades with a reasonable good quality of life – especially to young patients. Today, however, the vast majority of incident patients are older than 65 years and display a considerable degree of co-morbidity, which in turn reduces their tolerance of standard treatment. New tools for an individualisation of haemodialysis therapy are therefore clearly needed. The most promising technical developments in this context are summarised here, including precise measurement of the fluid compartments in patients by way of bioimpedance spectroscopy, as well as closed feedback loops for a tighter integration between patient and dialysis machine.

Introduction with Hypothesis/Objective: Management of long-term conditions requires a holistic approach, which places equal emphasis on the biomedical and the psychosocial. In chronic kidney disease (CKD), whilst biochemical and haematological parameters are routinely measured in accordance with UK Renal Association Standards and Guidelines this is not the case for health-related quality of life (HRQoL).There is evidence that achieving Renal Association biochemical/haematological targets improves mortality & morbidity. However, little evidence is available on whether achieving these targets enhances health-related quality of life (HRQoL). This study’s primary aim was, therefore, to determine whether there was any association between the extent to which patients achieved Renal Association biochemical and haematological targets and their HRQoL. A secondary aim was to explore the association between demographic and other treatment-related factors and HRQoL.Methods: A cross-sectional postal survey was conducted, involving 301 adult maintenance haemodialysis patients (age 18 + yrs.) in North-west England. HRQoL data were collected using the KDQoL-SF and patient records were searched for demographic variables and key biochemical/haematological markers derived from the UK Renal Association Standards and Guidelines. Biomarker achievement was categorised as ‘low achievers’ (patients who reached 0 – 2 Renal Association targets), ’medium achievers’ (3 – 5 targets) and ‘high achievers’ (6 – 8 targets). Data were initially analysed descriptively then using univariate and multivariate (multiple regression) analysis. Results: Participants were older (mean age 63.4 years), mostly male (64.0%) and predominantly white (87.0%); they had been on HD for a mean of 42.0 months (median 28.0). Patients typically had low scores for most aspects of HRQoL. For Renal Association targets, 5.6 % of the sample were ‘low achievers’, 57.1% ‘medium achievers’ and 35.2% ‘high achievers’. Apart from the KDQoL-SF subscale of symptom/problem list (medium achievers p<0.012, high achievers p<0.009), there was no association between HRQoL and the level of RA biomarkers achieved. Being Asian was negatively associated with several KDQoL-SF subscales. Increased age was positively associated with many subscales, suggesting a better toleration of poor health in older patients. The individual biomarker albumin was negatively associated with a number of the KDQoL subscales. Conclusion: The study’s findings demonstrate little association between achievement of Renal Association biochemical/haematological targets and HRQoL. A more holistic approach is required to address other aspects of physical and psychological health. Guidelines are needed that contain recommendations for routine monitoring of HRQoL scores. There is a need for better recognition of HRQoL as a specific treatment goal.

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<p>Abstract</p><p>The aim of the study was to examine the relation between estimated fluidintake and real fluidintake among dialysis patients. The data were collected through study specific questionnaire and data from the medical record. Patients attached to eleven Swedish dialysis units were asked to participate. The number of patients that fulfilled the inclusion criteria were 222 persons of whom145 (65%) chose to participate in the study. The dialysis patients estimated their fluid intake for a day in average 9,06 deciliter. The dialysis patients real fluid intake for a day were in average 10,34 deciliter. The results showed that 58% of the dialysis patients that participated in the study had an estimated fluid intake less than what they actually consumed. The relation between estimated fluid intake and real fluid intake was r=0,288, which showed a fairly poor relation.</p>

Abstract The aim of the study was to examine the relation between estimated fluidintake and real fluidintake among dialysis patients. The data were collected through study specific questionnaire and data from the medical record. Patients attached to eleven Swedish dialysis units were asked to participate. The number of patients that fulfilled the inclusion criteria were 222 persons of whom145 (65%) chose to participate in the study. The dialysis patients estimated their fluid intake for a day in average 9,06 deciliter. The dialysis patients real fluid intake for a day were in average 10,34 deciliter. The results showed that 58% of the dialysis patients that participated in the study had an estimated fluid intake less than what they actually consumed. The relation between estimated fluid intake and real fluid intake was r=0,288, which showed a fairly poor relation.

A study was done to examine factors that facilitate adherence to haemodialysis therapy amongst patients with chronic renal failure and the sources of support available to them. A self developed questionnaire was used to collect data from the respondents. The respondents were purposive and conveniently selected according to the set criteria. The sample consisted of 118 respondents that were selected from four hospitals, two provincial hospitals and two private hospitals. Permission to conduct the study was requested by means of written letters to all people concerned. Letters granting permission were obtained from the two provincial hospitals. The Heads of the Renal Units of the two private hospitals gave verbal permission. Data was analyzed using the Statistical Package for the Social Sciences (SPSS 11.5). Demographic data was analysed through frequency counts. Crosstabulations using Chi-square analysis was performed to test the relationship between the factors that facilitate adherence to haemodialysis therapy and the indicators for adherence. The results were presented in the form of Tables and Figures (Graphs). From the findings the researcher concluded that in order for a haemodialysis patient to adhere to therapy restrictions, the following should be adequate: physical factors, socio-economic factors, psychosocial factors which also encompasses cultural factors. Health education proved to be having a very good impact. Higher level of education is not that essential as long as the patient can read, write and understand the instructions. Religious factors did not have much effect on facilitation of adherence to haemodialysis therapy. / Thesis (M.A.)-University of KwaZulu- Natal, Durban, 2004.