Introdução: Doença Renal Crônica (DRC) consiste, principalmente, na redução da capacidade dos rins em filtrar substâncias tóxicas, acarretando alterações metabólicas e hormonais. Em fases terminais, a terapia renal substitutiva (TRS) torna-se necessária, e o transplante renal tem sido relatado como a melhor opção terapêutica e de reabilitação para pacientes com DRC. Entretanto a DRC e o transplante renal podem afetar a qualidade de vida relacionada à saúde (QVRS) desses pacientes, podendo ser influenciada por aspectos da saúde física e mental, tais como os sintomas depressivos (SDs). Objetivos: Caracterizar os pacientes com DRC, após transplante renal, em um município do estado de São Paulo quanto aos aspectos sociodemográficos, econômicos e clínicos; descrever a QVRS e os SDs; correlacionar a QVRS e os fatores sociodemográficos, econômicos e clínicos; comparar a QVRS, segundo as dimensões do SF-36, entre os pacientes sem e com SDs e correlacionar a QVRS com os SDs. Material e Método: Trata-se de um estudo transversal, de natureza quantitativa, que incluiu pacientes que realizaram transplante renal entre 6 e 24 meses retroativos da data de início da coleta de dados, maiores de 18 anos e faziam acompanhamento no ambulatório de Transplante Renal do HCFMRP-USP, na cidade de Ribeirão Preto-SP. Foram excluídos os pacientes que apresentavam instabilidade clínica, o que totalizou a inclusão de 60 pacientes no estudo. Os instrumentos utilizados foram: instrumento para caracterização dos participantes, o qual foi adequado ao estudo e submetido à avaliação de conteúdo, Medical OutcomesStudy (MOS SF-36) para avaliação da QVRS e o Inventário de Depressão de Beck (IDB) para avaliar os SDs. Os dados foram obtidos por meio de entrevista individual com o paciente e de consulta ao prontuário. A coleta de dados ocorreu de abril a agosto de 2011. O projeto foi aprovado pelo Comitê de Ética em Pesquisa da Escola de Enfermagem de Ribeirão Preto - Universidade de São Paulo. A análise dos dados constou da análise estatística descritiva; coeficiente de correlação de Pearson (r) para verificar a correlação entre os domínios do SF-36 com o escore total do IBD; análise de variância (ANOVA) para comparar os domínios do SF-36, nos grupos com ausência e com presença de SD; Teste Exato de Fisher para verificar a associação entre as variáveis qualitativas relacionadas ao escore de IDB e às diversas variáveis independentes, além disso, a quantificação da associação foi mensurada por meio de modelos de regressão logística na qual calculamos o OddsRatio Bruto com seus respectivos intervalos de confiança de 95%. Todas as análises estatísticas foram realizadas com a utilização do software estatístico SAS® 9.0. Valores de p menores que 0,05 foram considerados significativos. Resultados: Dos 60 pacientes, 51 eram adultos e 9 idosos; 41 eram homens e 19 eram mulheres. Os domínios do SF-36 que obtiveram menores escores médios foram: aspectos físicos (59,58), capacidade funcional (64,67) e vitalidade (71,42), e os que obtiveram maiores escores médios foram: aspectos sociais (79,79), dor (78,12) e aspectos emocionais (75,56). Quanto aos escores do IDB, 43 pacientes apresentaram ausência de SDs, 12 apresentaram disforia e 5 apresentaram SDs classificados entre leves e moderados. Não possuir trabalho aumentou a chance em 7,7 vezes de ter SDs que ter trabalho. Os pacientes com ausência de SDs apresentaram escores médios mais elevados nos domínios do SF-36, refletindo melhor QVRS, quando comparados aos pacientes com algum grau de SDs, com notória diferença na comparação (p<0,05). Encontramos correlações negativas entre os domínios do SF-36 e os escores do IDB, ou seja, à medida que aumentaram os escores de SDs, decresceram os escores médios nos domínios de QVRS. Tais correlações apresentaram p valor <0,05, exceto para o domínio estado geral de saúde. Conclusão: A presença de SDs se relacionou negativamente com a QVRS dos pacientes transplantados renais, evidenciando a necessidade de incluir a avaliação dos sintomas depressivos e respectivos atendimentos das alterações quando identificadas, na prática clínica que engloba a atuação do enfermeiro, para otimizar a QVRS desses pacientes. / Introduction: Chronic Kidney Disease (CKD) mainly involves the decrease in the kidney\'s ability to filter toxic substances, causing metabolic and hormonal alterations. In terminal stages, renal replacement therapy (RRT) becomes necessary, and kidney transplantation has been reported as the best treatment and rehabilitation option for CKD patients. CKD and the kidney transplantation can affect these patients\' healthrelated quality of life (HRQoL) though, which can be influenced by physical and mental health aspects, including depressive symptoms (DS). Aims: Characterize CKD patients after kidney transplantation in a city in São Paulo State regarding socio-demographic, economic and clinical aspects; describe HRQoL and DS; correlate HRQoL with the socio-demographic, economic and clinical factors; compare HRQoL, according to the SF-36 dimensions, between patients with and without DS and correlate HRQoL with the DS. Material and Method: This quantitative and crosssectional study included patients who underwent a kidney transplantation between 6 and 24 months before the start of data collection, over 18 years of age and monitored at the Kidney Transplantation outpatient clinic of HCFMRP-USP in RibeirãoPreto-SP, Brazil. Clinically unstable patients were excluded, totaling 60 patients included in the study. The following instruments were used: patient characterization instrument, which was adapted to the study and submitted to content assessment, Medical Outcomes Study (MOS SF-36) for HRQoL assessment and Beck\'s Depression Inventory (BDI) for the assessment of DS. Data were collected through an individual interview with the patient and consultation of patient files. Data collection took place between April and August 2011. Approval for the project was obtained from the Institutional Review Board at the University of São Paulo at RibeirãoPreto College of Nursing. Data analysis comprised descriptive statistical analysis; Pearson\'s correlation coefficient (r) to check the correlation between the SF-36 domains and the total BDI score; variance analysis (ANOVA) to compare the SF-36 domains in the groups with and without DS; Fisher\'s Exact Test to verify the association between the qualitative variables related to the BDI score and the different independent variables. In addition, the association was quantified through logistic regression models, in which the Gross Odds Ratio was calculated with its respective 95% confidence intervals. SAS® 9.0 statistical software was used for all statistical analyses. P-values inferior to 0.05 were considered significant. Results: 51 out of 60 patients were adults and 9 elderly; 41 were men and 19 women. The SF-36 domains with the lowest mean scores were: physical aspects (59.58), functional capacity (64.67) and vitality (71.42); while the domains with the highest mean scores were: social aspects (79.79), pain (78.12) and emotional aspects (75.56). As for the BDI scores, 43 patients presented absence of DS, 12 dysphoria and 5 DS classified between mild and moderate. Not having a job increased the chance of DS by 7.7 times. Patients without DS obtained higher mean scores on the SF-36 domains, reflecting a better HRQoL in comparison with patients with some degree of DS, with a statistically significant difference (p<0.05). We found negative correlations between the SF-36 domains and the BDI scores, that is, to the extent that DS scores increased, the mean scores on the HRQoL domains dropped. The p-value for these correlations was <0.05, except for the general health status domain. Conclusion: The presence of DS was negatively related with the HRQoL of kidney transplant patients, evidencing the need to include the assessment of depressive symptoms and attend to the alterations when identified in clinical practice, which includes nursing actions, in order to improve these patients\' HRQoL.

A hiperfosfatemia em pacientes com doença renal crônica pode levar a complicações como o desenvolvimento do distúrbio mineral e ósseo (DMO) e a calcificação de tecidos moles. As estratégias terapêuticas para o controle da hiperfosfatemia na DMO visam à redução da ingestão de fósforo, redução da absorção intestinal por meio de quelantes e remoção por meio da diálise. O objetivo desse estudo foi elaborar e aplicar uma tabela de contagem de fósforo (TCF) para controle da hiperfosfatemia em pacientes em hemodiálise. Foram selecionados 50 pacientes, os quais tiveram o uso de quelantes de fósforo suspenso trinta dias antes do início da intervenção. Foi realizada a avaliação do estado nutricional (EN) por meio da avaliação subjetiva global, índice de massa corporal e coletado dados dietéticos por meio de registro alimentar (RA). Após 30 dias da suspensão do quelante (T0), no final do 1º e 2º mês de intervenção (T1 e T2) foram realizadas coletas de sangue para análise de exames bioquímicos, visando auxiliar na avaliação do EN e observar os níveis séricos de fósforo, cálcio, hormônio da paratireoide (PTH) e produto cálcio-fósforo (CaxP). No T0 os pacientes receberam orientação nutricional por meio da TCF, a qual seguiram por um período de 2 meses, com acompanhamento quinzenal. Ao final do estudo foi realizada nova avaliação do EN e aplicado novo RA. Não foi encontrada alteração nos níveis séricos de fósforo e no produto CaxP ao final da intervenção. Já o cálcio sérico reduziu de T0 para T1 (p=0,05). Quando a amostra foi classificada de acordo com a aderência à TCF, o grupo aderente não apresentou alteração do fósforo e cálcio séricos, porém o produto CaxP do T1 (p=0,05) e T2 (p=0,02) diminuíram em relação ao T0. Já para o grupo não aderente houve aumento de T0 para T2 para o fósforo sérico (p=0,007) e produto CaxP (p=0,03), assim como de T1 para T2 (p=0,05 e p=0,05 respectivamente). O cálcio sérico não se alterou nesse grupo. O PTH aumentou ao final do estudo no grupo total (p<0,001), no aderente (p=0,002) e no não aderente (p=0,002). Não foi observado prejuízo do EN e alteração na ingestão de fósforo segundo o RA após a intervenção. Esse estudo mostrou que a TCF auxilia no controle dos níveis séricos de fósforo, talvez sem a necessidade do uso de quelantes de fósforo ou o uso em doses menores e demonstrou, também, que se for seguida corretamente permite ao paciente o autoajuste da dieta. / The hyperphosphatemia in patients with chronic kidney disease can lead to complications such as the development of mineral and bone disorder (BMD) and soft tissue calcification. The therapeutic strategies for the control of hyperphosphatemia in patients with BMD include intake reduction of phosphorus, reduction of the intestinal absorption through chelation and removal by dialysis. The aim of this study was to develop and apply a phosphorus counting table (PCT) for the control of hyperphosphatemia in hemodialysis patients. Were selected 50 patients and they had phosphate binders suspended thirty days prior to the start of the intervention. At this period was evaluated the nutritional status (NS) by subjective global assessment, body mass index and collected dietetic information through food records (FR). After 30 days of suspension of the phosphate binder (T0), at the end of the 1st and 2nd month of intervention (T1 and T2) were collected blood samples for analysis of biochemical tests to assist in the evaluation of NS and to analyze the serum phosphorus, serum calcium, serum parathyroid hormone (PTH) and calcium-phosphorus (CaxP) product. At T0 the patients received nutrition orientation through the PCT, which was followed by a period of two months monitored biweekly. At the end of the study was realized a new evaluation of the NS and applied new FR. There was no change in serum phosphorus levels and the CaxP product in the end of intervention. Serum calcium decreased in time T0 to T1 (p=0.05). When the sample was divided according to the adherence to PCT, the adherent group showed no change in serum phosphorus and calcium, however the CaxP product at T1 (p=0.05) and T2 (p=0.02) decreased in respecting T0. Whereas non-compliant group showed an increase at T0 to T2 for phosphorus serum (p=0.007) and CaxP product (p=0.03) and, too, increase at T1 to T2 (p=0.05 and p=0.05, respectively). The serum calcium didn\'t change in this group. PTH increased at the end of the study for the total group (p<0.001), adherent group (p=0.002) and non-compliant group (p=0.002). There was no damage to the NS and change in phosphorus intake according to FR after the intervention. This study showed that PCT assists in the control of serum phosphorus, perhaps without the use of phosphate binders or to use a reduction doses, and showed that if it was followed correctly allows the patient to make selfadjust diet.

Bakgrund: Kronisk njursvikt är ett globalt växande folkhälsoproblem. Många patienter är i ett stadie i sin sjukdom som kräver hemodialysbehandling, något som är förenat med en högre dödlighet och en väsentligt lägre livskvalité. Komplementär och alternativ medicin (KAM) kan därmed vara ett aktuellt ämne att studera som ett tillägg till traditionell konventionell medicin för att lindra symtom. Erikssons vårdteori utgjorde teoretisk referensram för detta examensarbete. Syfte: Att undersöka om fysiska- och mentala symtom samt livskvalitet hos patienter som genomgår hemodialys kan påverkas av alternativa- och komplementära behandlingsalternativ. Metod: En allmän litteraturöversikt där 10 kvantitativa artiklar valt ut för att användas. För att finna relevanta artiklar som besvarade studiens syfte användes databaserna: PubMed, CINAHL, PsykINFO och Cochrane Library. En om modifiering av Olsson och Sörensens (2011) kvaliteétsmall användes för kvalitetsgranskning av de kvantitativa artiklarna. Resultatanalysmetoden som användes var utarbetad av Forsberg och Wengström (2016), analysen genomfördes för att på ett enklare sätt identifiera likheter och skillnader mellan de utvalda artiklarna.  Resultat: Användning av KAM visade varierande resultat. I studierna fanns en reducering av smärta och klåda efter att patienterna lyssnat på livesång och utfört aromaterapi. Gällande depression, ångest och livskvalité fanns ett varierande resultat beroende på vilken behandlingsmetod som användes. Två kategorier och sju underkategorier identifierades. Slutsats: Användningen av KAM kan ha positiv påverkan på den fysiska- och mentala symtomen samt livskvaliteten. Mer forskning kring ämnet krävs för att sjukvårdspersonalen ska kunna erbjuda detta som ett komplement i omvårdnaden. / Background: Chronic kidneyfailure is a growing global public health problem. Many patients are at a stage in their illness that requires hemodialysis treatment, something that is associated with a higher mortality rate and a significantly lower quality of life. Complementary and alternative medicine is a topical subject to study as a supplement to the traditional medicine to reduce symptoms. Eriksson's theory of care was the theoretical reference frame for this thesis. Aim: Investigating whether physical and mental symptoms as well as quality of life in patients undergoing hemodialysis can be influenced by alternative and complementary treatment options. Method: A literature review based on 10 quantitative articles. To find relevant articles that answered the study's purpose PubMed, CINAHL, PsykINFO and Cochrane Library were used as databases. A modification of Olsson and Sörensen's (2011) quality template was used for quality review of the quantitative articles. The results analysis method used was developed by Forsberg and Wengström (2016), the analysis was carried out in order to more easily identify similarities and differences between the selected articles. Results: The use of CAM therapy showed varying results. In the studies, there was a reduction in pain and itching after the patients listened to live singing and performed aromatherapy. Regarding depression, anxiety and quality of life, there were varying results depending on the treatment method used. Two categories and seven subcategories are identified. Conclusion: The use of CAM medicine can have positive effects on the physical and mental quality of life. More research on the subject is required before the healthcare staff will be able to offer this as a complement to the nursing care.

Background In the event of an acute coronary syndrome (ACS), the risk of death and complications such as stroke and re-infarction is high during the first month. Diabetes, impaired kidney function, elevated markers of systemic inflammation and high level of platelet reactivity have all been associated with worsened prognosis in ACS patients. Impaired kidney function is a condition with high cardiovascular morbidity and there is an established association between level of kidney function and outcome in the event of an ACS. Aims We sought to investigate the level of platelet reactivity during the first days of an ACS and specifically the level of platelet reactivity in patients with different conditions associated with worsened prognosis in the event of an ACS. We also wanted to investigate the prognostic impact of baseline levels of cystatin C as well as the importance of decreasing kidney function during the first days of an ACS. Methods We included 1028 unselected patients with ACS or suspected ACS during the years 2002 and 2003, of which 534 were diagnosed with an acute myocardial infarction (AMI). Blood samples for measuring platelet aggregation, cystatin C levels and other clinically important biomarkers were collected day 1, 2, 3 and 5 following admission. Platelet reactivity was measured using 2 different methods. Platelet aggregation was measured using Pa-200, a particle count method, based on scattering of laser light. PFA 100 is a method of measuring primary hemostasis in whole blood. Results Platelet aggregation and comorbidities. We found an increase in platelet aggregation when an ACS was complicated by an infection and there was an increased frequency of aspirin non-responsiveness in patients suffering from pneumonia during the first days of an ACS. Furthermore, we found an independent association between levels of C-reactive protein and platelet aggregation. During the first 3 days following an acute myocardial infarction, platelet aggregation increased despite treatment with anti-platelet agents. Platelet aggregation was found to be more pronounced in patients with diabetes. Patients with impaired kidney function, showed increased platelet aggregation compared to patients with normal renal function, however, this difference was explained by older age, higher prevalence of DM and levels of inflammatory biomarkers. We found no independent association between chronic kidney disease (CKD) and levels of platelet aggregation. Kidney function and outcome Serum levels of cystatin C on admission had an independent association with outcome following an acute myocardial infarction. With a mean follow-up time of 2.9 years, the adjusted HR for death was 1.62 (95% CI 1.28-2.03; p&lt;0.001) for each unit of increase in cystatin C on admission. The level of dynamic changes in cystatin C during admission for an acute myocardial infarction was independently associated with prognosis in patients with normal or mild impairment of renal function. The adjusted HR for death was 10.1 (95% CI 3.4-29.9; p&lt;0.001). Conclusion In patients suffering from an AMI platelet aggregation increases during the first days, despite anti-platelet treatment. Diabetes, age and biomarkers of inflammation are independently associated with platelet aggregation. Admission levels of cystatin C as well as changes in cystatin C levels during hospitalisation are independently associated with outcome.

Background and aim: There had been no randomized end-point studies with statins for patients with severe renal failure. The purpose of this prospective, open, randomized, controlled study was to investigate whether atorvastatin (10 mg/day) would alter cardiovascular end-points and the overall mortality rate of patients with chronic kidney disease stage 4 or 5 (creatinine clearance&lt;/30 ml/min) and to influence risk factors. Material &amp; Methods: This was an open, prospective, randomized study. A total of 143 patients were included: 73 were controls and 70 were prescribed 10 mg/day of atorvastatin. As efficacy variables, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol and triglyceride levels were determined at the start of the study and at 1, 3, 6, 12, 18, 24, 30 and 36 months. The primary end-points were all cause of mortality, non-lethal acute myocardial infarction, and coronary artery intervention. Various risk factors were studied. In the 97 patients on haemodialysis inter dialysis weight gain (IDWG) was calculated as ultrafiltration in kg/body weight in kg given in percentage of the weight. The burden of IDWG was analyzed. Results: In the atorvastatin group, total cholesterol and low-density lipoprotein cholesterol were significantly reduced, the latter by 35% at 1 month and then sustained. Atorvastatin was withdrawn in 23% of patients due to unacceptable side effects, most frequent complaints being gastrointestinal discomfort and headache. Primary end-points occurred in 74% of the subjects. There was no difference in cardiovascular endpoint and survival between the control and atorvastatin groups. The 5-year end-point-free survival rate from study entry was 20%. There was no evidence of more benefit of atorvastatin for patients with diabetes mellitus and chronic kidney disease versus the other patients; instead plasma fibrinogen increased. The IDWG was significantly larger in patients who suffered from end-points due to cardiovascular reasons, cardiac reasons, congestive heart failure, aortic aneurysm, and intracerebral bleeding. Conclusion: These data showed that in contrast to other patient groups, patients with severe chronic kidney disease 4 and 5, including those with diabetes mellitus, seem to have no benefit from 10mg/day of atorvastatin. Instead we found a high IDWG to be an important risk factor that should be prevented. There was no evident connection between atorvastatin medication and IDWG.

Η χρόνια νεφρική ανεπάρκεια οφείλεται σε διάφορα αίτια βλάβης του σπειράματος και του διαμεσοσωληναριακού χώρου. Χαρακτηρίζεται ιστολογικά από την παρουσία σοβαρού βαθμού σπειραματικής σκλήρυνσης, ίνωσης του διάμεσου ιστού, ατροφίας των ουροφόρων σωληναρίων και υαλίνωσης των αρτηριδίων. Η αρχική βλάβη του σπειράματος που προκαλείται από διάφορα είδη ερεθισμάτων μπορεί να ακολουθήσει την οδό της αποκατάστασης ή να εξελιχθεί προς σκλήρυνση, διαδικασίες στις οποίες συμμετέχουν κυτταροκίνες και αυξητικοί παράγοντες που προέρχονται από ενδοθηλιακά, μεσαγγειακά, επιθηλιακά σωληναριακά κύτταρα, μονοκύτταρα και ινοβλάστες1 . Ο Transforming Growth Factor-β1 (TGF-β1) είναι ο κυριότερος αυξητικός παράγοντας που μέσω πολλαπλών μηχανισμών συμμετέχει στην ανάπτυξη σκληρυντικών αλλοιώσεων2. Προάγει την παραγωγή συστατικών της εξωκυττάριας θεμέλιας ουσίας και μειώνει την αποικοδόμησή τους, προκαλεί ενεργοποίηση των μυοϊνοβλαστών, δηλαδή κυττάρων με μεταναστευτικές ιδιότητες που παράγουν κολλαγόνο, συμμετέχει στη διαφοροποίηση των επιθηλιακών σωληναριακών κυττάρων προς ινοβλάστες και ευοδώνει την κυτταρική απόπτωση η οποία οδηγεί στην απογύμνωση του νεφρικού ιστού από τα φυσιολογικά του κύτταρα. Η χρήση αντισωμάτων κατά του TGF-β1 και αναστολέων του μετατρεπτικού ενζύμου της αγγειοτενσίνης σε διάφορα πειραματικά μοντέλα νεφρικής βλάβης έχει συμβάλλει στην κατανόηση μηχανισμών που συμμετέχουν στη διαδικασία εξέλιξής της. Σε πειραματικά μοντέλα έχει διαπιστωθεί ότι ο TGF–β ευθύνεται για την αυξημένη παρουσία μυοινοβλαστών, την εναπόθεση κολλαγόνου και την απώλεια του σωληναριακού επιθηλίου. Πιο πρόσφατα, ένα μέλος της υπερ-οικογένειας των ΤGF–β, η ΒΜΡ7, φάνηκε να εξουδετερώνει την ίνωση που προκαλείται μέσω του TGF–β. Οι δραστηριότητα των παραγόντων αυτών ελέγχεται από άλλες πρωτείνες οι οποίες μπορούν να αυξήσουν ή να καταστείλουν τη διέγερση των υποδοχέων των παραγόντων αυτών. Τα BMPs είναι ενδογενή μόρια που προστατεύουν το νεφρό από διάφορα είδη βλάβης όπως γενετικές βλάβες, ανοσολογικές αντιδράσεις, περιβαλλοντικοί παράγοντες, μεταβολικά αίτια και καταστάσεις οξείας ή χρόνιας νεφρικής βλάβης. / -

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研究目的 對於慢性腎臟病患者而言，睡眠困擾是十分常見的問題。過去相關研究中，研究對象較偏重於已進入透析治療的患者，且大多著重於探討人口學及臨床變項，而忽略了心理及行為因素（例如睡前激發狀態、睡眠衛生行為）的影響。本研究試圖改善過去研究之不足，釐清心理及行為因子在慢性腎臟病患者的睡眠問題中所扮演之角色。 研究方法 本研究採橫斷性調查研究，於腎臟科門診及血液透析室招募第三期到第五期（eGFR＜60 ml/min/1.73m2）的慢性腎臟病患者。最終納入分析的個案共有152人，其中77人為未達尿毒症的慢性腎臟病患者，75人為穩定接受血液透析治療（3個月以上）的尿毒症患者。受試者需完成匹茲堡睡眠品質量表、失眠嚴重度量表、睡眠衛生行為量表、睡前激發狀態量表、醫院焦慮與憂鬱量表，並且回答和不寧腿症候群、疼痛及皮膚癢程度相關的問題，此外，本研究亦從病歷紀錄中抄錄相關的檢驗數値以及共病情形。 研究結果 未透析患者約有29.9%睡眠品質不佳、23.4%有失眠問題；而血液透析患者約有57.3%睡眠品質不佳、28.0%有失眠的問題。血液透析患者和未透析患者相比，其睡眠品質顯著較差，且失眠較為嚴重。迴歸分析結果顯示，MMSE得分較低、共病較多、疼痛程度較高、和焦慮相關行為較多可預測較差的睡眠品質，而焦慮與憂鬱情緒較高、焦慮相關行為較多、和認知激發程度較高可預測較嚴重的失眠。未透析患者的睡眠問題主要是受到和激發相關的行為或認知活動的影響，而血液透析患者的睡眠則較容易受到疾病和症狀相關因素的影響。 結論 疾病與臨床因素、身體症狀、以及睡眠心理及行為相關因素對於慢性腎臟病患者的睡眠有所影響，但對於未透析和已透析的患者，其影響因素和影響程度可能不同。

Background The remarkably efficient mechanisms of the human body to maintain its core temperature of 37°C can be inadequate when harsh climatic conditions and excessive muscle movement lead to heat stress, dehydration and potential heat illness, ranging from minor symptoms such as fatigue to a potentially fatal heat stroke. Agricultural workers in the tropics are at high risk, which is expected to increase with climate change. Sugarcane harvesting in Costa Rica is largely done by cutting the cane with a machete, by temporary, sub-contracted workers who are often migrants and living in poverty. Sugarcane harvesters are known to be affected by an epidemic of chronic kidney disease of non-traditional origin, currently hypothesized to be related to working conditions. Objectives This work aimed to better understand and document sugarcane harvester exposure to heat and the health consequences of working under such conditions. Specific objectives were to 1) Document working conditions and heat in the Costa Rican sugarcane industry (Paper I); 2) Quantify heat stress exposures faced by sugarcane harvesters in Costa Rica (Paper II); and 3) Quantify the occurrence of heat stress symptoms and abnormal urinary parameters in sugarcane workers in Costa Rica (Papers III and IV). Methods This study took place over three harvests following a pilot assessment prior to the first harvest. Methods included direct observation, semi-structured interviews with 24 individuals and a participatory workshop with 8 harvesters about heat-related perceptions, exposures and coping strategies during the harvest and non-harvest season (Pilot). Researchers accompanied workers in the field during all three harvests, measured wet bulb globe temperature (WBGT) and conducted direct observation. Heat exposure assessment was conducted by calculating metabolic load, WBGT and corresponding limit values based on international guidelines (NTP and OSHA) (Harvest 1). Self-reported symptom data were collected using orally-administered questionnaires from 106 sugarcane harvesters and 63 non-harvesters from the same company (Harvest 2). Chi-square test and gamma statistic were used to evaluate differences in self-reported symptoms and trends over heat exposure categories. Finally, liquid consumption during the work shift was documented and urinalysis was conducted pre-and post-shift in 48 sugarcane harvesters on three days; differences were assessed with McNemar´s test on paired proportions (Harvest 3). Results Sugarcane workers in both the harvest and non-harvest seasons are exposed to heat, but particularly during the harvest season. Field workers have to carry their own water to the field and often have no access to shade. Some plantworkers are also exposed to intense heat. The metabolic load of sugarcane harvesting was determined to be 261 W/m2. The corresponding threshold value is 26 ◦C WBGT, above which workers should decrease work load or take breaks to avoid the risk of heat stress. Harvesters in this study were at risk of heat stress as early as 7:15 am on some mornings and by 9:00 am on all mornings. After 9:15 am, OSHA recommendations would require that harvesters only work at full effort 25% of each hour to avoid heat stress. Heat and dehydration symptoms at least once per week were experienced significantly more frequently among harvesters than non-harvesters (p&lt;0.05): headache, tachycardia, fever, nausea, difficulty breathing, dizziness, and dysuria. Percentages of workers reporting heat and dehydration-related symptoms increased over increasing heat exposure categories. Total liquid consumed ranged from 1 to 9 L and differed over days (median 5.0, 4.0 and 3.25 on days 1, 2 and 3 respectively). On these same days, the two principle indicators of dehydration: high USG (≥1.025) and low pH (≤5), changed significantly from pre to post-shift (p=0.000 and p=0.012).Proportions of workers with proteinuria &gt;30 mg/dL, and blood, leucocytes and casts in urine were also significantly different between pre and post-shift samples at the group level, but unlike USG and pH, these alterations were more frequent in the pre-shift sample. 85% of workers presented with proteinuria at least once and 52% had at least one post-shift USG indicative of dehydration. Conclusion Heat exposure is an important occupational health risk for sugarcane workers according to international standards. A large percentage of harvesters experience symptoms consistent with heat exhaustion throughout the harvest season. Pre and post-shift urine samples demonstrate dehydration and other abnormal findings. The results of this study demonstrate an urgent need to improve working conditions for sugarcane harvesters both under current conditions and in adaptation plans for future climate change.

Angiotensin II (AngII), the major effector of the renin angiotensin system, mediates kidney disease progression by signalling through AT-1 receptor (AT-1R), but there are no specific measures of renal AngII activity. Accordingly, we sought to define an AngII-regulated proteome in primary human proximal tubular cells (PTEC) in order to identify potential AngII activity markers in the kidney. We utilized stable isotope labelling with amino acids (SILAC) in PTECs to compare proteomes of AngII-treated and control cells. Of 4618 quantified proteins, 83 were differentially regulated. SILAC ratios for 18 candidates were confirmed by Selected Reaction Monitoring (SRM) assays. Both SILAC and SRM revealed the nuclear factor erythroid 2-related 2 (Nrf2) target protein, heme oxygenase-1 (HO-1) as the most significantly upregulated protein in response to AngII stimulation. AngII-dependent regulation of HO-1 gene and protein was further verified by qRT-PCR and ELISA in PTECs. In order to extend these in vitro observations, we utilized a systems biology approach. We thus overlaid a network of significantly enriched gene ontology (GO) terms from our AngII-regulated proteins with a dataset of differentially expressed kidney genes from AngII-treated wild type mice and AT-1R knock-out mice. Five GO terms were enriched both in vitro and in vivo, and all included HO-1. Furthermore, four additional Nrf2 target proteins were functionally important in vitro and in vivo. We then studied HO-1 kidney expression and urinary excretion in AngII-treated wild type mice and mice with PTEC-specific AT-1R gene deletion. Deletion of the AT-1R gene in PTECs lowered both kidney expression and urine excretion of HO-1, confirming AngII/AT-1R mediated regulation of HO-1. In summary, our in vitro experiments identified novel molecular markers of AngII activity in PTECs and the animal studies demonstrated that these markers also reflect AngII activity in PTECs in vivo. These interesting proteins hold promise as specific markers of renal AngII activity in patients and in experimental models.