Le but de ce travail est l'étude de la bioimpédancemétrie appliquée à des populations particulières de néphrologie (hémodialyse, insuffisance rénale et transplantation), afin d'évaluer l'apport de cette technique et les facteurs d'influence modifiant la mesure ou son interprétation. Nous avons pu identifier (à travers deux appareils d'impédancemétrie) plusieurs profils de patients, selon leurs « réponses » à la technique de bioimpédance, en fonction des séances d'hémodialyse, de l'âge, des comorbidités, de matériel implantable, de la fonction rénale après transplantation. Il y a une bonne validité des données physiques mesurées. Sur les valeurs calculées, il y a des valeurs aberrantes, tant sur les volumes hydriques que sur le diagnostic d'hydratation (calcul de l'excès d'eau). La principale hypothèse est l'existence d'algorithmes dans les logiciels, établis sur des populations caractéristiques, et avec de nombreux facteurs correctifs, mais qui restent inadaptés dès que le sujet mesuré s'éloigne un peu de ces patients « normés ». La présence de matériel dans le corps humain influencerait les mesures et rendrait les algorithmes inadaptés. Ce travail nous amène à conclure que quelque soit le logiciel, donc l'appareil utilisé, le patient devrait être son propre témoin de mesure, hypothèse non vérifiée dans la littérature. Enfin, le deuxième point de recherche pourrait être la notion d'une fréquence tissulaire propre à chacun, autre que la classique fréquence de 50 kHz, celle théorique à laquelle l'effet capacitif membranaire est maximal, et caractérise donc la cellule. Notre étude montre que cette fréquence est loin d'être de 50 kHz. Les études restent à faire / The goal of this work is to study bioimpedance through different and particular people in nephrology (hemodialysis, renal disease or kidney graft), to assess this electrical engineering and the factors of onfluence that can change the measures or their meaning. We succeed to identify (through two bioimpedance instrument) several profiles of patients, according to their "response and behaviour" to this bioimpedance technique, depending on hemodialysis sessions, age, morbidity, presence of electrical device or after kidney transplantation. Through our population, we find a good validity of the electrical and physical measures. But when the values body composition are calculated from the electrical data, there is often aberrant values, concerning body composition, fluid compartment or the excess water. The main hypothesis is the existence of algorithms in the devices, compiled from statistics on healthy populations, with several corrective factors, but these algorithms probably don't fit with "particular" population. This work allows us to propose that what are the devices used, the patient might be his own measure witness. There is no study in the literature. Finally, an idea could be the existence of a specific tissue frequency, specific to each one, and different from the theoretical frequency of 50 kHz. This 50 kHz frequency corresponds to the highest cell membrane capacity and so characterizes the cell. Our study shows that the frequency corresponding to this highest reactance is precisely not 50 kHz. The hypothesis is the existence of a own characteristic frequency. Sudies remain to be done

This thesis focused on the acute management of patients with ST-segment elevation myocardial infarction (STEMI) in an effort to provide information that may improve outcome. The aim was to evaluate the efficacy and safety of bivalirudin versus unfractionated heparin (UFH) in STEMI patients during primary PCI. Furthermore, to provide pharmacodynamic data of novel ways of ticagrelor administration compared to standard tivcagrelor. Additionally, to identify subgroups of patients, such as women who may derive greater benefit from specific antithrombotic strategies due to their risk/benefit profile. Finally, to evaluate current formulas for estimation of renal function in the acute phase of STEMI. In Paper I, all STEMI patients in Sweden between 2008 and 2014, treated with primary PCI and UFH or bivalirudin were included in our analysis. Of the total population of 23 800 patients, 8 783 (36.9%) were included in the UFH group and 15 017 (63.1%) in the bivalirudin group. Concomitant GPI administration was 68.5% in the UFH arm compared to 3.5% in the bivalirudin arm (p<0.01).The adjusted incidence of 30-day mortality was not significant different between the two groups (UFH vs bivalirudin, adjusted HR 0.94; 95% CI 0.82 -1.07). The adjusted risk for 1-year mortality, 30-day and 1-year stent thrombosis and re-infarction did not differ significantly between the two groups. In contrast, patients treated with UFH had a significantly higher incidence of major in-hospital bleeding (adjusted OR 1.62; 95%CI 1.30 -2.03). In Paper II pharmacodynamic data of chewed or crushed ticagrelor compared to standard ticagrelor loading dose (LD) was assessed in 99 patients with stable angina. Platelet reactivity (PR) was assessed with VerifyNow before, 20 and 60 minutes after LD. High Residual platelet reactivity (HRPR) was defined as > 208 P2Y12 reaction units (PRU). Chewed ticagrelor tablets resulted in significantly lower PRU values compared to crushed or integral tablets at 20 and 60 minutes. Crushed ticagrelor LD resulted in significantly lower PRU values compared to integral tablets at 20 minutes whereas no difference was observed at 60 minutes. At 20 minutes, no patients had HRPR with chewed ticagrelor compared to 68% with integral and 30% with crushed ticagrelor LD (p<0.01). In Paper III we presented a pre-specified gender analysis of the ATLANTIC trial including 1 862 STEMI patients that were randomly assigned to pre-hospital versus in-hospital administration of 180mg ticagrelor. Women were older and had higher TIMI risk score. Women had a 3-fold higher risk for all-cause mortality compared to men (5.7% vs 1.9%, HR 3.13, 95% CI 1.78 – 5.51). However, after adjustment for baseline characteristics, the difference was lesser and no longer significant (HR 1.98, 95% CI 0.97 – 4.04). Female gender was not an independent predictor of risk for bleeding after multivariable adjustments (BARC type 3-5 HR 1.52, 95% CI 0.74-3.09). There was no interaction between gender and efficacy or safety of randomised treatment. In Paper IV, forty patients with PCI- treated STEMI were included between November 2011 and February 2013. We validated the performance of the Cockcroft-Gault (CG), the Modification of Diet in Renal Disease (MDRD-IDMS), the Chronic Kidney Disease Epidemiology (CKD-EPI) and the Grubb relative cystatin C (rGCystC) equations for estimation of GFR against measured GFR (mGFR) during the index hospitalisation for STEMI. MDRD-IDMS and CKD-EPI demonstrated a good performance to estimate GFR with accuracy within 30% (P30) 82.5% vs 82.5%, respectively. CKD was best classified by CKD-EPI (Kappa 0.83). CG showed the worst performance with the lowest P30. The rG-CystC equation had a marked bias of -17.8% and significantly underestimated mGFR (p=0.03). Conclusions – In STEMI patients treated with primary PCI, bivalirudin should be preferred in patient at high risk for bleeding. With crushed or chewed ticagrelor tablets a more rapid platelet inhibition may be achieved, compared with standard integral tablets. In STEMI patients, fast and potent platelet inhibition with chewed ticagrelor may reduce the risk of early stent thrombosis and patients treated with a less aggressive antithrombotic strategy, such as UFH or bivalirudin monotherapy, may derive a greater benefit. Although gender differences in adverse outcomes could mainly be explained by older age and clustering of comorbidities in women, a bleedreduction strategy in women with high risk characteristics is warranted in order to improve their outcome. Regardless the choice of antithrombotic strategy, dose adjustment of drugs cleared by kidneys based on GFR estimation is of crucial importance. MDRD and CKD-EPI should be the formulas used for estimation of GFR in STEMI patients

The relationship between the endocannabinoid system in the renal medulla and the long-term regulation of blood pressure is not well understood. To investigate the possible role of the endocannabinoid system in renomedullary interstitial cells, mouse medullary interstitial cells (MMICs) were obtained, cultured and characterized for their responses to treatment with a selective inhibitor of fatty acid amide hydrolase (FAAH), PF-3845. Treatment of MMICs with PF-3845 increased cytoplasmic lipid granules detected by Sudan Black B staining and multilamellar bodies identified by transmission electron microscopy. HPLC analyses of lipid extracts of MMIC culture medium revealed a 205nm-absorbing peak that showed responsiveness to PF-3845 treatment. The biologic activities of the PF-3845-induced product (PIP) isolated by HPLC were investigated in anesthetized, normotensive surgically-instrumented mice. Intramedullary and intravenous infusion of PIP at low dose rates (0.5-1 AU/10 min) stimulated diuresis and natriuresis, whereas at higher doses, these parameters returned toward baseline but mean arterial pressure (MAP) was lowered. Whereas intravenous bolus doses of PIP stimulated diuresis, GFR and medullary blood flow (MBF) and reduced or had no effect on MAP, an intraperitoneal bolus injection of PIP reduced MAP, increased MBF, and had no effect on urinary parameters. Genetic or pharmacological ablation of the cannabinoid type 1 receptors in mice completely abolished the diuretic and vasodepressor properties of intramedullary infused PIP, suggesting that the PF-3845-induced product requires the presence of CB1 receptors in order to elicit its renal effects. In a radioactive competition binding assay, using Chinese hamster ovary cells expressing CB1 receptors, PIP successfully displaced the CB1 selective inverse agonist [3H] SR141716A, revealing that the lipid extract was able to compete for binding to CB1 receptors. Finally, we investigated the tubular location of diuretic activity that the PF-3845-induced lipid fraction exhibits. In a renal function in vivo experiment, we pre-treated anesthetized mice with an intramedullary infusion of one of four well-known diuretics. This procedure was followed by an intramedullary infusion of PIP (1AU). Only inhibition of the proximal tubule sodium reabsorption diminished the diuretic activity of the PF-3845-induced product, suggesting that the lipid fraction requires a physiologically intact proximal tubular reabsorption mechanism for it to produce diuresis. These data support a model whereby PF-3845 treatment of MMICs results in increased secretion of a neutral lipid which acts directly to promote diuresis and natriuresis and indirectly through metabolites to produce vasodepression. Efforts to identify the structure of the PF-3845-induced lipid and its relationship to the previously proposed renomedullary antihypertensive lipids are ongoing.

Submitted by Jordan (jordanbiblio@gmail.com) on 2017-05-26T16:46:19Z No. of bitstreams: 1 DISS_2014_Grasiele Cristina Lucietto.pdf: 976378 bytes, checksum: 59e1ef8e4c879c0e57ba6beec88252d7 (MD5) / Approved for entry into archive by Jordan (jordanbiblio@gmail.com) on 2017-05-26T16:48:55Z (GMT) No. of bitstreams: 1 DISS_2014_Grasiele Cristina Lucietto.pdf: 976378 bytes, checksum: 59e1ef8e4c879c0e57ba6beec88252d7 (MD5) / Made available in DSpace on 2017-05-26T16:48:55Z (GMT). No. of bitstreams: 1 DISS_2014_Grasiele Cristina Lucietto.pdf: 976378 bytes, checksum: 59e1ef8e4c879c0e57ba6beec88252d7 (MD5) Previous issue date: 2014-02-25 / Terapia Comunitária Integrativa (TCI) é um ambiente comunitário que visa a partilhar experiências de vida e sabedorias de forma horizontal e circular. Cada participante se torna seu próprio terapeuta através da escuta das histórias de vida relatadas neste espaço. Todos são corresponsáveis na busca de soluções e superação dos desafios do cotidiano, em um ambiente acolhedor e caloroso. A condição crônica na infância interfere no funcionamento corporal da criança em longo prazo, demanda assistência e acompanhamento por profissionais de saúde, limita as atividades diárias, origina alterações no seu processo de crescimento e desenvolvimento, comprometendo o cotidiano de todos os membros da família. Como na maioria das doenças crônicas na infância, as doenças crônicas renais alteram as vidas das crianças em todos os níveis, além de lhes restringir atividades rotineiras. Estudo descritivo, com enfoque qualitativo. A intervenção foi feita no Ambulatório de Nefrologia Pediátrica de um Hospital Universitário, no município de Cuiabá, Mato Grosso. Os sujeitos do estudo foram crianças, adolescentes e suas famílias atendidas no ambulatório, que participaram ao menos uma vez da roda de TCI. Também participaram duas acadêmicas de enfermagem, uma funcionária do hospital e uma terapeuta, totalizando 32 pessoas. O material empírico é composto da transcrição das rodas, que foram filmadas, e das anotações da observação participante. Os resultados evidenciaram que as rodas de TCI foram um instrumento de promoção da saúde, proporcionando um espaço comunitário para que os participantes ressignifiquem suas vivências, partilhem sabedorias e experiências, favorecendo desta forma a superação de dificuldades, a busca por soluções, promovendo a autonomia dos indivíduos. É um meio de integração entre as pessoas, que busca elevar a autoestima e descobrir potenciais, construir redes de apoio e orientar quanto aos seus direitos e seu papel social. Ressalta-se a relevância da TCI como espaço de partilha de experiências com outros familiares/cuidadores em situações semelhantes, visto que os assuntos mais recorrentes nas rodas de TCI foram a sobrecarga da família no cuidado, a responsabilização exacerbada/culpabilização pelo estado de saúde/cuidado do filho e a abnegação por parte da família para uma melhor assistência e acompanhamento do tratamento da criança/adolescente. Apesar das adversidades, ficou evidente que o vínculo afetivo entre mãe/familiar e filho torna o cuidado com a criança uma experiência gratificante. A TCI proporcionou o compartilhamento de sentimentos e vivências, fornecendo segurança e auxiliando a lidar com as incertezas geradas pela condição da criança. A análise dos resultados encontrados neste estudo possibilitou a constatação de que a Terapia Comunitária Integrativa prestada às crianças, adolescentes e suas famílias, em um Ambulatório de Nefrologia Pediátrica no município de Cuiabá, foi uma tecnologia de cuidado complementar, possibilitando uma assistência mais humanizada e acolhedora. / ABSTRACT: Community Integrative Therapy (TCI) is a community environment that aims to share life experiences and wisdoms horizontally and circularly. Each participant becomes his own therapist through listening to the life stories reported in this space. All share responsibility in finding solutions and overcoming the challenges of everyday life in a warm and friendly atmosphere. Chronic conditions in childhood interferes with the functioning body of the child in long term, demand assistance and monitoring by health professionals, limits daily activities, causes changes in its growth and development, affecting the daily lives of all family members. As in most chronic childhood diseases, chronic kidney diseases alter the lives of children at all levels, and restrict their routine activities. This is a descriptive study with a qualitative approach. The action was taken at an Ambulatory of Pediatric Nephrology of a University Hospital in the city of Cuiabá, Mato Grosso. The study subjects were children, adolescents and their families attended the clinic, who participated at least once in TCI circle. Two nursing students, an employee of the hospital and a therapist also participated, totaling 32 people. The empirical material consists of the transcript of the circles, which were videotaped, and the notes of participant observation. The results showed that the circles of TCI were an instrument for health promotion, providing a community space for participants resignify their experiences, share wisdom and experiences, thus favoring the overcoming of difficulties, the search for solutions, promoting the autonomy of the individuals. It is a mean of integration between people, who seek to raise the self-esteem and discovering potential, building networks of support and guidance about their rights and their social role. We stress the importance of TCI as an space to share experiences with other families / caregivers in similar situations , as the most recurrent issues on the TCI circles were overloading the family in care , the heightened accountability / culpability for health / child care and dedication by the family to better care and follow-up treatment of children / adolescents . Despite the adversities, it became evident that the emotional bond between parent / child and family makes child care a rewarding experience. TCI provided the sharing of feelings and experiences, providing security and helping to deal with the uncertainties generated by the child's condition. The results found in this study enabled the realization that Community Integrative Therapy provided to children , adolescents and their families in a Pediatric Nephrology Unit in the city of Cuiabá, it was a technology of complementary care, enabling a more humane and friendly assistance. / RESUMEN: Terapia Integradora de la Comunidad (TCI) es un entorno de comunidad que tiene como objetivo compartir experiencias de vida y sabidurías de forma horizontal y circular. Cada participante se convierte en su propio terapeuta a través de escuchar las historias de vida reportados en este espacio. Todos comparten la responsabilidad en la búsqueda de soluciones y la superación de los retos de la vida cotidiana en un ambiente cálido y acogedor. Las condiciones crónicas en la infancia interfieren en el funcionamiento del cuerpo del niño al largo plazo, demanda la asistencia y el seguimiento por profesionales de la salud, limita las actividades diarias, causa cambios en su crecimiento y desarrollo, lo que afecta la vida cotidiana de todos los miembros de la familia. Al igual que en la mayoría de las enfermedades crónicas de la infancia, las enfermedades renales crónicas alteran la vida de los niños en todos los niveles, y restringen sus actividades de rutina. Estudio descriptivo con enfoque cualitativo. La intervención fue tomada en el Ambulatorio de Nefrología Pediátrica de un Hospital Universitario en la ciudad de Cuiabá, Mato Grosso. Los sujetos del estudio fueron niños, adolescentes y sus familias asistidas en el ambulatorio, que participaron al menos una vez de la rueda de TCI. Dos estudiantes de enfermería, una empleada del hospital y una terapeuta también participaron, de un total de 32 personas. El material empírico consiste en la transcripción de las ruedas, las cuales fueron grabadas en video, y las notas de la observación participante. Los resultados mostraron que las ruedas de la TCI eran un instrumento para la promoción de la salud, proporcionando un espacio comunitario para que los participantes resignifican sus experiencias, compartir la sabiduría y experiencias, favoreciendo la superación de las dificultades, la búsqueda de soluciones, la promoción de la autonomía de los individuos. Es un medio de integración entre las personas, que busca elevar la autoestima y descubrir el potencial, la construcción de redes de apoyo y orientación sobre sus derechos y su papel social. Hacemos hincapié en la importancia de las TCI como un espacio para compartir experiencias con otras familias / cuidadores en situaciones similares, como los temas más recurrentes en las ruedas de TCI fueron la sobrecarga de la familia en el cuidado, la responsabilidad mayor / culpabilidad por la salud / cuidado de niños y la dedicación a la familia para una mejor atención y tratamiento de seguimiento de los niños / adolescentes. A pesar de las adversidades, se hizo evidente que el vínculo emocional entre padre / hijo y su familia hace que el cuidado de niños sea una experiencia gratificante. La TCI proporciona el intercambio de sentimientos y experiencias, proporcionan seguridad y ayuda a hacer frente a las incertidumbres generadas por la condición del niño. Los resultados encontrados en este estudio permitieron a la comprensión de que la Terapia Comunitaria Integrativa proporcionada a niños, adolescentes y sus familias en una Unidad de Nefrología Pediátrica en la ciudad de Cuiabá, era una tecnología de atención complementaria, lo que permite una asistencia más humana y agradable.

Pyelonefrit är en inflammation i njurarna och undersökningen som främst används vid utredning är dimerkaptosuccinat (DMSA)-scintigrafi. Pyelonefrit drabbar framförallt barn och risk finns för njurparenkymskador. Syftet med studien var att utreda om DMSA-scintigrafi efter pyelonefrit hos barn är berättigad. Detta granskades genom att beräkna den generella risken för cancer, specifika riskökningen för njurparenkymcancer, antal upptäckta njurparenkymskador och eventuella könsskillnader. Vetenskapliga artiklar söktes upp via sökmotorn PRIMO. Metoden var retrospektiv med kvantitativ ansats där materialet bestod av svarsutlåtanden från DMSA-scintigrafier på barn 0-2 år med frågeställning njurparenkymskador efter pyelonefrit. Urvalet bestod av 91 barn; 52 flickor och 39 pojkar varav 16 stycken exkluderades. Av de studerade 75 barnen hade sex (8 %) njurparenkymskador, med medelålder på 9,2 månader, och det fanns ingen signifikant skillnad mellan kön och njurparenkymskada (p=0,246). Medelvärdet på given aktivitet gav en effektiv medeldos på 0,69 mSv. Den generella riskökningen vid en DMSA-scintigrafi blev 0,01-0,014 och 0,00019 för njurparenkymcancer. Trots att relativt få barn drabbas av njurparenkymskador, finns ändå risk att drabbas av komplikationer från skadan. Skadorna är därför viktiga att upptäcka. Riskökningen för cancerutveckling och njurparenkymcancer efter DMSA-scintigrafi är mycket låg. Nyttan (att upptäcka njurparenkymskadorna) överväger risken (strålningen), vilket gör DMSA-scintigrafin till en berättigad undersökningsmetod. / A dimercaptosuccinic acid (DMSA) scintigraphy is used to test for pyelonephritis, an inflammation of the kidneys with risk of renal scarring. Aiming to investigate if DMSA scan after pyelonephritis in children is justified, we calculated the general cancer risk, the specific increased renal cancer risk, the number of discovered renal scarring and potential differences between the sexes. The method was retrospective and quantitative and data was based on results from DMSA scans of children aged 0-2 years. From the original set of 91 children (52 girls, 39 boys), 16 were excluded. Of the remaining 75, six (8 %) had renal scarring; with an average age of 9,2 months, and there was no significant difference between sex and renal parenchymal damage (p=0,0246). The mean activity from a DMSA scan equaled an effective dose of 0.69 mSv, with general cancer versus renal cancer risk being 0.01-0.014 and 0.00019, respectively. Even though only a few children develop renal scarring, there is still a risk of complications. Renal scarring is therefore important to discover. The increased risk for cancer and renal cancer after a DMSA scan is low. The benefits (discovering renal scarring) are greater than the risk (radiation), making the DMSA scan justified.

Submitted by Erika Demachki (erikademachki@gmail.com) on 2015-05-25T10:54:06Z No. of bitstreams: 2 Tese - Jacqueline Andréia Bernardes Leão Cordeiro - 2014.pdf: 2265003 bytes, checksum: a4c8887b282a064630ad20a55ee1cc33 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Approved for entry into archive by Erika Demachki (erikademachki@gmail.com) on 2015-05-25T10:55:40Z (GMT) No. of bitstreams: 2 Tese - Jacqueline Andréia Bernardes Leão Cordeiro - 2014.pdf: 2265003 bytes, checksum: a4c8887b282a064630ad20a55ee1cc33 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Made available in DSpace on 2015-05-25T10:55:40Z (GMT). No. of bitstreams: 2 Tese - Jacqueline Andréia Bernardes Leão Cordeiro - 2014.pdf: 2265003 bytes, checksum: a4c8887b282a064630ad20a55ee1cc33 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) Previous issue date: 2014-12-19 / Fundação de Amparo à Pesquisa do Estado de Goiás - FAPEG / Chronic kidney disease is considered a worldwide public health problem because of the high mortality rates and the physical, social and emotional limitations that interfere significantly in quality of life. The evaluation of the quality of life of chronic kidney disease carrier has demonstrated commitment to many aspects of life of these individuals and it was directed mainly to patients on dialysis. The number of referrals for pre - dialysis monitoring, resulting from complications due to comorbidities such as hypertension and diabetes mellitus is growing, and it requires that the focus of assistance is not only early diagnosis and treatment of disease, but also, aspects related to subjectivity, the perceptions of individuals in relation to their well - being and quality of life (QOL). At present there is no specific instrument to assess QOL of individuals in pre- dialysis treatment. This study aimed to analyze the factors associated with QOL related to the health of the chronic kidney disease carrier in pre- dialysis treatment. An analytical cross-sectional study was developed in three nephrology clinics of large hospitals in the city of Goiânia/Goiás, with 130 patients in stage IV and V of chronic kidney disease. Data collection was done through the application of socio - demographic - clinical - laboratory questionnaire and the specific QOL instrument for kidney disease, KDQOL -SF. A total of 57.7% of patients were male and the group average age was approximately 64 years old. Most patients were classified as stage 4 (69.2%) and some had no schooling (54.6 %). Among the comorbidities detected hypertension was more prevalent, followed by diabetes mellitus and 28.5% of patients had hemoglobin levels lower than expected. The dimensions of quality of life "the professional role" (25.38) and "the physical function" (28.08) showed lower values while "the stimulus by the clinic staff" (88.37) and "the cognitive function" (86.00) had the highest average. QOL is more compromised in women and in patients with five or more children who do not work and have no income, who are obese, hypertensive and show alterations especially in urea and creatinine. It was shown that QOL is influenced by chronic kidney disease, especially when there is change in laboratory parameters which control may extend the start of dialysis therapy or even minimize possible organic misfits. The KDQOL -SF was adequate to evaluate the QOL of individuals in pre- dialysis treatment. The gaps shown by the assessment of QOL in this study showed the importance of care to the kidney patient in the pre- dialysis phase, requiring more effective attention to the subjective demands. This could be achieved if the individual is taught to manage his condition, and it is essential a multidisciplinary monitoring to consider the level of patient understanding, so he can transform the information provided in benefits for his own health. / A doença renal crônica é considerada problema mundial de saúde pública em razão das elevadas taxas de mortalidade e das limitações físicas, sociais e emocionais que interferem de modo significativo na qualidade de vida das pessoas. A avaliação da qualidade de vida do portador de doença renal crônica tem demonstrado comprometimento em vários aspectos da vida desses indivíduos, tendo sido direcionada principalmente a pacientes em tratamento dialítico. O número de pessoas encaminhadas para acompanhamento pré-dialítico, resultante de complicações advindas de comorbidades como a hipertensão arterial e o diabetes mellitus é crescente, e impõe que o foco da assistência não seja mais somente o diagnóstico precoce e tratamento da doença, mas também, aspectos pertinentes à subjetividade, às percepções dos indivíduos em relação ao seu bem-estar e à sua qualidade de vida (QV). Na atualidade não existe instrumento específico que avalie a QV dos indivíduos em tratamento pré-dialítico. Objetivou-se analisar os fatores associados à QV relacionada à saúde do portador de doença renal crônica em tratamento pré-dialítico. Foi desenvolvido um estudo transversal analítico em três ambulatórios de nefrologia de hospitais de grande porte da cidade de Goiânia/Goiás, com 130 pacientes em estágios IV e V da doença renal crônica. A coleta de dados foi feita por meio da aplicação de questionário sócio-demográfico-clínico-laboratorial e do instrumento de QV específico para a doença renal, KDQOL-SF. O total de 57,7% dos pacientes era homem e a média da idade do grupo foi de, aproximadamente, 64 anos. A maioria dos pacientes foi classificada no estágio 4 (69,2%) e não tinha instrução escolar (54,6%). Dentre as comorbidades detectadas a hipertensão foi mais prevalente, seguida do diabetes mellitus e, 28,5% dos pacientes apresentaram níveis de hemoglobina abaixo do esperado. As dimensões da qualidade de vida “papel profissional” (25,38) e “função física” (28,08) apresentaram menores valores, enquanto que “estímulo por parte da equipe do ambulatório” (88,37) e “função cognitiva” (86,00) obtiveram as maiores médias. A QV está mais comprometida nas mulheres, e naqueles pacientes com cinco ou mais filhos, que não trabalham e não têm renda, obesos, hipertensos e que apresentam alterações, especialmente, de ureia e creatinina. Foi evidenciado que a QV é influenciada pela doença renal crônica, principalmente, quando há alteração dos parâmetros laboratoriais, cujo controle pode prorrogar o início da terapia dialítica ou mesmo minimizar possíveis desajustes orgânicos. O KDQOL-SF mostrou-se adequado para avaliação da QV dos indivíduos em tratamento pré-dialítico. As lacunas evidenciadas pela avaliação da QV nesse estudo apontaram a importância do cuidado ao renal na fase pré-dialítica, necessitando de atenção mais efetiva para as demandas subjetivas. Isso poderá ser alcançado se o indivíduo for ensinado a gerenciar sua doença, sendo fundamental acompanhamento multiprofissional que considere o nível de entendimento do paciente, para que ele consiga transformar as informações fornecidas em benefícios para sua saúde.

Submitted by Luciana Ferreira (lucgeral@gmail.com) on 2017-04-18T13:10:44Z No. of bitstreams: 2 Dissertação - Bruno César Teodoro Martins - 2017.pdf: 4104376 bytes, checksum: 49a3d1db7f9d234a786649127f99ddce (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) / Approved for entry into archive by Luciana Ferreira (lucgeral@gmail.com) on 2017-04-18T13:11:07Z (GMT) No. of bitstreams: 2 Dissertação - Bruno César Teodoro Martins - 2017.pdf: 4104376 bytes, checksum: 49a3d1db7f9d234a786649127f99ddce (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) / Made available in DSpace on 2017-04-18T13:11:07Z (GMT). No. of bitstreams: 2 Dissertação - Bruno César Teodoro Martins - 2017.pdf: 4104376 bytes, checksum: 49a3d1db7f9d234a786649127f99ddce (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Previous issue date: 2017-03-16 / Fundação de Amparo à Pesquisa do Estado de Goiás - FAPEG / Infection by the Hepatitis B virus (HBV) continues to be a significant problem in global public health, even being immunopreventable. Individuals receiving hemodialysis present an elevated risk for the acquisition of HBV due to a variety of factors, including immunosuppression and an elevated frequency of invasive procedures. The objective of this study was to investigate the epidemiology of infection by HBV among patients in hemodialysis in the State of Tocantins. This is an observational, cross-sectional, analytical study conducted in all hemodialysis services in the State of Tocantins. Data were obtained through interview and collection of a blood sample between October of 2014 and February 2015. All samples were tested for HBsAg, anti-HBs, and total anti-HBc markers through enzyme linked immunosorbent assay. Univariate and multivariate analyses were performed for the identification of possible risk factors for the exposure to HPV. A total of 394 individuals participated in the study. The majority were aged over 40 years (78.2%), male (58.6%), mixed race (58,6%), had a low level of education. The global prevalence for HBV was 34.56% (95% CI: 29.75-39.08), being 0.76% (95% CI: 0.26-2.21) for HBsAg, 30.20% (95% CI: 25.88-34.91) for anti-HBc and anti-HBs, and 3.30% (95% CI: 1.94-5.56) for isolated anti-HBc. Of the total of participants, 29.4% (95% CI: 25.16-34.12) presented positivity for isolated anti-HBs, and nearly all of them received three doses of the HBV vaccine. Only age over 55 years (PR: 1.84; p=0.022) and time and hemodialysis treatment (RP: 1.60; p=0.001) were predictors of exposure to HBV. The association between time in hemodialysis and HBV suggest the dialysis environment can promote viral exposure. The low frequency of sorological profile of immunization against Hepatitis B shows the necessity for greater vigilance of vaccination of individuals in hemodialysis in the state of Tocantins / A infecção pelo vírus da hepatite B (HBV) continua sendo um grande problema de saúde pública mundial, mesmo sendo imunoprevenível. Indivíduos em tratamento hemodialítico apresentam risco elevado para aquisição do HBV devido a vários fatores, incluindo imunossupressão e a frequência elevada que são submetidos a procedimentos invasivos. O objetivo deste estudo foi investigar a epidemiologia da infecção pelo HBV em pacientes em tratamento hemodialítico no Estado do Tocantins. Trata-se de um estudo observacional, de corte transversal, analítico, conduzido em todos os serviços de hemodiálise do Estado do Tocantins. Os dados foram obtidos por meio de entrevistas e coleta de amostras sanguíneas no período de outubro de 2014 a fevereiro de 2015. Todas as amostras foram testadas para os marcadores HBsAg, anti-HBs e anti-HBc total pelo ensaio imunoenzimático. Analises uni e multivariadas foram realizadas para identificação de possíveis fatores de risco para exposição ao HBV. Um total de 394 indivíduos participou do estudo. A maioria possuía idade superior a 40 anos (78,2%), era do sexo masculino (58,6%), de cor parda (58,6%) e de baixa escolaridade. A prevalência global para HBV foi de 34,56% (IC 95%: 29,75-39,08), sendo 0,76% (IC 95%: 0,26-2,21) para HBsAg, 30,20% (IC 95%: 25,88-34,91) para anti-HBc e anti-HBs e 3,30% (IC 95%: 1,94-5,56) para anti-HBc isolado. Do total de participantes, 29,4% (IC 95%: 25,16-34,12) apresentaram positividade isolada para anti-HBs, embora praticamente todos referissem no mínimo três doses da vacina contra o HBV. Somente idade acima de 55 anos (RP: 1,84; p=0,022) e tempo de tratamento hemodialítico (RP: 1,60; p=0,001) foram preditoras de exposição ao HBV. A associação entre tempo de hemodiálise e HBV sugere o ambiente dialítico como promotor de exposição viral. A baixa frequência do perfil sorológico de imunização contra hepatite B evidencia a necessidade de maior vigilância da vacinação nos indivíduos em hemodiálise no estado do Tocantins.

O objetivo deste estudo é compreender como as crianças com Síndrome Nefrótica estão sendo cuidadas, buscando identificar novos elementos contextuais e horizontes para reconstruir o cuidado de enfermagem, tendo como foco a família. Trata-se de um estudo qualitativo com apoio teórico-metodológico na hermenêutica, fundamentada principalmente em Gadamer e Ricouer. Foi realizado com famílias de crianças com Síndrome Nefrótica usuárias do Ambulatório de Nefrologia Pediátrica do Hospital Universitário Júlio Müller da Universidade Federal de Mato Grosso, em Cuiabá. Para a coleta de dados foram usados o histórico de enfermagem da família, a construção do genograma e do ecomapa, a análise de documentos e a entrevista. Seis famílias e quatro membros da equipe do serviço de saúde participaram do estudo, totalizando 42 participantes. Os encontros aconteceram no hospital ou no domicílio das famílias. Os resultados foram discutidos em quatro temas: Apresentação das famílias, no qual elas são mostradas por meio das suas biografias, projetos, personagens e contexto. Elas têm em comum história de perdas, afastamento das origens, morte de pessoas significativas, separações, paternidades presumidas e outros problemas de saúde além da doença da criança em foco. Não são famílias ‘convencionais’ e têm uma grande mobilidade no espaço geográfico. As condições materiais de existência são sofríveis. Padecem pelas condições próprias da doença e pela ausência de políticas sociais que dêem suporte ao seu cotidiano. Contam fatos que aparentemente não têm nenhuma relação com a criança doente, mas que foi entendido como um ‘dar-se a conhecer’ da família para que o contexto do cuidado pudesse ser compreendido; Na trajetória da doença da criança na família, são apresentados os caminhos percorridos desde o início da doença, o esforço para superar as dificuldades financeiras, as mudanças na vida da família, o temor das recidivas, a busca por explicações para a sua ocorrência e o orgulho da família em superar o pior; no cuidado da criança com Síndrome Nefrótica, revelam-se os horizontes dos cuidadores, familiares e profissionais de saúde, e o cuidado possível a partir dos arranjos da família e limites da equipe do serviço. Estes expuseram os seus dilemas e limites no enfrentamento do cuidado à criança e na abordagem da família. Familiares e equipe expressaram a necessidade de uma mútua interação para compor o produto do amplo diálogo, o cuidado, que deve incluir o conhecimento técnico-científico, as subjetividades e os horizontes das famílias. Ao final da discussão, faz-se o exercício da avaliação do cuidado e do serviço de Nefrologia Pediátrica a partir da proposta de avaliação formativa de Ayres, compreendida como um recurso técnico e político para a reorientação da racionalidade das práticas de saúde, por meio de um conjunto de procedimentos sistemáticos para dar visibilidade ao que é feito por referência ao que se pode e/ou se quer fazer em saúde. / This study aims to understand the care of children with Nephrotic Syndrome, searching to identify new elements and horizons to reconstruct the nursing care, focalizing to the family. A qualitative study was realized, using hermeneutics according to Gadamer and Ricouer as a theoretical-methodological reference framework. Study participants were families of children and adolescents with Nephrotic Syndrome who attended the Pediatric Nephrology Service at the University Hospital Júlio Müller of Mato Grosso Federal University in Cuiabá, Brazil. Data were collected by means of: the families’ nursing records, the construction of the genogram and ecomap, documentary analysis and talks with the families. A total of 42 subjects participated, including six families and four health team members. The meetings happened at the hospital or at the families’ homes. The results were organized in three themes: Presentation of the families by means of their projects, characters and context. They share a history of losses, distance from one’s origins, death of important persons, separations, presumed fatherhood and other health problems, besides the child’s disease. These are ‘unconventional’ families which are very mobile in terms of space. Material conditions are sufferable. They suffer as a result of the disease’s characteristic conditions and the absence of social policies to support their daily lives. They talk about facts that do not seem to be related with the sick child, but were considered as the family’s ‘getting to know’ in order to understand the context of care. The trajectory of the child’s disease in the family presents the family’s experiences since the start of the disease, their efforts to overcome financial difficulties, changes in family life, the fear of relapses, the search for explanations for their occurrence and the family’s pride when they get over the worst of it. The third theme Care for the nephrotic child reveals the viewpoints of caregivers, family members and health professionals, as well as possible care on the basis of family arrangements. The health team also exposes its dilemmas and limits in facing the child’s care and approaching the family. Family and team members express the need for mutual interaction to construct the product of this broad dialogue, that is, care, which should exclude neither technical-scientific knowledge nor the families’ perspective. What care is concerned, the exercise of formative assessment proposed by Ayres is recommended.

Orientador: José Eduardo Tanus dos Santos / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-21T04:17:50Z (GMT). No. of bitstreams: 1 Marson_BernardoPavinato_D.pdf: 29131187 bytes, checksum: 6a16c5b929f162ad17cdee05fa1926ce (MD5) Previous issue date: 2012 / Resumo: A insuficiência renal crônica é uma complicação grave de diferentes doenças, como diabetes, hipertensão e glomerulopatias. Quando os rins entram em falência, é preciso substituir a função renal, terapia geralmente feita através de hemodiálise. A população de pacientes dependentes de hemodiálise, cujo número cresce de forma geométrica, está exposta a taxas extremamente elevadas de eventos cardiovasculares fatais e não fatais. Fatores de risco clássicos e específicos da uremia se somam conferindo alterações patológicas severas na parede dos vasos. A própria sessão de hemodiálise ativa a inflamação e induz aterogênese. A degradação da elastina e a apoptose das células musculares lisas evoluem para a mudança do fenótipo da camada média, que se expande reduzindo o lúmem em um processo de acentuada calcificação arterial. Alterações na atividade das metaloproteinases de matriz extracelular (MMPs) 2 e 9 e desequilíbrios com seus inibidores endógenos, os TIMPs, ajudam a compor este cenário ao estimular o remodelamento cardiovascular e reorganizar a matriz extracelular, permitindo a expansão tecidual e o depósito de cálcio. Os níveis circulantes de MMP-2 e -9 estão relacionados com maior severidade de doenças cardiovasculares na hemodiálise. Diversos polimorfismos genéticos foram associados com alterações na concentração e/ou atividade destas enzimas, e é possível que diferenças nas distribuições dos polimorfismos ajudem a discriminar indivíduos expostos a níveis plasmáticos mais elevados de MMP-2 e -9 tanto antes como após a sessão de hemodiálise. Os principais polimorfismos são: um polimorfismo de nucleotídeo único (SNP) (C-1562T) e um microssatélite (-90 CA14-24) na região promotora, e um SNP no exon 6 (A855T, Q279R) da MMP-9, e dois SNPs (C-1306T e C-735T) no promotor da MMP-2. Como estes polimorfismos também foram associados com diversas doenças, o propósito deste estudo foi avaliar se eles influem na concentração plasmática de MMP-2 e MMP-9 em pacientes submetidos à hemodiálise crônica, e se afetam o efeito que a sessão de hemodiálise tem sobre os seus níveis circulantes. Para atingir nosso objetivo, estudamos 98 pacientes com idades entre 18 e 65 anos e submetidos à hemodiálise há mais de 3 meses. Amostras de sangue venoso foram coletadas em dois momentos, antes do início e após o término da sessão de hemodiálise. As concentrações de MMP-2 foram determinadas por zimografia e as de MMP-9, TIMP-1 e TIMP-2 foram analisadas por ELISA. O DNA genômico foi extraído a partir do sangue total e amostras foram então genotipadas para os polimorfismos da MMP-2 e MMP-9. As frequências dos haplótipos da MMP-2 e -9 foram estimadas pelo programa PHASE. Nossos resultados mostraram que a sessão de hemodiálise reduz os níveis circulantes de MMP-2 e não altera o TIMP-2, ao passo que os níveis de MMP-9 e TIMP-1 se encontram aumentados ao final da sessão. Encontramos uma associação entre os genótipos que envolvem o alelo de análise T do polimorfismo C-735T e o haplótipo CT demonstrando níveis pré hemodiálise significativamente aumentados de MMP-2 (P= 0,0077 e P= 0,01, respectivamente), mas não de TIMP-2. Os genótipos da MMP-2 não alteram o efeito da sessão da hemodiálise, que reduziu a MMP-2 e o TIMP-2 independente de marcadores genéticos. Marcadores genéticos da MMP-9 mostraram estar associados a níveis maiores de MMP-9 após a hemodiálise: os genótipos CC e QQ (P= 0,0081 e P= 0,0415, respectivamente) e o haplótipo CLQ (P= 0,0012). As concentrações de TIMP-1 aumentaram significativamente após a hemodiálise nos genótipos HH e QR (P= 0,0375 e P= 0,0113, respectivamente) e no haplótipo CHR (P= 0,0008). Adicionalmente, marcadores genéticos da MMP-9 não alteraram os níveis basais de MMP-9 e TIMP-1. Estes achados sugerem que marcadores genéticos da MMP-2 e -9 interferem nos níveis circulantes destas proteases no contexto da hemodiálise / Abstract: Chronic renal disease is a serious complication which may occur in patients who suffer from a vast range of diseases, such as diabetes, hypertension and glomerulonephritis, among others. When the kidneys fail, it becomes necessary to substitute the renal function, which is usually made through hemodialysis. The population of patients that are dependent of hemodialysis are rapidly growing in number. These patients are exposed to extremely high rates of cardiovascular events. Both traditional and uremic specific factors account for severe pathologic alterations on the walls of the vessels. The session of hemodialysis itself stimulates inflammation and induces atherogenesis. The degradation of elastin and the apoptosis of smooth muscle cells eventually progresses to a change in the phenotype of the media layer, which expands, thus reducing the arterial lumen in a process of accelerated calcification. Alteration in the activity of the matrix metalloproteinases (MMPs) 2 and 9 and imbalancements with its endogenous inhibitors - the TIMPs - help to set the scenario for cardiovascular diseases by stimulating cardiovascular remodelling and reorganizing the extracellular matrix, allowing tissue expansion and calcium deposits. The circulating levels of MMP-2 and -9 are associated with greater severity of cardiovascular diseases on patients undergoing hemodialysis. Diverse genetic polymorphisms were associated with alterations on the concentration and with the activity of these enzymes, and it is possible that differences on the distribution of these polymorphisms may help to discriminate individuals exposed to increased plasmatic levels of MMP-2 and -9, both before and after hemodialysis. The main polymorphisms known are: one single nucleotide polymorphism (SNP) (C-1562T) and one microsatellite (-90 CA14-24) on the promoter region, and one SNP on exon 6 (A855G, Q279R) of MMP-9, and two SNPs (C-1306T and C-735T) on the promoter of MMP-2. These polymorphisms were also associated with a number of diseases. Our purpose was to study whether they influence the circulating levels of MMP-2 and -9 in patients undergoing hemodialysis, and whether they affect the levels of these proteases after hemodialysis. In order to reach our aim, we have studied 98 patients whose ages ranged between 18 and 65 years of age and who were undergoing chronic hemodialysis for at least 3 months. Venous samples were collected in two moments, before and after hemodialysis. The concentrations of MMP-2 were assayed with gelatin zymography, and MMP-9, TIMP-1, and TIMP-2 were analyzed with ELISA. Genomic DNA were extracted and samples were genotypied for MMP-2 and -9 polymorphisms. The haplotypic frequencies were analyzed by the PHASE software. Our results show that sessions of hemodialysis reduce the levels of MMP-2, however, it does not alter TIMP-2, while MMP-9 and TIMP-1 suffer an increase after the hemodialysis session. We found an association amidst the genotypes with the variant allele T on the SNP C-735T and on the haplotype CT showing elevated pre hemodialysis levels of MMP-2 (P= 0,0077 and P= 0,01, respectively), but not on TIMP-2. The MMP-2 genotypes do not modify the effect of a hemodialysis session. Genetic markers of the MMP-9 were associated with enhanced levels of MMP-9 after hemodialysis: the CC and QQ genotypes (P= 0,0081 and P= 0,0415, respectively) and the haplotype CLQ (P= 0,0012). The concentrations of TIMP- 1 increased significantly after hemodialysis on the genotypes HH and QR (P= 0,0375 and P= 0,0113, respectively) and on the haplotype CHR (P= 0,0008). Furthermore, genetic markers of the MMP-9 have not altered the basal levels of MMP-9 and TIMP-1. These findings suggest that the genetic markers of MMP-2 and -9 interfere on circulating levels of these proteases on the hemodialysis setting / Doutorado / Farmacologia / Doutor em Farmacologia

Les maladies chroniques engagent réciproquement les soignants et les patients dans une relation de partenariat au long cours. L'offre de soins est orientée vers la prévention secondaire et la préservation de la qualité de vie. La maladie rénale chronique est une priorité de santé publique par sa prévalence, les comorbidités diabétiques et cardiovasculaires, la technicité des soins par dialyse ou greffe, les répercussions économiques et le retentissement sur le quotidien des patients. Les recommandations de bonnes pratiques incitent à une prise en charge thérapeutique précoce avec des parcours de soins personnalisés. Les réseaux de néphrologie ont pour mission de sensibiliser au dépistage de l'insuffisance rénale, de coordonner les suivis pluridisciplinaires et favoriser le décloisonnement entre établissements de soins et médecine de premier recours. Ce travail porte sur le rôle des réseaux français de néphrologie. Une enquête sur l'accès aux soins et le soutien organisationnel des parcours de soins montre une forte hétérogénéité dans leur fonctionnement. Alors que la littérature internationale relate l'impact positif de la coordination des prises en charge sur l'évolution de la fonction rénale et sur la qualité de vie, le recours aux réseaux de néphrologie par les professionnels et les patients reste inégal. L'étude suggère de promouvoir l'accompagnement des patients dans des parcours de soins et d'harmoniser les pratiques par la formation continue, la pluridisciplinarité et la posture éducative. L'enjeu sanitaire des maladies chroniques pour chaque projet de vie est d'intégrer l'ensemble des morbidités dans un même parcours de soins coordonné et évalué / Chronic diseases necessarily imply partnership between patients and medical team. The health care system is directed towards secondary prevention and the preservation of quality of life. Chronic kidney disease is a public health priority by its prevalence, diabetes and cardiovascular comorbidities, specific care as dialysis or transplantation, economics and impact on patients’ way of life. Guidelines encourage early therapeutic care plan. Renal care networks aim at raising awareness of kidney disease detection, coordinate and promote multidisciplinary follow-up and connections between hospitals and ambulatory care. This work analyses the role of renal care networks in France. A survey on access to care and care plan running supports shows a strong heterogeneity in their organisation and management. While international literature describes the positive effect of such supported care management on evolution of renal function and quality of life, using renal care networks by professionals and patients remains uncertain. The study suggests promoting supporting patients in care management and globalizing practices through training, multidisciplinary approach and pedagogic attitude. Every plan of life has to integrate all morbidities in a same coordinated and evaluated care plan