Bakgrund: Antal personer som lever med kronisk njursvikt ökar med befolkningsökningen. Peritonealdialys är en vanlig livsuppehållande behandling för patienter som lever med kronisk njursvikt som främst sköts av patienter i hemmet. För att kunna fortsätta leva med sjukdomen under kontroll kräver peritonealdialys införande av nya livsförändringar som på olika sätt kan vara påfrestande för patienterna. Syfte: Syftet var att beskriva patienters upplevelser av att leva med peritonealdialys i sin vardag. Metod: Litteraturöversikten baserades på elva vetenskapliga artiklar med kvalitativa ansatser hämtade från databaserna CINAHL complete och PsyINFO. Sökorden som användes vid artikelsökning var patient experience, living with" och "peritoneal dialysis" som vidare utökades till "perspective", "home dialysis, qualitative study och interview'' med års begränsning 2000- 2017. Resultat: Litteraturöversikten visade att patienternas upplevelser av att leva med peritonealdialys innefattade en livsförändringsprocess med upplevelser av övergång som en besvärlig vändpunkt i livet vilket började redan vid PD- initiering. De första sex månaderna var den svåraste tiden att hitta balansen och anpassa sig till ett nytt levnadssätt, under den perioden hade patienterna stora behov av stöd både från sjukvården och det egna sociala nätverket dels för att bearbeta de olika förluster och begränsningar relaterad till PD- behandlingen, dels för att upprätthålla motivationen för att fortsätta sköta sin behandling. Med tiden ökade patienterna upplevelser av oberoende självständighet i att hantera sin egenvård och deras behov av stöd minskade, stödet från sjukvården minskade till enbart rutinkontroller. Diskussion: Patienters upplevelser av att leva med PD diskuterades och analyserades utifrån Orems teori om egenvårdsbalans och tidigare forskning. Större delen av diskussionen understryker betydelse av sjukvårdpersonalens bemötande som kan såväl positivt som negativt påverka patienters upplevelser. Hur väl en patient lyckades med sin egenvård berodde mycket på bemötandet, anpassad information, typ av stöd i patientens sociala nätverk och vilka vårdinsatser patienten fick under behandlingsprocessen.

<p>Antalet personer med kronisk njursvikt ökar i Sverige, orsakat av att diabetesnefropati ökar, som en följd av att allt fler får diabetes mellitus typ 2. Peritonealdialys är en behandling för personer med kronisk njursvikt och kan skötas i hemmet. Syftet med studien är att beskriva hur peritonealdialys inverkar på dagligt liv bland personer med kronisk njursvikt. Studien genomfördes som en allmän litteraturstudie och vetenskapliga artiklar har sökts via elektroniska databaser och manuella sökningar. Femton artiklar granskades och analyserades med hjälp av innehållsanalys. Resultatet visade fyra kategorier som utgjordes av oberoende, delaktighet, förändring av välbefinnande och ny medvetenhet om kroppen. De olika kategorierna beskrev peritonealdialysens inverkan på personernas dagliga liv. Genom delaktighet i behandlingen får personen ett oberoende i dagligt liv. Förekomst av fatigue, oro och förändrad kroppsuppfattning kan inverka på personens livskvalitet. Behandling med peritonealdialys har inverkan både på den enskilde personen och på familjen. En beskrivning av peritonealdialysens inverkan på dagligt liv, kan förbereda distriktssköterskan i mötet och omvårdnaden av personer med peritonealdialysbehandling.</p> / <p>The number of persons with chronic renal failure is increasing in Sweden, caused by an increasing number of diabetes nephropathia, as a result of a larger number of diabetes mellitus type 2. Peritoneal dialysis is a treatment for persons with chronic renal failure and can be performed at home. The aim of the study is to describe the influence of peritoneal dialysis in the daily life of persons with chronic renal failure. The study was implemented as a general literature study and scientific articles have been acquired via electronic databases and manual searches. Fifteen articles were reviewed and analysed through content analysis. The results showed four categories consisting of independence, participation, change in well-being and new awareness of the body. The different categories described influence of peritoneal dialysis in daily life. By means of participation in the treatment the person gets independence in daily life. The existence of fatigue, anxiety and change of body image can influence a person’s quality of life. Treatment with peritoneal dialysis can influence both the individual and the family. A description of influence of peritoneal dialysis in daily life can prepare the district nurse in the meeting and nurturance of persons with peritoneal dialysis.</p>

Although two-thirds of colorectal cancer patients are cured by surgery, approximately 50% of the patients with this disease develop locally recurrent or distant metastases during the course of their illness. The aim of this study was to identify metastatic sites associated with poor prognosis in rectal cancer and then to investigate methods that can prevent the development and growth of metastases and optimise uptake of drugs at these sites in animal models. In a defined population, 151 patients with irresectable metastatic or local rectal cancer were identified. Bilateral liver involvement, abnormal liver function tests, paritoneal growth or abdominal lymph node metastases implied a poor prognosis. In a study on Wistar rats with liver metastases from colorectal cancer, blocking of hyaluronan uptake and elimination by the liver enhanced the hyaluronan uptake in liver metastases. Hyaluronan may thus be used to promote uptake of drugs in specific hyaluronan receptor-positive turnout sites. Adjuvant intravenous radioimmunotherapy delivered as a specific or unspecific monoclonal antibody prevented human colonic cancer calls inoculated into the portal vein of nude rats from developing into liver metastases. Furthermore, intraperitoneally administered radioimmunotherapy inhibited the growth of peritoneal metastases. Blocking of 5-FU absorption with a vasoconstrictive agent enhanced the uptake of 5-FU in peritoneal metastases. In addition, the uptake of 5-FU in peritoneal metastases could be improved when these turnouts were mechanically disintegrated by surgical turnout reduction and the drug was given intraperitoneally.

Peritoneal carcinomatosis (PC) is traditionally regarded as a terminal stage of disease with a poor prognosis and systemic chemotherapy is regarded as palliative treatment. In order to improve survival and even to achieve cure for selected patients with PC, cytoreductive surgery and intraperitoneal che-motherapy have been advocated. Despite complete macroscopic removal of tumour, residual microscopic malignant cells might result in recurrence. Intraperitoneal chemotherapy aims to kill residual malignant cells and thereby needs to be distributed in the entire peritoneal cavity. This aggres-sive combined loco-regional treatment has a high risk of morbidity and mor-tality. Whether the increased risks are acceptable to improve survival re-quires investigation and the impact of loco-regional treatment of PC on health-related quality of life (HRQL) needs to bee explored The overall aim of this thesis was to analyse the impact of cytoreductive surgery and intraperitoneal chemotherapy on patients with peritoneal carci-nomatosis. A significant survival improvement (median 32 months) was seen in 18 patients with PC of colorectal origin subjected to loco-regional treatment, in comparison to matched controls treated with systemic chemotherapy (me-dian survival 14 months, Paper I). The results of single-photon emission computer-tomography (SPECT) in 51 patients were correlated to the number of intraperitoneal chemotherapy courses that could be performed without further surgery (Paper II). Postoperative 30-days morbidity and 90-days mortality was investigated in 123 PC-patients after loco-regional treatment. Severe adverse events occurred in 51 (41%) patients. Five patients (4%) had treatment-related mortality. Stoma formation, duration of surgery, periopera-tive blood loss, and extent of PC was associated with morbidity (Paper III). HRQL was investigated in 64 patients. HRQL was negatively affected at 3 months but a partial recovery was seen at 8 months. 30-day morbidity did not have any impact on HRQL at 8 months (Paper IV). This treatment there fore appears justified despite considerable toxicity in view of possible life prolongation.

Peritoneal carcinomatosis (PC) is a common manifestation of both gastrointestinal and gynecologic malignancies. Until recently, this condition was considered beyond curative intent treatment. Since the 1980s, new treatment strategies combining cytoreductive surgery (CRS) with perioperative intraperitoneal and intravenous chemotherapy have emerged. The underlying hypothesis considers CRS responsible for the removal of the macroscopic disease and that perioperative chemotherapy should address the residual microscopic disease. These new treatment regimens have presented encouraging clinical results that contrast with prior failure. The parameters for perioperative chemotherapy are mainly extrapolated from literature on peritoneal dialysis and data from systemic chemotherapy. The overall aim of this thesis was to provide a pharmacokinetic and pharmacodynamic rationale for perioperative intraperitoneal (IP) and intravenous (IV) chemotherapy in PC patients and, to assess its toxicity. After intraoperative IV administration of 5-fluorouracil or ifosfamide, substantial levels of these drugs were found inside the peritoneal fluid and tumor nodules (Papers I and II). This created a pharmacologically advantageous situation whereby a normothermic administered IV drug was subject to the effect of the local hyperthermia in the peritoneal fluid and tumor nodule. High levels of 5-fluouracil, ifosfamide and doxorubicin were observed inside the tumor nodules (Papers I, II and III) and, the identical pharmacokinetic advantage (expressed as Area Under the Curve (AUC) IP/IV ratios)) resulted in different drug levels of doxorubicin according to the density of the tumor nodules (Paper III). These data stressed the importance of pharmacodynamic variables such as tumor nodule density, size, and, vascularity. Therefore, the tumor nodule is proposed as a more appropriate pharmacological endpoint than AUC ratios. After IP Mitomycin C administration in PC patients with a contracted abdomen, mitomycin clearance from the abdomen decreased (Paper IV), which indicated  these patients at risk of under-treatment. Consequently, these pharmacologic data indicate a change in dosimetry for these treatment protocols might be warranted according to the diffusion area. Although diffusional vectors are viewed the main driving force for these treatment protocols, only pharmacokinetic variables such as dose, volume and duration are considered. As pharmacodynamic variables are equally important in the pharmacological assessment of cytotoxic effect, the tumor nodule was proposed as the center of a new conceptual model (Paper I). Mitomycin C data on non-metabolizers ( Paper IV) indicated the cytotoxicity of these cancer chemotherapy protocols is at the level of the individual tumor nodules. The morbidity and mortality of a new bidirectional intraoperative chemotherapy regimen in PC patients was analyzed (Paper V) which provided a means for identifying subsets of patients at risk for increased toxicity. This thesis provides pharmacokinetic and pharmacodynamic guidance for improving perioperative chemotherapy treatment strategies in PC patients and reports its toxicity.

Sleep problems affect a considerable number (49-86%) of patients undergoing peritoneal dialysis (PD) treatment. Insomnia i.e. difficulties to initiate and/or maintain sleep or too early wakening, combined with daytime symptoms, seems to be the dominating problem. Despite these facts there is a lack of research in PD-patients, especially studies with objective data on the sleep-wake cycle and evaluation of sleep promoting non-pharmacological  interventions. The overall aim of this thesis was to describe sleep problems from different perspectives, and how these problems affect daily life and health in patients treated with PD at home. The aim was also to evaluate an individualised non-pharmacological intervention for improvement of sleep quality outcomes. Four studies were conducted during eight years, starting in 2002. Patients from six hospitals in the south-east of Sweden were invited to participate. In addition, data from a reference group with Coronary Artery Disease and a population group were used for comparisons with PD-patients in one of the studies. Data was collected by self-reported questionnaires, actigraphy registrations and interviews. Sleep was evaluated in a 17-week single-case study with an intervention focusing on sleep hygiene advice. Data from a total of 700 sleep-wake cycles was collected in the patients’ homes. The main findings clearly demonstrated that PD-patients have seriously fragmented sleep compared to the CAD- and population group, and that the PD-patients have a high prevalence of insomnia. The sleep was mainly disturbed by pruritus and Restless Legs Syndrome (RLS). Daytime impairments and a frequent napping behaviour were detected. The prevalence of fatigue was also reported to be extremely high. The patients described that an ever-present tiredness and poor sleep had consequences in their everyday life both physically, mentally, socially and existentially. The nurse-led intervention demonstrated that individual, non-pharmacological sleep interventions can improve sleep and daytime activities in PD-patients. This thesis elucidates that deteriorated sleep with serious fragmentation leads to a variety of daytime impairments and fatigue. By adopting “renal supportive care” in clinical work a more elaborate assessment and individualised non-pharmacological treatment of sleep problems may improve sleep quality and activity in frail patients undergoing peritoneal dialysis at home.

Antalet personer med kronisk njursvikt ökar i Sverige, orsakat av att diabetesnefropati ökar, som en följd av att allt fler får diabetes mellitus typ 2. Peritonealdialys är en behandling för personer med kronisk njursvikt och kan skötas i hemmet. Syftet med studien är att beskriva hur peritonealdialys inverkar på dagligt liv bland personer med kronisk njursvikt. Studien genomfördes som en allmän litteraturstudie och vetenskapliga artiklar har sökts via elektroniska databaser och manuella sökningar. Femton artiklar granskades och analyserades med hjälp av innehållsanalys. Resultatet visade fyra kategorier som utgjordes av oberoende, delaktighet, förändring av välbefinnande och ny medvetenhet om kroppen. De olika kategorierna beskrev peritonealdialysens inverkan på personernas dagliga liv. Genom delaktighet i behandlingen får personen ett oberoende i dagligt liv. Förekomst av fatigue, oro och förändrad kroppsuppfattning kan inverka på personens livskvalitet. Behandling med peritonealdialys har inverkan både på den enskilde personen och på familjen. En beskrivning av peritonealdialysens inverkan på dagligt liv, kan förbereda distriktssköterskan i mötet och omvårdnaden av personer med peritonealdialysbehandling. / The number of persons with chronic renal failure is increasing in Sweden, caused by an increasing number of diabetes nephropathia, as a result of a larger number of diabetes mellitus type 2. Peritoneal dialysis is a treatment for persons with chronic renal failure and can be performed at home. The aim of the study is to describe the influence of peritoneal dialysis in the daily life of persons with chronic renal failure. The study was implemented as a general literature study and scientific articles have been acquired via electronic databases and manual searches. Fifteen articles were reviewed and analysed through content analysis. The results showed four categories consisting of independence, participation, change in well-being and new awareness of the body. The different categories described influence of peritoneal dialysis in daily life. By means of participation in the treatment the person gets independence in daily life. The existence of fatigue, anxiety and change of body image can influence a person’s quality of life. Treatment with peritoneal dialysis can influence both the individual and the family. A description of influence of peritoneal dialysis in daily life can prepare the district nurse in the meeting and nurturance of persons with peritoneal dialysis.

published_or_final_version / Nursing Studies / Master / Master of Nursing in Advanced Practice

Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2007. / Härtill 6 uppsatser.