Made available in DSpace on 2016-04-27T13:10:24Z (GMT). No. of bitstreams: 1 Juliane Casas.pdf: 1780723 bytes, checksum: 981765aaf3c65f06c377adf5d9653d40 (MD5) Previous issue date: 2014-03-14 / Chronic renal failure patients are exposed to several nutritional issues, including restrictive diet. Adequate nutrition is of vital importance in the treatment of those patients and nutritional education is a very important matter since it can change the patient s behavior and therefore improve their nutritional status, decreasing risks of inadequate diets. Special attention must be directed to electrolytes, proteins, energy and liquid intake. Objectives: To assess the effects of a specific nutritional education program developed for dialytic patients and designed to give information for adequate decisions and contributions to patient s self-care; To assess changes in feeding habits and laboratorial tests that may be induced by the program. Methodology: 27 patients in HD, randomly chosen, who received a course that consisted of classes about: renal failure, HD and nutrition; liquids, dry weight and interdialytic weight gain; electrolytes and proteins. Before and after the course, patients underwent comparative food questionnaires and were evaluated about their nutritional knowledge. Blood levels of albumin, phosphorus, potassium and interdialytic weight gain, body mass index were also compared in the two moments. The course were evaluated through the gain of knowledge and by open questions about the course itself. Results: Patients demonstrated a very low level of comprehension of basic questions about nutrition before the course (24% of correct answers). This comprehension improved after the course (60% of correct answers), but food questionnaires, interdialytic weight gain and laboratorial data were similar in both moments, despite a very good satisfaction evaluation of the course by patients. Conclusions: The educational program induced a gain of knowledge in nutritional aspects for dialysis patients, but did not induce significant changes of the quality/amount of food intake nor in the laboratorial levels. Positive assessment of the program was observed. It s possible that changes in the nutritional aspects and in laboratorial level demand more time of observation / Os pacientes com insuficiência renal crônica em programa hemodialitico (HD) estão expostos a múltiplas questões nutricionais, incluindo dieta restritiva. A nutrição desempenha papel vital no tratamento destes pacientes. A Educação Nutricional é um tema de extrema importância para os pacientes em HD, uma vez que pode provocar mudanças comportamentais capazes de melhorar o estado nutricional e diminuir os riscos a que estes pacientes se submetem com dietas inadequadas. Objetivos:. Avaliar os efeitos de um programa de educação nutricional específico desenvolvido para pacientes em hemodiálise, de forma a auxiliar para a adequação das decisões e contribuir para o autocuidado dos pacientes; Avaliar mudanças induzidas pelo conhecimento sobre nutrição, hábitos alimentares e nos exames laboratoriais dos pacientes. Metodologia: Foram estudados 27 pacientes em HD, escolhidos aleatoriamente e que receberam aulas sobre Insuficiência Renal, HD e Nutrição; líquidos, Peso seco e ganho de peso interdialítico; eletrólitos e Proteínas. Antes e após o curso, os pacientes foram submetidos a inquéritos alimentares e a avaliações sobre assuntos relacionados à nutrição, sendo as respostas destes dois momentos comparadas entre si. Os valores antes e após o programa de albumina, fósforo, potássio, ganho de peso interdialitico e índice de massa corporal também foram comparados. O curso foi avaliado através de questionamento aos pacientes sobre suas impressões, percepções e a importância atribuída às aulas. Resultados: os pacientes demonstraram antes do curso baixo nível de conhecimentos sobre aspectos básicos de nutrição (24% de acerto). Houve melhora de compreensão após o curso (60% de acerto), mas os inquéritos alimentares mostraram-se similares nos dois momentos indicando não ter havido alterações na qualidade e quantidade de sua ingestão alimentar. Também não notamos, após o curso, alterações em relação aos exames laboratoriais e ao ganho de peso interdialitico. O questionário voltado para avaliar o grau de satisfação demonstrou elevada satisfação dos pacientes e a importância da reprodução do curso. Conclusões: O curso melhorou o nível de compreensão dos pacientes sobre os aspectos nutricionais, mas não induziu a mudanças significativas no comportamento alimentar e nos exames laboratoriais. Os pacientes demonstraram elevado grau de satisfação com o curso. É possível que alterações nos hábitos alimentares e possíveis alterações laboratoriais demandem maior tempo de observação

Chronic kidney disease (CKD) is a non-communicable progressive disease that can lead to kidney failure or end-stage renal disease. In Nigeria, many people do not have access to health care due to extreme poverty, which means that those suffering from diabetes or high blood pressure, or both diseases, which have been identified as the 2 main risk factors, may not know their health status. The purpose of this phenomenological study was to explore the level of CKD awareness among Nigerians and if cultural beliefs affect individuals' health seeking behaviors because of the diverse nature of the Nigerian population. The protection motivation theory provided the framework for the study. Data were collected through semi-structured interviews with 14 participants, and data analysis included traditional coding. Findings indicated that CKD awareness in Nigeria is low. The social change implication is that the findings may be used to increase awareness of the CKD mortality and morbidity rate in Nigeria to facilitate the development and implementation of health policies that could lower the morbidity and mortality rate of CKD.

La maladie rénale peut se manifester avec différents types de pathologies buccales pouvant augmenter les risques de bactériémie. Bien que l’endocardite infectieuse soit une condition rare chez les patients atteints de maladie rénale, elle peut toutefois être retrouvée suite à des infections nosocomiales. Dans le passé, une antibiothérapie prophylactique était prescrite aux patients hémodialysés pour les protéger de l’endocardite infectieuse et de l’infection de l’accès d’hémodialyse. Aujourd’hui, cette recommandation est révolue. Afin de contrer les risques de bactériémie transitoire, une attention particulière doit être apportée aux soins d’hygiène orale à la maison. Le but de l’étude est d’évaluer l’efficacité de deux méthodes d’enseignement d’hygiène orale chez les patients atteints de maladie rénale. Objectifs de recherche Les trois objectifs de recherche sont a) d’évaluer les connaissances des parents de patients atteints de maladies rénales sur l’endocardite infectieuse et le lien avec la santé buccodentaire; b) d’évaluer la perception des parents par rapport à la santé buccodentaire de leur enfant et leurs habitudes d’hygiène orale; et c) de comparer l’influence de deux méthodes d’hygiène orale sur l’indice de plaque chez les enfants atteints de maladies rénales. Hypothèses Les deux hypothèses de recherche sont que a) les parents d’enfants atteints de maladies rénales connaissent et adhèrent aux recommandations émises par l’American Heart Association; et que b) l’amélioration de l’indice de plaque chez les patients atteints de maladies rénales est plus grande pour le groupe recevant des instructions par le matériel audiovisuel par rapport à ceux qui les reçoivent par le néphrologue. Méthodologie Suite à l’obtention d’un certificat d’éthique à la recherche du Centre Hospitalier Universitaire Sainte-Justine, 37 des 38 sujets recrutés âgés entre 6 et 16 ans (19 filles et 18 garçons) ont participé à cette étude transversale. Suite à la signature d’un consentement éclairé, les sujets sont assignés par randomisation à l’un des deux groupes d’instructions d’hygiène orale, soit celui sans instructions spécifiques (groupe 1) ou par matériel audiovisuel (groupe 2). Un questionnaire portant sur les connaissances des parents en rapport avec la santé buccodentaire est remis aux parents. Un indice de plaque initial est noté avant l’application des instructions d’hygiène orale reçues. Un indice de plaque final mis en évidence à l’aide de pastilles révélatrices est documenté avec des photographies intra-orales et mesuré par deux observateurs, testés pour la fiabilité intra et inter-observateurs. Résultats Les analyses statistiques ne démontrent aucune différence significative entre les deux groupes d’instructions d’hygiène orale. Les variables à l’étude (âge, sexe, suivi dentaire, fréquence des soins à la maison, connaissances et motivation) ne montrent aucune influence significative sur la qualité de l’hygiène orale des sujets. Seul l’indice de plaque initial est inversement relié à la perception des parents face à la santé buccodentaire de leur enfant : plus le relevé de plaque est bas, plus la santé buccodentaire est perçue comme bonne. Conclusion Selon les résultats de notre étude, il n’existe pas de différence statistiquement significative entre les deux méthodes d’instructions d’hygiène orale. Néanmoins, les deux techniques permettent de diminuer significativement l’indice de plaque chez les enfants atteints de maladies rénales et de conscientiser cette population à l’importance du maintien d’une bonne santé buccodentaire. / Renal diseases are known to cause oral changes that can increase the risk of developping a bacteraemia. Even if infective endocarditis is a rare condition in patients with renal disease, it is associated with nosocomial infections. In the past, antimicrobial therapy was recommended for haemodialysis patients to prevent infective endocarditis and indwelling venous catheter-related infections. The administration of prophylactic antibiotics is no longer supported, given the lack of evidence concerning this approach. To prevent patients from developing a transitory bacteraemia, home oral care has to be improved. The goal of this study is to assess the efficacy of two oral health instruction methods in children with renal disease. Objectives The objectives of this study are to assess the knowledge on infective endocarditis and its link to the oral health of parents with children who present with renal disease; to evaluate the perception of parents in relation with their child’s oral health and their dental behaviour and finally to compare the impact of the oral health instruction methods on the plaque index of children with renal disease. Hypothesis The two hypotheses of this study are a) parents of children suffering from renal diseases know and respect the guidelines published by the American Heart Association and b) that the improvement of the plaque index is better in the group who receives oral health instructions from the audio-visual material compared to the one receiving instructions from the nephrologist. Methods An ethic’s certification was obtained from the Centre Hospitalier Universitaire Sainte-Justine for children. Of the 38 recruited patients, 37 patients (19 girls, 18 boys) ranging in age from 6 to 16 years participated in this transversal study. Consent was obtained prior to randomised assignment to either oral hygiene delivered by means of an audio-visual aid (groupe 1) or by a nephrologist (group 2). A questionnaire investigating parental knowledge on renal disease linked with oral health was administered. An initial plaque index was taken before applying oral health instructions. A final plaque index using disclosing tablets was measured by two observers tested for intra and inter-reliability through intra-oral pictures. Results The statistical analyses do not show any significant differences between the two oral health instruction groups. No significant relation was found between oral health status and age, gender, dental follow up, frequency of home dental hygiene and motivation. The only significant relationship found was as parents perception of their child’s oral health increases, the initial plaque index decreases. Conclusion The results indicate that even if there is no statistically significant difference between the two methods of oral health instruction, both techniques are capable of reducing the plaque index of children suffering from renal disease.

Τα μέχρι σήμερα βιβλιογραφικά δεδομένα συνηγορούν υπέρ της ύπαρξης σύνδεσης μεταξύ της γονεϊκής νόσου και αυξημένης επίπτωσης συναισθηματικών και συμπεριφοριστικών προβλημάτων στα παιδιά Ωστόσο, στην Ελλάδα δεν υπάρχουν καθόλου βιβλιογραφικά δεδομένα, σχετικά με την σύνδεση της Χρόνιας Νεφρικής Ανεπάρκειας και ειδικότερα της θεραπείας ενδονοσοκομειακής αιμοκάθαρσης (ΑΜΚ) στους γονείς και της πιθανής εμφάνισης ψυχοπαθολογίας στα τέκνα αυτών. Εστία αυτής της μελέτης αποτέλεσε η συσχέτιση της ΧΝΑ και της ΑΜΚ στον γονέα με συγκεκριμένες διαγνωστικές κατηγορίες ή υποκατηγορίες Ψυχικών Διαταραχών στα παιδιά των ασθενών αυτών. Μελετήθηκαν προοπτικά 53 παιδιά, των οποίων ο πατέρας ή η μητέρα υποβαλλόταν σε ΑΜΚ, ηλικίας 6-21 ετών, με την χρήση των Ερωτηματολογίων της Achenbach για γονείς καθώς και με τη χρήση της Ημιδομημένης Ψυχιατρικής Διαγνωστικής Συνέντευξης για Παιδιά και Εφήβους K-SADS-PL. Επίσης εξετάσθηκε η ψυχική υγεία των ασθενών γονέων, με την χρήση της διαγνωστικής συνέντευξης SCID-I και SCID-II και των υγιών γονέων με την χρήση των ερωτηματολογίων ΗΑΜ-D και HAM-A. Διαπιστώθηκαν στατιστικά σημαντικές διαφορές σε όλες τις ομάδες συμπεριφορών της κλίμακας CBCL και στις δυο ηλικιακές ομάδες (6-18 & 18-21). Επίσης αναδείχθηκε ότι τα παιδιά της πειραματικής ομάδας παρουσίαζαν υψηλότερα ποσοστά ψυχοπαθολογίας, συγκριτικά με τους μάρτυρες ως προς την ψυχική υγεία των ασθενών γονέων ευρέθη ότι το 48.3% συμπλήρωναν τα κριτήρια για μια τουλάχιστον Ψυχική Διαταραχή, ενώ το αντίστοιχο ποσοστό στους μάρτυρες ήταν 20.7% (ΟR=6.7, 95% CI 2.0-28.7). Η μέση τιμή της βαθμολογίας που καταγράφηκε για την κατάθλιψη των συζύγων ασθενών ήταν 15.31 (SD=11.7) ενώ των συζύγων-μαρτύρων ήταν 3.19 (SD=3.65), διαφορά η οποία είναι στατιστικώς σημαντική (p<0.001). Τα υπό μελέτη παιδιά εμφανίζουν μεγαλύτερη ψυχοπαθολογία συγκριτικά με τους μάρτυρες, με επικρατέστερη της διαταραχή «Ειδική Φοβία» αλλά και την «Κατάθλιψη» και «Διαταραχή Διαγωγής». Επίσης, παρουσιάζουν περισσότερα συμπεριφορικά προβλήματα σε όλες τις επιμέρους Συμπεριφορές της κλίμακας CBCL, χαμηλότερες τιμές στο προφίλ ικανοτήτων, ενώ στα μεγαλύτερα σε ηλικία παιδιά ανεβρέθηκαν περισσότερα συναισθηματικά προβλήματα. Οι ασθενείς γονείς εμφανίζουν συντριπτικά υψηλότερα ποσοστά στις διαταραχές Διάθεσης, ενώ και στους υγιείς γονείς αναδείχτηκαν πολύ αυξημένα επίπεδα αγχώδους και καταθλιπτικής συμπτωματολογίας. Απαραίτητη είναι η διεξαγωγή προοπτικών μελετών, που θα αναδείξουν την ψυχοκοινωνική εξέλιξη των παιδιών αυτών στο χρόνο. / Bibliographic data up to today speak in favour of the existence of a strong connection between the parental illness and increased sentimental and behaviouristic problems in the children. However, in Greece no data exists. The aim of the present study was to explore the possible psychological impact on the children, who have a parent undergoing in-centre hemodialysis (HD) in Greece. We investigated 53 children, aged 6-21 years old, living at home, whose one parent was undergoing in-centre haemodialysis. The parents were recruited from 4 different haemodialysis centres in Southern Greece. Control subjects were matched with the study children for age, sex, place of residence, socioeconomic status and parental educational level. The data collection was carried out by filling the Child Behavior Checklist (CBCL) and the Adult Behavior Checklist (ABCL), with reports of the ill parent describing specific behavioral and emotional problems of the child, when the psychopathology of the children and their ill parents was studied according to DSM-IV criteria. Children of parents undergoing haemodialysis scored statistically significantly higher than the children in the control group (p<0.01, Wilcoxon signed-ranks test for paired data) on all aspects of trends in behavior (internalizing, externalizing, neither internalizing nor internalizing) on the CBCL and the ABCL scale. We found that this result would remain, even if it was tested with respect to sex (male/female) and age (6-18, 18-21). On the internalizing composite scale females aged 18-21 scored higher than males of same age. Also psychiatric disorders were by 1.8 -fold more frequent in the children of HD parents than in the control children. Ill parents suffered more from a psychiatric disorder (65.5%) in comparison with their controls (20%). The results of this study suggest that parental illness affects negatively the mental health of their dependent offspring aged 6-21 years old. Older children and mainly females seem to be more prone to depressive symptoms. Ill parents suffer greatly from psychiatric disorders and the most common is depression. Also it seems that parental mental health (both in the ill and the healthy parent) influence the mental health of the children. Essential is the conduct of prospective studies that will elect the psychosocial development of this population.

Depression is common in haemodialysis (HD) patients and is often unrecognised and undertreated, though associated with excess morbidity and mortality. Diagnosis is challenging due to symptom overlap with kidney failure, with fatigue being the most common overlapping symptom. Research on the effectiveness of antidepressant medication in this setting is sparse. A recent systematic review advocated well-designed Randomised Controlled Trials (RCTs) in this setting. The studies reported in this thesis had a number of aims. The main aim was to undertake a multicentre feasibility randomised, double blind, placebo-controlled trial of sertraline in patients on HD with Major Depressive Disorder (MDD). To identify suitable patients for this, a screening phase was required, which also allowed determination of the prevalence of depression in this setting and of the relative effectiveness of screening tools Patient Health Questionnaire-2 (PHQ-2), Patient Health Questionnaire-9 (PHQ-9), and Beck Depression Inventory-II (BDI-II). It also allowed examination of the relationships of fatigue in this setting (assessed mainly by the Multidimensional Fatigue Inventory (MFI), including those with a diagnosis, and management of depression. The finding, during screening, that a large proportion of the HD cohort was already on antidepressant treatment, presented the opportunity to study 'real-life' practice patterns in the management of antidepressant treatment in this setting. Recruitment into the RCT was difficult. 1,355 patients in five HD centres were considered for screening, but 243 of these were excluded, mainly because of their inability to read and understand English. Of the remaining 1,110 patients, 709 consented to screening. 231 of these screened positive for high depression symptoms but 130 were not considered for the trial phase, mainly because of concurrent treatment for depression (68 patients), and other contraindicated conditions and medication. In addition, 38 patients declined to take part in the psychiatric interview necessary for diagnosis of MDD. Of the 63 who underwent the diagnostic interview, 37 (58.7%) were diagnosed with MDD and 30 consented to enter the RCT and were randomised into sertraline or placebo groups. This was half of the anticipated recruitment into the RCT. Twenty-one patients (70%) completed the six-month study, eight of 15 in the sertraline group and 13 of 15 in the placebo group (p < 0.05). Drop out was mainly due to adverse or serious adverse events. Depression scores (BDI-II and Montgomery-Åsberg Depression Rating Scale (MADRS)) improved significantly in both the sertraline and placebo groups over six months but there were no significant differences between the treatment groups. There was a slight suggestion of more rapid improvement over the first two months on sertraline, but this was not significant. Fatigue scores were high in all sub-domains - with only a weak relationship with age and comorbidity. Mental fatigue was the strongest independent predictor of high depressive symptoms (BDI-II ≥16, PHQ-9 ≥8), while physical fatigue had the strongest relationship with dialysis recovery time, and survival. Distinguishing between these components of fatigue may have a role in refining the diagnosis and management of MDD. Forty-one of the 76 patients on antidepressant medication at screening were followed up for a mean of 14±5 months. Ten different antidepressant agents were being taken - the most common being Citalopram (39%). Most had been prescribed by GPs. Two-thirds of patients either deteriorated or failed to improve in terms of BDI-II scores during follow-up, many of whom had had no adjustment of medication during this time. Diagnostic evaluation at follow-up showed 37% to be suffering from current or recurrent major depressive episodes (MDE), 48% to have evidence of past MDE, and 15% to have no evidence of ever having been depressed. These empirical studies confirm that depression is very common in HD patients. Its diagnosis is complicated due to symptom overlap with the uraemic syndrome. Fatigue seems to be a key area of overlap with symptoms of depression with a complex relationship. There was no obvious benefit from antidepressants in this feasibility RCT and there was a high drop-out rate due to adverse events, particularly in the sertraline group. These findings raise concerns about the benefits and risks of antidepressants in patients on HD. Current practice patterns may be subjecting patients to substantial risk for little or no benefit. Identifying whether antidepressant medication is effective in this context is a major clinical need, hence the requirement for a definitive study. There is no doubt that to undertake a definitive study would pose considerable recruitment challenges. The findings presented here emphasise the importance of finding ways to overcome these challenges that might include efforts to incorporate patients already taking antidepressants.

Orientadora: Profa. Dra. Marcela Sorelli Carneiro Ramos / Tese (doutorado) - Universidade Federal do ABC, Programa de Pós-Graduação em Biossistemas, 2017. / A isquemia e reperfusão renal, além de causar danos nos rins, promove a instalação de quadro inflamatório sistêmico estérilatravés da liberação defatores na corrente sanguínea, que podem atingir os mais diversos órgãos, como por exemplo o coração,levando a uma série de complicações fisiológicas e morfológicas, o que caracteriza a síndrome cardiorrenal do tipo 4. A resposta iniciada por receptores do tipo Toll-like,culminana síntese de pró-IL-1?, queé clivada em IL-1?pelo inflamassoma, formado por Caspase-1, NLRP3 e ASC-1.A IL-1?se liga ao receptor IL-1R, e pode intensificar a resposta inflamatória, levando ao desenvolvimento de doenças cardiovasculares. Diante do exposto, o presente estudoobjetivou elucidar se a via de síntese ou a via ativada pelaIL-1??estaria envolvida em alterações funcionais e morfológicas no tecido cardíaco. Para tanto, camundongos machos C57BL/6J foram submetidos a isquemia e reperfusão renal (I/R),através da oclusão do pedículo renal esquerdo durante 60 minutos, seguido por reperfusão durante 8, 12 ou 15 dias. Foi administrado o antagonista comercial (Kineret)do receptor de IL-1,foram utilizadoscamundongos TLR2-/-, TLR4-/-, Casp-1-/-, NLRP3-/-, IL-1R-/-e animais tratados com clodronato (para depleção de macrófagos). A I/Rfoi capaz de induzir o desenvolvimento de hipertrofia cardíaca(HC)a partir do décimo segundo dia de reperfusão, acompanhada por alterações eletrofisiológicas (prolongamento do intervalo QT/QTc) e elevaçãonos níveis de IL-1?no soroa partir do oitavo dia de reperfusão. A ausência dos receptores TLR2 ou TLR4 foi suficiente para prevenir a HC. Interessantemente, na ausência de NLRP3ainda observou-se a HC e na ausência deCasp-1, a HC induzida foimais acentuada do que nos animais WT. Jáa interrupção da via de sinalizaçãode IL-1?foi capaz de prevenir a HC.Os resultados obtidos indicam queas vias de síntese e ativada pelaIL-1?estão envolvidasno desenvolvimento de HC em animais submetidosa I/R renal, o mesmo, no entanto não pode ser dito dos componentes NLRP3 e casp-1 do inflamassoma. Em relação as alterações eletrofisiológicas, tantoobloqueio da via de IL-1??quanto a retirada de proteínas chave na constituição do inflamossoma são capazesde prevenir alterações eletrofisiológicas provenientes da inflamação sistêmica. / Renal ischemia promotesnot only damage to the kidneys, but also a sterilesystemic inflammatorystate. Within inflammation, several inflammatory factors are released on the blood stream, reaching other organs, once they reach the heart, they can induce a stress response, leading to morphologic and physiologic changes. Such occurrence characterize type IV cardiorenal syndrome. The cardiac response may occur through activation of Toll-like receptors, resulting in synthesis of an inactive form of IL-1?and this cytokine is activated via NLRP3 inflammasome,composed by NLRP3, Caspase-1 and ASC proteins. IL-1?is activated upon assembling ofNLRP3, which may in turn intensify inflammatory response by binding to its receptor (IL-1R), leading to development of cardiovascular diseases. Therefore, the aim of thisproject was to evaluate whether IL-1?synthesis or activation pathway was involved withheart morphometric and electrophysiological alterationsinduced by I/R.Hence, we used the model of unilateral 60 minutes renal ischemia, followed by reperfusion of 8,12 or 12 days(I/R). Thus,C57bl6 male mice were treated with IL-1R commercial antagonist (Kineret), additionally, we used C57bl6TLR2-/-, TLR4-/-, Casp-1-/-, NLRP3-/-and IL-1R-/-and WT clodronate (macrophage depletion agent) treated mice. WT mice developed prolongation in QT interval after 8 days of reperfusion along with a peak of circulating IL-1?, followed by development of cardiac hypertrophy, starting at day 12. TLR2 and TLR4 absence prevented cardiac hypertrophy. Interestingly, both Kineret or clodronate treatment prevented QT prolongation, the same was observed either on knockout mice to NLRP3 inflammasome components (NLRP3 and Casp-1) or IL-1R.On the other hand, cardiac hypertrophy was more pronounced in Casp-1-/-and was not prevented on NLRP3-/-mice. Data presented here indicate that IL-1?is essential to cardiac electrophysiological alterations. Moreover, molecular pathways involved in synthesis andactivated by IL-1?participate of development of CH induced by I/R.

Made available in DSpace on 2015-04-17T15:02:56Z (GMT). No. of bitstreams: 1 arquivototal.pdf: 1377692 bytes, checksum: 3f9ed1b868827e7be04d2e3b20d643a0 (MD5) Previous issue date: 2011-12-15 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES / The carotid artery calcification (CAC) is one of the most serious and frequent complications occurring in patients with chronic kidney disease. In recent years, the dental literature has warned dentists about the possibility of panoramic radiography to detect these lesions. However, little is known about the reliability of this method in the diagnosis of calcifications. The objective of this study was to evaluate by means of two scientific articles the prevalence of CAC in digital panoramic radiographs (DPR) of patients with chronic kidney failure under hemodialysis treatment and see if this examination can be reliable in the diagnosis of these lesions. The first article analyzed the prevalence of calcifications in the DPR of patients with chronic kidney failure and compared these results with the radiographic findings of a group of healthy patients. Statistical analysis using chi-square test revealed a significant difference (p <0.001) in the prevalence of these lesions among the study groups, since 28% (n = 14) of the radiographs of patients on hemodialysis had pictures of CAC, whereas only 2% (n = 1) radiographs of the control group had these images. The second article verified the reliability of the DPR in the diagnosis of CAC, comparing the results of that examination with ultrasonography (USG). The parameters used for this evaluation were precision, sensitivity, specificity and positive predictive value. The results showed that the panoramic radiograph was 71.43% accurate in diagnosing cases of CAC confirmed by ultrasound, with low sensitivity (37.93%), high specificity (95.12%) and good positive predictive value (84.61%). In addition, the McNemar test revealed a statistically significant difference (p <0.001) between the ability of DPR to diagnose CAC compared to the USG. On the above, we can conclude that patients with chronic kidney failure under hemodialysis treatment are significantly more affected by the CAC that the healthy population and that despite the DPR is not indicated as test of choice to investigate the presence of CAC, it can be a useful tool in the diagnosis of lesions in asymptomatic patients. / A calcificação na artéria carótida (CAC) é uma das complicações mais graves e frequentes que ocorre nos pacientes portadores de doença renal crônica. Nos últimos anos, a literatura odontológica tem alertado os cirurgiões-dentistas quanto à possibilidade de a radiografia panorâmica detectar essas lesões. Entretanto, pouco se sabe a respeito da confiabilidade desse método no diagnóstico dessas calcificações. Assim, o objetivo do presente trabalho foi avaliar por meio de dois artigos científicos a prevalência de CAC nas radiografias panorâmicas digitais (RPD) de doentes renais crônicos sob tratamento de hemodiálise e verificar se esse exame pode ser confiável no diagnóstico dessas lesões. O primeiro artigo analisou a prevalência das calcificações nas RPD de doentes renais crônicos e comparou esse resultado com os achados radiográficos de um grupo de pacientes saudáveis. A análise estatística pelo teste qui-quadrado revelou diferença significativa (p< 0.001) na prevalência dessas lesões entre os grupos avaliados, uma vez que 28% (n= 14) das radiografias dos pacientes que realizavam hemodiálise apresentavam imagens de CAC, enquanto que apenas 2% (n=1) das radiografias do grupo controle possuíam essas imagens. O segundo artigo verificou a confiabilidade da RDP no diagnóstico da CAC, comparando os resultados obtidos nesse exame com os da ultrassonografia (USG). Os parâmetros utilizados para essa avaliação foram a precisão, sensibilidade, especificidade e o valor preditivo positivo. Os resultados mostraram que a radiografia panorâmica foi precisa em diagnosticar 71,43% dos casos de CAC confirmados pela ultrassonografia, apresentando baixa sensibilidade (37.93%), alta especificidade (95.12%) e bom valor preditivo positivo (84.61%). Além disso, o teste de McNemar revelou uma diferença estatisticamente significante (p< 0.001) entre a capacidade de diagnosticar CAC da RPD, quando comparada à USG. Diante do exposto, pode-se concluir que os doentes renais crônicos sob tratamento de hemodiálise são significativamente mais afetados por CAC do que a população saudável e que apesar da RPD não ser indicada como exame de escolha para investigação da presença de CAC, ela pode ser uma ferramenta útil no diagnóstico de lesões em pacientes assintomáticos.

Submitted by isabela.moljf@hotmail.com (isabela.moljf@hotmail.com) on 2017-06-19T12:43:50Z No. of bitstreams: 1 felipemartinsdovalle.pdf: 1212367 bytes, checksum: 1eb080fe9bb9c5ae3bdedfa118be339b (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2017-06-29T12:23:35Z (GMT) No. of bitstreams: 1 felipemartinsdovalle.pdf: 1212367 bytes, checksum: 1eb080fe9bb9c5ae3bdedfa118be339b (MD5) / Made available in DSpace on 2017-06-29T12:23:35Z (GMT). No. of bitstreams: 1 felipemartinsdovalle.pdf: 1212367 bytes, checksum: 1eb080fe9bb9c5ae3bdedfa118be339b (MD5) Previous issue date: 2017-02-22 / Introdução: O sedentarismo é altamente prevalente e aumenta a taxa de mortalidade por todas as causa em pacientes com doença renal crônica (DRC) em hemodiálise (HD). Em contraste, um estilo de vida mais ativo está associado a ganhos para esses pacientes. Assim, investigamos os efeitos do treinamento resistido intradialítico e supervisionado no nível de atividade física diária (NAFD), na capacidade funcional (CF), na qualidade de vida (QV) e na força muscular (FM) de pacientes com DRC em HD. Métodos: Vinte e quatro pacientes com DRC (54,2 ± 13,5 anos) em HD (6,0 ± 5,7 anos) foram randomizados para treinamento resistido de moderada intensidade ou controle. O treinamento resistido foi realizado durante as duas primeiras horas das sessões de HD, três vezes por semana, durante três meses. O NAFD foi avaliado por um acelerômetro pelo tempo gasto em diferentes atividades da vida diária (caminhando, em pé, sentado e deitado) e o número de passos. O acelerômetro foi utilizado por sete dias consecutivos (três dias dialíticos e quatro dias de não dialíticos). A CF, a QV e a FM foram avaliadas pelo teste de caminhada de seis minutos (TC6M), questionário SF-36 e pelo teste de contração isométrica voluntária máxima (CIVM), respectivamente. Os valores foram representados em deltas (pós-tratamento menos pré-tratamento). Resultados: Após três meses de treinamento resistido, não foi encontrada diferença significativa no tempo de caminhada (-1,2 ± 18,3 vs. -9,2 ± 13,1 min/dia), no tempo em pé (-10,2 ± 28,6 vs. ± 20,1 min/dia), no tempo sentado (20,8 ± 58,9 vs. -30,0 ± 53,0 min/dia), no tempo deitado (-9,3 ± 57,9 vs. 34,6 ± 54,0 min/dia) e no número de passos [-147 (1834) vs. -454 (2066)] entre os grupos exercício e controle, respectivamente. A distância percorrida no TC6M aumentou significativamente no grupo de treinamento em relação ao grupo controle (48,8 ± 35,9 vs. 6,9 ± 45,9 m, p=0,04). Não foi encontrada diferença significativa na FM (3,4 ± 7,2 vs. 0,5 ± 7,3 Kgf) entre os grupos treinamento e controle, respectivamente. Três domínios do SF-36 apresentaram aumento significativo no grupo treinamento em relação ao controle, respectivamente [capacidade funcional = 13,7 ± 9,9 vs. -12,5 ± 16,7, p=0,003; limitação por aspectos físicos = 0,0 (0,0) vs. -50,0 (93,7), p=0,03; estado geral da saúde = 6,6 ± 14,1 vs. -10,4 ± 21,4, p=0,01). O treinamento resistido intradialítico foi realizado com segurança por todos os participantes. Conclusão: O presente estudo demonstrou que o NAFD não foi modificado após três meses de treinamento resistido intradialítico em pacientes com DRC submetidos à HD. No entanto, esse programa de exercícios foi capaz de aumentar a CF e alguns domínios da QV nesses pacientes. / Background: Physical inactivity is highly prevalent and increases all causes of mortality in end-stage renal disease (ESRD) patients on hemodialysis (HD). In contrast, a more active lifestyle is associated with better outcomes in these patients. We therefore investigated the effects of supervised intradialytic resistance training on physical activities in daily life, physical capacity, quality of life and muscle strength in ESRD patients. Methods: Twenty four ESRD patients (54.2 ± 13.5 years) under HD (6.0 ± 5.7 years) were randomly assigned to either 3-month moderate-intensity resistance training or a control period. Resistance training was performed during the first two hours of HD sessions, three times a week, for three months. Physical activities in daily life was evaluated using an accelerometer regarding the time spent in different activities and positions of daily life (walking, standing, sitting and lying down), and the number of steps taken. The accelerometer was used for seven consecutive days (three dialysis days and four nondialysis days). Physical capacity, quality of life and muscle strength were evaluated by six-minute walking test (6MWT), SF-36 questionnaire and maximum voluntary isometric contraction test, respectively. The values were expressed as delta (post-pre treatment). Results: After three months of training, we didn’t find significant difference in walking time (-1.2 ± 18.3 vs. -9.2 ± 13.1 min/day), standing time (-10.2 ± 28.6 vs. 3.2 ± 20.1 min/day), sitting time (20.8 ± 58.9 vs. -30.0 ± 53.0 min/day), lying down time (-9.3 ± 57.9 vs. 34.6 ± 54.0 min/day) and number of steps taken [-147 (1834) vs. -454 (2066)] in training and control groups, respectively. The 6MWT distance increased significantly in training group when compared with control group (48.8 ± 35.9 vs. 6.9 ± 45.9 m, p=0.04). No significant difference was found in muscle strength (3.4 ± 7.2 vs. 0.5 ± 7.3 Kgf) in training and control groups, respectively. Three domains of the SF-36 showed significant increase in training group when compared with control group, respectively (physical functioning = 13.7 ± 9.9 vs. -12.5 ± 16.7, p=0.003; role physical = 0.0 (0.0) vs. -50.0 (93.7), p=0.03; general health = 6.6 ± 14.1 vs. -10.4 ± 21.4, p=0.01). Intradialytic resistance training was safely performed by all participants. Conclusions: The present study showed that daily life activities were not modified after three months of intradialytic resistance training in HD patients. However, the exercise program was able to increase the physical capacity and some domains quality of life in these patients.

Abstract The aim of this work was to evaluate the outcome of childhood Henoch-Schönlein purpura (HSP), the effectiveness of Cyclosporine A (CyA) for treating severe HSP nephritis (HSN), and more particularly the possibility for influencing the course of HSP disease by early prednisone treatment. A total of 47 adults who had had childhood HSP were evaluated after a mean of 24.1 years (16.4–35.6). The outcome was highly dependent on the renal symptoms at onset, since 7 out of 20 adults (20%) who had severe renal symptoms at onset had renal impairment as adults, compared with 2 out of 27 (7%) with mild or no renal symptoms at onset (relative risk 4.7; 95% CI 1.3–18.7). 70% of pregnancies in women after childhood HSN were complicated by hypertension or proteinuria. The annual incidence of HSN with nephrotic-range proteinuria was 2 per million children under 15 years. After a mean follow-up of 4.6 years, only three patients out of 19 were in complete remission. Kidney biopsy did not predict the outcome in these patients. CyA seemed to be promising for the treatment of severe HSN with nephrotic-range proteinuria, since four out of seven patients treated with CyA achieved stable remission and three had preserved their renal function after a mean follow-up of 6.0 years. Treatment at an early stage in the disease was associated with stable remission. The efficacy of early prednisone treatment was evaluated in a randomized double-blind trial involving 171 patients (84 prednisone, 87 placebo). Prednisone, given at a dose of 1 mg/kg/day for 2 weeks, with weaning over the next two weeks, was effective in reducing the intensity of abdominal pain (pain score 2.5 vs. 4.8; t-test p = 0.029) and shortening its duration (1.5 days vs. 2.7 days; t-test p = 0.028) compared with the placebo. The mean scores for joint pain were lower in the prednisone group (4.6 vs. 7.3; t-test p = 0.030) and the improvement from joint symptoms was faster (log rank p = 0.007). Prednisone did not prevent the development of renal symptoms but it was effective in treating them, since renal symptoms resolved in 61% of the prednisone patients after treatment compared with 34% of the placebo patients (difference 27%, 95% CI 3–47%, p = 0.024). Prednisone was most effective for children aged 6 or more with renal symptoms at onset, since only two patients needed to be treated in order to save one from renal involvement (95% CI's for NNT 2–6). The long-term outcome of HSP is dependent on renal symptoms. Severe renal symptoms indicate early immunosuppressive treatment for HSN, and patients with renal involvement at the acute phase need long-term follow-up, especially women during and after pregnancy. Early treatment with prednisone is effective in reducing the abdominal and joint symptoms involved in HSP and is also effective in altering, but not preventing, the course of renal involvement. / Tiivistelmä Väitöskirjatyön tarkoituksena oli selvittää lapsuusiän Henoch-Schönleinin purppuran (HSP) pitkäaikaisennustetta, Siklosporiini-A:n (CyA) tehoa vaikean HSP-nefriitin hoidossa ja tutkia varhain aloitetun prednisonihoidon hyötyä HSP-taudin oireisiin. HSP:n pitkäaikaisennustetta selvitettiin tarkastamalla 47:n lapsena HSP-taudin sairastaneen aikuisen terveystilanne keskimäärin 24.1 vuoden (16.4-35.6) seuranta-ajan jälkeen. HSP-taudin ennuste oli vahvasti riippuvainen munuaisoireen vaikeusasteesta: 20 % niistä, joilla taudin alussa oli vaikeat munuaisoireet, kärsi vielä aikuisiällä munuaisoireista; vastaava luku munuaisoireettomilla ja niillä, joilla oli ollut vain lievää veri- tai valkuaisvirtsaisuutta, oli 7 %, (RR 4.7; 95 % CI 1.3–18.7). Raskauskomplikaatiot olivat yleisiä lapsuusiällä HSP-taudin sairastaneilla naisilla, sillä 70 % raskauksista komplisoi korkea verenpaine tai valkuaisvirtsaisuus. Vuosittain 2 lasta miljoonasta sairastuu vaikeaan nefroottistasoiseen HSP-nefriittiin Suomessa. Vain kolme nefroottistasoiseen HSP-nefriittiin sairastuneesta 19 lapsesta oli 4.6 vuoden seurannan jälkeen parantunut oireettomaksi. Ensimmäisen munuaisbiopsian vaikeusaste ei ennakoinut selviytymistä. CyA näytti olevan lupaavan tehokas lääke vaikean HSP-nefriitin hoidossa, sillä neljä seitsemästä CyA-hoitoa saaneesta lapsesta, oli oireeton 6.0 vuoden seurannan jälkeen. Mitä aikaisemmin vaikean nefriitin hoito oli aloitettu, sen parempi hoitotulos oli. Varhain aloitetun prednisonihoidon hyötyä HSP-taudin oireisiin selvitettiin satunnaistetulla kaksoissokkotutkimuksella, johon satunnaistettiin 171 lasta (84 prednisoni, 87 lumelääke) saamaan joko prednisonia 1 mg/kg/päivä 2 viikon ajan tai lumelääkettä. Prednisoni vähensi tehokkaasti vatsa- ja nivelkipuja ja se lyhensi merkitsevästi myös niiden kestoa. Prednisoni ei estänyt munuaisoireen kehittymistä lapselle, mutta niiltä, joille se kehittyi, oireet hävisivät merkitsevästi nopeammin lumelääkitykseen verrattuna (61 % versus 34 %, 95 % CI 3–47 %, p = 0.024). Kaikkein tehokkainta prednisoni oli yli 6 vuotiaille lapsille, joilla oli munuaisoire heti taudin alussa (NNT 2, 95 % CI 2–6). Tutkimuksen perusteella voidaan sanoa, että lapsuusiällä HSP-nefriitin sairastaneet lapset tarvitsevat seurantaa aikuisiällä, erityisesti naiset raskauden aikana. HSP-nefriitin varhainen hoitaminen on tärkeää. Varhainen prednisonihoito ei estä munuaisoiretta, mutta hoitaa jo kehittynyttä nefriittiä ja vähentää vatsa- ja nivelkipuja tehokkaasti.

Les objectifs sont d’évaluer l’efficience (survie, qualité de vie et le coût) des deux techniques de dialyse de rechercher les déterminants qui orientent le choix vers l’une ou l’autre des techniques de dialyse et d’évaluer le parcours de soins des patients en dialyse. La première partie de ce travail de thèse à analyser les données de la région PACA issues du registre REIN. Cette analyse est descriptive et porte sur le profil des patients démarrent un traitement en dialyse (HD et DP). Une analyse de survie a été réalisée selon la technique de dialyse initiale et selon le parcours de soins. Dans une seconde partie, le coût et sur la qualité de vie ont été évalués selon les différentes techniques de dialyse afin d’évaluer l’efficience de ces modalités à partir des données recueillies dans un PHRC régional. Dans une troisième partie, les facteurs liés au choix initial de la technique de dialyse, DP ou HD ont été recherchés. Ce travail a fait l’objet d’une étude ciblée auprès de patients et de néphrologues au sein de 4 structures de dialyse. La survie et la qualité de vie des patients sont similaires entre HD et DP. Le changement de technique, de la DP vers l'HD, a un impact positif sur la survie. La DP est moins coûteuse que l’HD. Les contre-indications médicales à la DP ne concernaient que 26,7% des patients inclus. En absence de contre-indications, la préférence du patient et les pratiques des professionnelles (information et pratiques de centre) sont les deux principaux facteurs liés au choix initial de la technique de dialyse, notamment par la DP. Une meilleure information pourrait contribuer à augmenter le choix de la DP. / The objectives of this work were to assess and compare the efficiency (survival, quality of life and cost) of patients initially treated with peritoneal dialysis (PD) or hemodialysis (HD), to search determinants that guide the initial choice towards either dialysis techniques and to assess the trajectory between dialysis modalities. The first part of this thesis was to analyze the database, from the PACA region (2004 – 2014), issue from the French REIN registry. This analysis was descriptive and focused to analyze main characteristics and outcome (survival) of dialysis patients (initial dialysis and switching) and to identify risk factors. The second part of this thesis was to measure and compare dialysis patient quality of life and health’s care costs between dialysis modalities (HD and PD). Database was issued from PHRC. The third part was to search the factors related to the initial choice of dialysis technique, PD or HD. This work was the subject of a targeted survey of patients and neurologists in a dialysis structure. The survival and the quality of life were similar between hemodialysis and peritoneal dialysis. Switching to HD may improve positively the survival compared to those who remained on PD, whereas, switching to PD was not. The DP is less expensive than HD. Medical contraindications to the PD were for 26.7%. In the absence of contraindications, patient preference and professional practices (information and practical center) are the two main factors related to the initial choice of dialysis technique, in particular to choice of PD. Better information could help to increase the choice of DP