The management and treatment of chronic diseases, such as end-stage renal disease, is often unproductive because of patients' poor adherence to treatment. The chronic care model toolkit is an Agency for Healthcare Research and Quality supported framework, associated with improved outcomes in patients living with chronic disease. The purpose of this project was to develop and plan an educational program using the chronic care model toolkit for the interdisciplinary clinical staff of a renal hemodialysis center. The goal of this project was to adapt team building between patients and their clinicians through the use of the chronic care model in order to improve patients' adherence to treatment. The educational program materials were developed, including a plan for future implementation over 6 weeks in 2-hour twice-weekly sessions. Program planning accounted for the mixed roles and responsibilities of the interdisciplinary clinical team members, who will share their knowledge among the team and act as patient advisors. The pretest and posttest materials were developed from the toolkit Team Health Audit Questionnaire, which can be used to evaluate staff learning after the program is delivered. Existing clinical metrics are tracked through a Quality Assessment Performance Improvement measure, which will be used to evaluate potential long term influences of the program on patient adherence and outcomes. The project may contribute to social change in practice by enhancing teamwork that has the potential to improve clinical outcomes. Future research should include longitudinal studies on team building using the chronic care model toolkit to determine if its adaption enhances team effort and contributes to a collaborative workforce that improves clinical outcomes.

<p>Diabetes mellitus (DM) is one of the leading causes of end stage renal failure. An increased susceptibility to renal ischemia/reperfusion (I/R)-injury was found in DM rats. Unilateral renal ischemia for as short as 20 minutes led to an irreversible progressive injury in DM kidneys, whereas the injury in non-DM kidneys was almost reversible. The renal I/R injury was characterized by anuria, infiltration of inflammatory cells, tubular atrophy, dilation of the remaining tubuli and tubulointerstitial fibrosis. Necrotic areas were found in the inner parts of the outer medulla and in the papilla. The renal medulla was the most vulnerable part of the kidney. This was seen both by the extent of fibrosis four and eight weeks after I/R and by the presence of TUNEL-positive (apoptotic) cells 6h after ischemia. Increased accumulation of HA and enhanced CD44 expression was seen after I/R in DM kidneys.</p><p>Treatment with long acting insulin 7-14 days before I/R, decreased the number of apoptotic cells in the renal medulla and protected renal function and morphology after the insult, while insulin treatment after the injury did not have any protective effect. Short acting insulin given 2-6 hours before I/R partially protected renal function but did not improve the morphological picture.</p><p>Treatment with the angiotensin II receptor type 1 blocker candesartan, the PAF-antagonist UR-12670, the immunosuppressive agents tacrolimus and cyclosporin A, or prednisolone did not improve the outcome of the renal I/R injury in DM. Injection of cobalt protoporphyrin (CoPP) intraperitoneally in order to induce an over-expression of heme oxygenase-1 (HO-1) resulted in a trend towards a better function in DM kidneys after I/R. However, the induction of HO-1 by intraperitoneal CoPP injection was not achieved in all rats, when examined by western blot.</p><p>In conclusion, unilateral renal I/R leads to a severe progressive injury in DM kidneys. Insulin treatment before ischemia, but not after, reduces the renal injury in DM rats. Studies using a more reliable administration of CoPP are required to decide if induction of HO-1 protects against renal I/R injury in DM.</p>

Diabetes mellitus (DM) is one of the leading causes of end stage renal failure. An increased susceptibility to renal ischemia/reperfusion (I/R)-injury was found in DM rats. Unilateral renal ischemia for as short as 20 minutes led to an irreversible progressive injury in DM kidneys, whereas the injury in non-DM kidneys was almost reversible. The renal I/R injury was characterized by anuria, infiltration of inflammatory cells, tubular atrophy, dilation of the remaining tubuli and tubulointerstitial fibrosis. Necrotic areas were found in the inner parts of the outer medulla and in the papilla. The renal medulla was the most vulnerable part of the kidney. This was seen both by the extent of fibrosis four and eight weeks after I/R and by the presence of TUNEL-positive (apoptotic) cells 6h after ischemia. Increased accumulation of HA and enhanced CD44 expression was seen after I/R in DM kidneys. Treatment with long acting insulin 7-14 days before I/R, decreased the number of apoptotic cells in the renal medulla and protected renal function and morphology after the insult, while insulin treatment after the injury did not have any protective effect. Short acting insulin given 2-6 hours before I/R partially protected renal function but did not improve the morphological picture. Treatment with the angiotensin II receptor type 1 blocker candesartan, the PAF-antagonist UR-12670, the immunosuppressive agents tacrolimus and cyclosporin A, or prednisolone did not improve the outcome of the renal I/R injury in DM. Injection of cobalt protoporphyrin (CoPP) intraperitoneally in order to induce an over-expression of heme oxygenase-1 (HO-1) resulted in a trend towards a better function in DM kidneys after I/R. However, the induction of HO-1 by intraperitoneal CoPP injection was not achieved in all rats, when examined by western blot. In conclusion, unilateral renal I/R leads to a severe progressive injury in DM kidneys. Insulin treatment before ischemia, but not after, reduces the renal injury in DM rats. Studies using a more reliable administration of CoPP are required to decide if induction of HO-1 protects against renal I/R injury in DM.

Introduction: Forty years ago the life saving and life prolonging therapy of dialysis was rationed. It was extremely unlikely that people aged over 50 years would be offered treatment. Today, those aged over 65 years are becoming the fastest growing group of patients on dialysis. Changing population demographics and referral patterns, the opening up of eligibility for dialysis to high risk individuals, refinement and developments in dialysis technology and its ‘success’ in keeping more patients alive for longer periods, along with rising public expectation, are just some of the reasons behind this change in the age profile of those being currently treated for kidney failure. Older people are likely to have multiple co-morbidities and decreased functional status that may complicate their decision-making about dialysis and limit their treatment options. / Enhancing choice and involvement in treatment decision-making to the patient’s satisfaction is a central theme of health care ethics. Current national and international ethical guidelines about the initiation of dialysis recommend shared or joint decision-making and discuss patient ‘benefit’ and patient ‘need’. This project sought to determine how these recommendations, and other ethical issues related to informed consent, possible withdrawal of treatment and quality of life, were embodied in the personal experiences of a group of older people facing dialysis decisions. / Aim: The general aim of this research was to follow the dialysis decision-making process over time amongst a group of people aged 65 years and older. More specifically, this research sought to explore with the participants the following issues: what factors impacted on their dialysis decision-making; how they understood both what was happening to them and the goals of treatment; their preferences for information seeking; how they perceived any future decision-making; how or whether the commencement and experience of dialysis influenced their decision-making; and once treatment had been initiated, how they felt about their initial decisions. / Method: A predominantly longitudinal qualitative study was undertaken. Meetings were conducted prior to the potential initiation of dialysis with 21 participants. These meetings involved a semi-structured interview and the administration of three questionnaires focusing on preferences for decision-making, information seeking and quality of life. Data was also collected from the participants’ health records. For those participants who commenced dialysis a further two meetings were undertaken one month and then six months after treatment was instigated. The qualitative data was analysed thematically using concepts that had either been pre-determined and explored within the interviews or, had emerged from the participants’ stories. / Findings: Findings from this study include: participants not feeling that they had a choice about dialysis; a mismatch between theoretical expectations of informed consent and shared decision-making and the ‘actor centred experiential’ model of decision-making adopted by participants; a need to re-evaluate the balance and relationships between physiological measures of effectiveness emphasised by health professionals, and psychosocial and functional markers valued by participants; and treatment goals not being individually negotiated. / Conclusion: An interest in remaining alive was the driving force behind why participants chose to have dialysis. Other factors impacting on decisions about dialysis were multi-faceted and were based on priorities other than what health professionals consider important. Shared decision-making, as described in the literature, is not unproblematic. However, health professionals need to accept the underlying premises on which shared decision-making is based so that they can find out what expectations patients have of treatment, beyond that of saving life. Such expectations need to be discussed with patients and the various treatment options need to be negotiated in an attempt to achieve patients’ goals. Patients should be encouraged however to be involved in decision-making to the extent to which they desire.

Introdução. Danos no DNA mitocondrial (DNAmt) têm sido descritos em pacientes com doença renal crônica (DRC). Estes danos podem ser avaliados através da deleção 4977pb do DNAmt em diversos tecidos. Métodos. Identificamos a prevalência da deleção 4977pb do DNAmt através da técnica da reação em cadeia da polimerase (PCR) no sangue de pacientes com DRC em tratamento conservador (creatinina >2mg/dl) ou submetidos a hemodiálise. Resultados. A freqüência da ocorrência da deleção do DNAmt foi de 73.1% (38/52) nos pacientes com DRC submetidos a hemodiálise, 57.1% (27/42) nos pacientes com DRC em tratamento conservador e 27.8% (15/54) nos controles (P< 0.001). Não encontramos aumento da freqüência desta deleção em relação a idade dos pacientes com DRC (P= 0.54) ou ao tempo de diálise (P= 0.70). Conclusão. Danos no DNAmt podem ser induzidos pela DRC em especial nos pacientes submetidos a hemodiálise. Desta forma, a deleção 4977pb do DNAmt pode servir como um marcador de danos moleculares em pacientes com DRC. / Background. Damage to mitochondrial DNA (mtDNA) has been described in patients with chronic renal disease (CRD). The presence of mtDNA 4977bp deletion in many different tissues can serve as a marker of this damage. Methods. Polymerase chain reaction techniques (PCR) were used to identify the prevalence of 4977bp deletion in mtDNA from the blood of hemodialysis patients or patients with CRD receiving conservative treatment. Results. The frequency of 4977bp deletion in mtDNA was 73.1% (38/52) in patients undergoing hemodialysis, 57.1% (27/42) in patients with CRD receiving conservative treatment and 27.8% (15/54) in control samples (P< 0.001). Higher frequencies of this mutation were not associated with patient age (P= 0.54) or time on dialysis (P= 0.70). Conclusion. Damage to mtDNA can be induced in CRD, especially in patients undergoing dialysis. Thus, mtDNA with 4977bp deletion can serve as a marker of molecular damage in patients with CRD.

Objetivos: Descrever o perfil epidemiológico dos pacientes em Terapia Renal Substitutiva (TRS) no período de 2000 a 2006 a partir do subsistema de Autorização de Procedimentos de Alta Complexidade em Terapia Renal Substitutiva – APAC/TRS e avaliar o potencial desse sistema para a vigilância e o monitoramento da Doença Renal Crônica Terminal no Brasil. Metodologia: Este estudo constituiu-se na descrição da Doença Renal Crônica e APAC/TRS por meio da análise dos instrumentos normativos e outros documentos técnico– administrativos e análise do perfil epidemiológico dos pacientes no período de 2000 a 2006. Resultados: No período, 148.284 pacientes iniciaram procedimentos de diálise e hemodiálise, destes 57% eram do gênero masculino. A incidência relativa foi maior em homens que em mulheres e aumentou com a idade, mas nas mulheres o pico ocorreu na faixa etária de 65 a 74 anos. A incidência global anual foi de 119,8/1.000.000 habitantes para todo Brasil, variando de 143,6/1.000.000 na região sul a 66,3/1.000.000 na região norte e se mantendo estável no período. Hipertensão foi causa da insuficiência renal em 32.571 (22,0%), diabetes mellitus em 20.412 (13,8%) e glomerulonefrites em 10.654 (7,2%) casos, sendo 66.439 (44,8%) casos de causa incerta. Conclusão: A APAC/TRS apresenta limitações inerentes a bancos de dados administrativos, com lacunas a serem preenchidas. Mesmo assim, recomenda-se sua utilização para subsidiar ações de promoção, prevenção, assistência da doença renal crônica terminal , elaboração de indicadores e fomento de estudos epidemiológicos e econômicos. / Objectives: Describe the subsystem Authorization of Procedures of High Complexity in Therapy Renal Substitutiva - APAC TRS, the epidemiological profile of the patients in the period 2000 to 2006 and evaluate its potential as one of the tools to support the monitoring and tracking of Chronic Renal Disease. Methodology: This study’s objective is to describe the Authorization of High Complexity Procedures for Renal Replacement Therapy database, and evaluate its potential for surveillance of chronic renal disease through analysis of the epidemiologic profile of incident cases of dialysis. APAC datafiles were aggregated and verified for inconsistencies and duplicities. Incident cases were described according to age, gender, region of the country, and underlying cause of renal disease. Results: From 2000 to 2006, 148.284 patients initiated dialysis, 57% being men. The relative incidence is higher in men than in women and increases monotonically with age, although the peak in women occurs in the age bracket of 65 to 74 years. The overall annual incidence was 119,8/1,000,000 habitants, varying from 143,6/1,000,000 in southern Brazil to 66,3/1,000,000 in the northern region, and maintaining stability over the period. Hypertension was listed as cause of renal disease in 32.571 (22,0%), diabetes mellitus in 20.412 (13.4%) and glomerulonephritis in 10.654 (7,2%), with 66.439 (44,8%) cases having no determined cause. Conclusion: The APAC/TRS system presents limitations inherent to administrative databases, with gaps requiring attention. Nevertheless, these data demonstrate its potential to support public health measures for chronic renal disease, including the elaboration of health indicators and to stimulate epidemiologic and economic studies.

Objetivos: Descrever o perfil epidemiológico dos pacientes em Terapia Renal Substitutiva (TRS) no período de 2000 a 2006 a partir do subsistema de Autorização de Procedimentos de Alta Complexidade em Terapia Renal Substitutiva – APAC/TRS e avaliar o potencial desse sistema para a vigilância e o monitoramento da Doença Renal Crônica Terminal no Brasil. Metodologia: Este estudo constituiu-se na descrição da Doença Renal Crônica e APAC/TRS por meio da análise dos instrumentos normativos e outros documentos técnico– administrativos e análise do perfil epidemiológico dos pacientes no período de 2000 a 2006. Resultados: No período, 148.284 pacientes iniciaram procedimentos de diálise e hemodiálise, destes 57% eram do gênero masculino. A incidência relativa foi maior em homens que em mulheres e aumentou com a idade, mas nas mulheres o pico ocorreu na faixa etária de 65 a 74 anos. A incidência global anual foi de 119,8/1.000.000 habitantes para todo Brasil, variando de 143,6/1.000.000 na região sul a 66,3/1.000.000 na região norte e se mantendo estável no período. Hipertensão foi causa da insuficiência renal em 32.571 (22,0%), diabetes mellitus em 20.412 (13,8%) e glomerulonefrites em 10.654 (7,2%) casos, sendo 66.439 (44,8%) casos de causa incerta. Conclusão: A APAC/TRS apresenta limitações inerentes a bancos de dados administrativos, com lacunas a serem preenchidas. Mesmo assim, recomenda-se sua utilização para subsidiar ações de promoção, prevenção, assistência da doença renal crônica terminal , elaboração de indicadores e fomento de estudos epidemiológicos e econômicos. / Objectives: Describe the subsystem Authorization of Procedures of High Complexity in Therapy Renal Substitutiva - APAC TRS, the epidemiological profile of the patients in the period 2000 to 2006 and evaluate its potential as one of the tools to support the monitoring and tracking of Chronic Renal Disease. Methodology: This study’s objective is to describe the Authorization of High Complexity Procedures for Renal Replacement Therapy database, and evaluate its potential for surveillance of chronic renal disease through analysis of the epidemiologic profile of incident cases of dialysis. APAC datafiles were aggregated and verified for inconsistencies and duplicities. Incident cases were described according to age, gender, region of the country, and underlying cause of renal disease. Results: From 2000 to 2006, 148.284 patients initiated dialysis, 57% being men. The relative incidence is higher in men than in women and increases monotonically with age, although the peak in women occurs in the age bracket of 65 to 74 years. The overall annual incidence was 119,8/1,000,000 habitants, varying from 143,6/1,000,000 in southern Brazil to 66,3/1,000,000 in the northern region, and maintaining stability over the period. Hypertension was listed as cause of renal disease in 32.571 (22,0%), diabetes mellitus in 20.412 (13.4%) and glomerulonephritis in 10.654 (7,2%), with 66.439 (44,8%) cases having no determined cause. Conclusion: The APAC/TRS system presents limitations inherent to administrative databases, with gaps requiring attention. Nevertheless, these data demonstrate its potential to support public health measures for chronic renal disease, including the elaboration of health indicators and to stimulate epidemiologic and economic studies.

Introdução. Danos no DNA mitocondrial (DNAmt) têm sido descritos em pacientes com doença renal crônica (DRC). Estes danos podem ser avaliados através da deleção 4977pb do DNAmt em diversos tecidos. Métodos. Identificamos a prevalência da deleção 4977pb do DNAmt através da técnica da reação em cadeia da polimerase (PCR) no sangue de pacientes com DRC em tratamento conservador (creatinina >2mg/dl) ou submetidos a hemodiálise. Resultados. A freqüência da ocorrência da deleção do DNAmt foi de 73.1% (38/52) nos pacientes com DRC submetidos a hemodiálise, 57.1% (27/42) nos pacientes com DRC em tratamento conservador e 27.8% (15/54) nos controles (P< 0.001). Não encontramos aumento da freqüência desta deleção em relação a idade dos pacientes com DRC (P= 0.54) ou ao tempo de diálise (P= 0.70). Conclusão. Danos no DNAmt podem ser induzidos pela DRC em especial nos pacientes submetidos a hemodiálise. Desta forma, a deleção 4977pb do DNAmt pode servir como um marcador de danos moleculares em pacientes com DRC. / Background. Damage to mitochondrial DNA (mtDNA) has been described in patients with chronic renal disease (CRD). The presence of mtDNA 4977bp deletion in many different tissues can serve as a marker of this damage. Methods. Polymerase chain reaction techniques (PCR) were used to identify the prevalence of 4977bp deletion in mtDNA from the blood of hemodialysis patients or patients with CRD receiving conservative treatment. Results. The frequency of 4977bp deletion in mtDNA was 73.1% (38/52) in patients undergoing hemodialysis, 57.1% (27/42) in patients with CRD receiving conservative treatment and 27.8% (15/54) in control samples (P< 0.001). Higher frequencies of this mutation were not associated with patient age (P= 0.54) or time on dialysis (P= 0.70). Conclusion. Damage to mtDNA can be induced in CRD, especially in patients undergoing dialysis. Thus, mtDNA with 4977bp deletion can serve as a marker of molecular damage in patients with CRD.

Introdução. Danos no DNA mitocondrial (DNAmt) têm sido descritos em pacientes com doença renal crônica (DRC). Estes danos podem ser avaliados através da deleção 4977pb do DNAmt em diversos tecidos. Métodos. Identificamos a prevalência da deleção 4977pb do DNAmt através da técnica da reação em cadeia da polimerase (PCR) no sangue de pacientes com DRC em tratamento conservador (creatinina >2mg/dl) ou submetidos a hemodiálise. Resultados. A freqüência da ocorrência da deleção do DNAmt foi de 73.1% (38/52) nos pacientes com DRC submetidos a hemodiálise, 57.1% (27/42) nos pacientes com DRC em tratamento conservador e 27.8% (15/54) nos controles (P< 0.001). Não encontramos aumento da freqüência desta deleção em relação a idade dos pacientes com DRC (P= 0.54) ou ao tempo de diálise (P= 0.70). Conclusão. Danos no DNAmt podem ser induzidos pela DRC em especial nos pacientes submetidos a hemodiálise. Desta forma, a deleção 4977pb do DNAmt pode servir como um marcador de danos moleculares em pacientes com DRC. / Background. Damage to mitochondrial DNA (mtDNA) has been described in patients with chronic renal disease (CRD). The presence of mtDNA 4977bp deletion in many different tissues can serve as a marker of this damage. Methods. Polymerase chain reaction techniques (PCR) were used to identify the prevalence of 4977bp deletion in mtDNA from the blood of hemodialysis patients or patients with CRD receiving conservative treatment. Results. The frequency of 4977bp deletion in mtDNA was 73.1% (38/52) in patients undergoing hemodialysis, 57.1% (27/42) in patients with CRD receiving conservative treatment and 27.8% (15/54) in control samples (P< 0.001). Higher frequencies of this mutation were not associated with patient age (P= 0.54) or time on dialysis (P= 0.70). Conclusion. Damage to mtDNA can be induced in CRD, especially in patients undergoing dialysis. Thus, mtDNA with 4977bp deletion can serve as a marker of molecular damage in patients with CRD.

Objetivos: Descrever o perfil epidemiológico dos pacientes em Terapia Renal Substitutiva (TRS) no período de 2000 a 2006 a partir do subsistema de Autorização de Procedimentos de Alta Complexidade em Terapia Renal Substitutiva – APAC/TRS e avaliar o potencial desse sistema para a vigilância e o monitoramento da Doença Renal Crônica Terminal no Brasil. Metodologia: Este estudo constituiu-se na descrição da Doença Renal Crônica e APAC/TRS por meio da análise dos instrumentos normativos e outros documentos técnico– administrativos e análise do perfil epidemiológico dos pacientes no período de 2000 a 2006. Resultados: No período, 148.284 pacientes iniciaram procedimentos de diálise e hemodiálise, destes 57% eram do gênero masculino. A incidência relativa foi maior em homens que em mulheres e aumentou com a idade, mas nas mulheres o pico ocorreu na faixa etária de 65 a 74 anos. A incidência global anual foi de 119,8/1.000.000 habitantes para todo Brasil, variando de 143,6/1.000.000 na região sul a 66,3/1.000.000 na região norte e se mantendo estável no período. Hipertensão foi causa da insuficiência renal em 32.571 (22,0%), diabetes mellitus em 20.412 (13,8%) e glomerulonefrites em 10.654 (7,2%) casos, sendo 66.439 (44,8%) casos de causa incerta. Conclusão: A APAC/TRS apresenta limitações inerentes a bancos de dados administrativos, com lacunas a serem preenchidas. Mesmo assim, recomenda-se sua utilização para subsidiar ações de promoção, prevenção, assistência da doença renal crônica terminal , elaboração de indicadores e fomento de estudos epidemiológicos e econômicos. / Objectives: Describe the subsystem Authorization of Procedures of High Complexity in Therapy Renal Substitutiva - APAC TRS, the epidemiological profile of the patients in the period 2000 to 2006 and evaluate its potential as one of the tools to support the monitoring and tracking of Chronic Renal Disease. Methodology: This study’s objective is to describe the Authorization of High Complexity Procedures for Renal Replacement Therapy database, and evaluate its potential for surveillance of chronic renal disease through analysis of the epidemiologic profile of incident cases of dialysis. APAC datafiles were aggregated and verified for inconsistencies and duplicities. Incident cases were described according to age, gender, region of the country, and underlying cause of renal disease. Results: From 2000 to 2006, 148.284 patients initiated dialysis, 57% being men. The relative incidence is higher in men than in women and increases monotonically with age, although the peak in women occurs in the age bracket of 65 to 74 years. The overall annual incidence was 119,8/1,000,000 habitants, varying from 143,6/1,000,000 in southern Brazil to 66,3/1,000,000 in the northern region, and maintaining stability over the period. Hypertension was listed as cause of renal disease in 32.571 (22,0%), diabetes mellitus in 20.412 (13.4%) and glomerulonephritis in 10.654 (7,2%), with 66.439 (44,8%) cases having no determined cause. Conclusion: The APAC/TRS system presents limitations inherent to administrative databases, with gaps requiring attention. Nevertheless, these data demonstrate its potential to support public health measures for chronic renal disease, including the elaboration of health indicators and to stimulate epidemiologic and economic studies.