Introduction: The high transmissibility and lethality of the novel coronavirus SARS-CoV-2 (COVID-19) have been catastrophic. Acute kidney injury (AKI) is one of the frequent complications in patients with respiratory insufficiency caused by the virus. The pathogenic mechanism is based on the binding of its S-proteins to the angiotensin-converting enzyme (ACE) receptors, which will trigger a cellular damage. A podocyte and tubular compromise are found in the kidneys which can lead to tubular necrosis and the consequent AKI. Objectives: The objective of this report is to identify the main risk factor to develop AKI in patients infected with SARS-CoV-2 with critical acute respiratory distress. Patients and Methods: We performed this report study, collecting data from 48 ICU patients. Data from 13 of them who developed AKI and needed renal replacement therapy (RRT)were analyzed. Clinical characteristics and laboratory findings were reported using STATA 10.0. Results: AKI was present in 27.08% of patients, mostly male (92.3%) with a mean age of 63.8 years old. Hypertension, diabetes and obesity were the main comorbidities in those patients. Additionally, the meantime between admission and AKI diagnosis was 2.69 days. All patients showed fibrinogen, D-dimer, ALT and values above normal range. Mortality was seen in 61.5% of patients. Conclusion: This report tries to show AKI as an important clinical manifestation in critically ill patients infected with SARS-CoV-2, with high mortality. Further studies are needed to demonstrate if there are independent risk factors. / Revisión por pares

Hintergrund: Die regionale Citrat-Antikoagulation im Rahmen der Nierenersatztherapie hat bei interdisziplinären Intensivpatienten in den letzten Jahren zunehmend an Bedeutung gewonnen. Für Schwerbrandverletzte existieren bislang kaum Untersuchungen zu diesem Verfahren. Ziel dieser Arbeit war es, die kontinuierliche Nierenersatztherapie mit Citrat-Antikoagulation bei Intensivpatienten mit akutem Nierenversagen nach schwerem Verbrennungstrauma im Hinblick auf Praktikabilität, Effektivität und Komplikationshäufigkeit sowie die Stabilität von Elektrolyt- und Säure-Basen-Haushalt und Gerinnung zu untersuchen. Daneben sollten Aussagen zur Prävalenz des akuten Nierenversagens in dieser Patientengruppe und zu dessen Einfluss auf die Letalität getroffen werden. Methode: Im Rahmen einer retrospektiven Untersuchung wurden unter Verwendung von Patientenakten und Patientendatenmanagementsystem (PDMS) Daten von 27 Schwerbrandverletzten (VKOF ≥ 20% oder ABSI ≥ 8) mit akutem Nierenversagen ausgewertet, die zwischen Januar 2004 und Dezember 2009 im Verbrennungszentrum des Klinikums Sankt Georg Leipzig mit einer kontinuierlichen Nierenersatztherapie behandelt wurden. Bei allen Patienten kam ein Dialysegerät Prisma CFM (Gambro Hospal GmbH, Deutschland) mit einer Polyacrylnitril-Filtermembran (AN 69, Filterset M 100) der gleichen Firma zum Einsatz. Standardverfahren war eine kontinuierliche veno-venöse Hämodiafiltration (CVVHDF) im Prädilutionsmodus. Bei 18 Patienten wurde eine regionale Citrat-Antikoagulation als Antikoagulationsverfahren eingesetzt, bei 7 Patienten eine systemische Heparin-Antikoagulation, bei 2 Patienten kamen alternierend beide Verfahren zum Einsatz. Für die 18 Patienten unter regionaler Citrat-Antikoagulation erfolgte eine detaillierte Analyse des akuten Nierenversagens unter Einbeziehung des klinischen Verlaufes, der Laborparameter und der Behandlungsdaten des Nierenersatzverfahrens. Ergebnisse: Die Prävalenz eines akuten Nierenversagens mit Notwendigkeit zur Nierenersatztherapie bei Schwerbrandverletzten betrug 15,5%. Die Sterblichkeitsrate war in der Patientengruppe mit Nierenversagen etwa fünffach erhöht (25,9 vs. 4,8%). Die Letalitätsrate bei den Patienten unter systemischer Heparin-Antikoagulation war bei vergleichbarem Verbrennungsausmaß etwa fünfmal höher als unter regionaler Citrat-Antikoagulation (57,1 vs. 11.1%). Die Nierenersatztherapie wurde im Median nach 6 Tagen begonnen, die mediane Behandlungsdauer pro Patient betrug 7 Tage. Bei Start der CVVHDF wiesen 94,4% der Patienten einen Schockzustand mit Notwendigkeit einer Vasopressortherapie auf, 83,3% zeigten schwere Dysfunktionen in mindestens 3 Organsystemen, der SOFA-score lag im Median bei 14. Bei einer mittleren Citratkonzentration von 3,6 mmol/l Blut im Extrakorporalkreiskauf konnte eine mediane effektive Filterlaufzeit von 67 Stunden erreicht werden. Hypocalcämien (<0,9 mmol/l) fanden sich in 1,1%, Hypercalcämien (>1,3 mmol/l) in 0,4%. Hypernatriämien (<150 mmol) waren mit 0,4% ebenso selten wie metabolische Alkalosen (pH >7,50 und BE >4) mit 0,2%. Im Gesamtdialysezeitraum von 3790 Stunden gab es nur ein Blutungsereignis, die Gerinnungsparameter zeigten bis auf einen passageren Abfall der Thrombozytenzahl keine signifikanten Veränderungen. Die erzielte mittlere Dialysedosis war mit 35,1 ml/kg Körpergewicht/h ausreichend hoch. Neben einer Reduktion der Nierenretentionsparameter Serum-Creatinin und Serum-Harnstoff fanden sich unter dem Nierenersatzverfahren verbesserte Oxygenierungsindices und sinkende SOFA-scores. Keiner der überlebenden Patienten war zum Zeitpunkt der Entlassung dialysepflichtig. Zusammenfassung: Die CVVHDF unter regionaler Citrat-Antikoagulation ist bei Schwerbrandverletzten ein effektives und in Bezug auf Säure-Basen-Haushalt, Elektrolyte und Gerinnung sicheres Verfahren. Neben einer effektiven Elimination harnpflichtiger Substanzen konnten eine exzellente Stabilität von Elektrolyten und metabolischen Parametern sowie eine suffiziente Antikoagulation im Extrakorporalkreislauf mit niedrigem Blutungsrisiko und konstant langen Filterlaufzeiten nachgewiesen werden. Die Prävalenz des akuten Nierenversagens bei Schwerbrandverletzten ist hoch, die Letalität bei Vorliegen des Organversagens vier-bis fünffach erhöht.

(v AJ) For my diploma thesis I chose Nursing care for patients with complicated peritonitis as a topic, because care for these patients must be complex and often requires long-term stay at the anesthesiology and resuscitation department. These patients require organ support, undergo repeated surgical revisions, and ultimately, if they overcome this critical period, they learn very often self- care, walking, and sometimes adapt to permanent changes in health. It is a disease where there are often sudden changes in the patient's condition. In the theoretical part I tried to describe the disease leading to the development of peritonitis and complications in the form of septic shock and multiorgan failure. In the National Medical Library, I have searched for a comprehensive review of literature since 2005. I searched for keywords and phrases: Peritonitis, Nursing Care, Sepsis, Multiorgan Failure, Circulatory Support, Artificial Pulmonary Ventilation, Continuous Function Replacement kidney care, laparotomy care, drainage care, intra-abdominal hypertension. I obtained other documents using the central search engine UKAŽ, I drew from licensed databases: Bibliographia medica Čechoslovaca, Ebsco, Medline, Pubmed. For the processing of nursing procedures I used the recommendations of professional societies:...

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End Stage Renal Disease (ESRD) is the irreversible loss of kidney function, which can be due to various causes. Its treatment is one of the most costly chronic disease treatments. There are now approximately one million people worldwide living with ESRD and this number is predicted to increase in the future. The main reasons for the increasing incidence of ESRD worldwide are population ageing, the rapid increase of diabetes mellitus reaching epidemic proportions, and changes in age limits for treatment initiation. In Greece, during the period 2005-2009, 74% of the ESRD patients were on hemodialysis (HD), 7% on peritoneal dialysis (PD) and 19% were living with a functioning graft. The latter percentage brings Greece in the 26th place out of 36 countries in prevalence of functioning grafts worldwide. Cost-effectiveness analyses of these treatments have shown that RTx is overall the least expensive, followed by PD, while centre HD is the most expensive. Moreover, these treatments are also listed in the exact same order concerning the quality of life they provide to patients. The main reasons for the low RTx rate in Greece are the lack of organ donation, largely due to inadequate information, the inefficient organ distribution system, a high number of private HD centers not interested in RTx, as well as social factors. The objective of the present work was to implement a model for the projection of the ESRD patients’ number by 2020 in Greece and investigate the impact of different scenarios of an increase in RTx. In addition, a cost-effectiveness analysis of the increase in RTx was performed. The projection was performed based on a Markov chain model. The Markov models are distinguished by their simplicity and their ability to accurately represent many clinical problems. A deterministic Markov chain model was implemented in order to predict the future number of prevalent ESRD patients in Greece. Monte Carlo techniques were applied in order to add robustness to the model. Thus two models of prediction were implemented, a Markov chain and a Markov Chain Monte Carlo (MCMC) model. Age-specific data (<45, 45-65, >65 age groups) on incident and prevalent ESRD patients’ number for Greece, available from the European Renal Association – European Dialysis and Transplant Association reports for the period 1998-2009, were used for the implementation. The basic component of the Markov chain is the transition matrix defining the probability for the patient to move between the four states, i.e. HD, PD, RTx and death. An iterative error minimization technique was used in defining the transition probabilities of the Markov chain, based on the data from 1998 to 2006. Both Markov chain and MCMC models were successfully validated based on data for the period from 2007 to 2009. In each model the ESRD incident patients’ number in Greece was predicted in a different way. For the Markov chain model three incidence rate scenarios were applied: low, medium and high. Additionally, two different approaches were proposed for the increase in RTx, one for each model. In the Markov chain model, two scenarios of RTx increase were applied on the number of prevalent patients. The first one was based on the assumption that the average number of transplants performed in Greece during the period 2005-2009 will double by 2020. The second one assumed that Greece will reach by 2020 the transplantation rate of Norway in 2009, the highest transplantation rate reported during that year worldwide. In the MCMC model, the increase of RTx was accomplished by increasing annually by 1% the number of incident patients receiving RTx and reducing accordingly the number of patients performing HD. The Markov chain model projected an increase in the number of prevalent patients’ in Greece by 19.3%, 24.4% and 42.2% in 2020 compared to 2009, depending on the incidence scenario applied. Similarly, the MCMC model projected a 25.0% prevalence increase. In the Markov chain model, the results of the increase in RTx indicated that in 2020 there will be a 64.6% (first scenario) or a 107.2% (second scenario) increase in the number of RTx patients compared to 2009, resulting in total saving of €50.2 and €112.37 million, respectively, for the period 2010-2020. Finally, the increase in RTx accomplished in the MCMC model indicated a 57.9% increase of patients living with a transplanted kidney, resulting in total saving of €68.2 million. The results of both models suggest that performing more kidney transplantations instead of HD would reduce the treatment costs for the country’s healthcare system, while at the same time it would improve the quality of life for a significant number of ESRD patients. / Η Τελικού Σταδίου Χρόνια Νεφρική Ανεπάρκεια (ΤΣΧΝΑ) είναι η μη αναστρέψιμη απώλεια της νεφρικής λειτουργίας, η οποία μπορεί να οφείλεται σε διάφορα αίτια. Η θεραπεία της είναι μία από τις πιο δαπανηρές όσον αφορά τις χρόνιες παθήσεις. Σήμερα, υπολογίζεται ότι περίπου ένα εκατομμύριο άνθρωποι παγκοσμίως ζουν με ΤΣΧΝΑ, ενώ ο αριθμός τους προβλέπεται να αυξηθεί στο μέλλον. Οι κύριοι παράγοντες αύξησης της επίπτωσης (δηλαδή του αριθμού των νεοεντασσόμενων ασθενών) της ΤΣΧΝΑ παγκοσμίως είναι η αύξηση της μέσης ηλικίας του πληθυσμού, η αλματώδης αύξηση του σακχαρώδους διαβήτη που λαμβάνει επιδημικές διαστάσεις, καθώς και οι αλλαγές στα ηλικιακά όρια για έναρξη θεραπείας. Στην Ελλάδα, κατά την περίοδο 2005-2009 το 74% ασθενών με ΤΣΧΝΑ έκανε αιμοκάθαρση, το 7% έκανε περιτοναϊκή κάθαρση και το 19% ζούσε με νεφρικό μόσχευμα. Το τελευταίο ποσοστό κατατάσσει την Ελλάδα στην 26η θέση ανάμεσα σε 36 χώρες παγκοσμίως όσον αφορά τον αριθμό των ασθενών που ζουν με μεταμοσχευμένο νεφρό. Η ανάλυση κόστους-αποτελεσματικότητας δείχνει πως η λιγότερο δαπανηρή θεραπεία της ΤΣΧΝΑ είναι η μεταμόσχευση, ακολουθούμενη από την περιτοναϊκή κάθαρση, ενώ η αιμοκάθαρση αναδεικνύεται ως η πιο δαπανηρή. Οι θεραπείες κατατάσσονται με την ίδια ακριβώς σειρά όσον αφορά και την ποιότητα ζωής που παρέχουν στους ασθενείς. Οι βασικές αιτίες για το χαμηλό ποσοστό μεταμοσχεύσεων στην Ελλάδα είναι η έλλειψη δωριζόμενων οργάνων, που οφείλεται κατά πολύ στην ελλιπή πληροφόρηση, η ανεπάρκεια του συστήματος διανομής οργάνων, ο υψηλός αριθμός ιδιωτικών κέντρων αιμοκάθαρσης, τα οποία δεν ενδιαφέρονται για μεταμοσχεύσεις, καθώς και κοινωνικοί παράγοντες. Ο σκοπός της παρούσας διατριβής ήταν η υλοποίηση ενός μοντέλου για την πρόβλεψη του αριθμού των ασθενών με ΤΣΧΝΑ στην Ελλάδα το 2020, καθώς επίσης και η διερεύνηση της επίδρασης διαφόρων σεναρίων αύξησης των μεταμοσχεύσεων. Επιπλέον, πραγματοποιήθηκε ανάλυση κόστους-αποτελεσματικότητας της αύξησης των μεταμοσχεύσεων. Η πρόβλεψη έγινε με βάση ένα μοντέλο Μαρκόφ. Τα μοντέλα Μαρκόφ διακρίνονται για την απλότητα αλλά και την ικανότητά τους να αναπαριστούν με ακρίβεια πολλά κλινικά προβλήματα. Για την παρούσα εργασία, υλοποιήθηκε ένα ντετερμινιστικό μοντέλο Μαρκόφ για την πρόβλεψη του μελλοντικού αριθμού των ασθενών με ΤΣΧΝΑ σε Θεραπεία Υποκατάστασης της Νεφρικής Λειτουργίας (ΘΥΝΛ) στην Ελλάδα. Επίσης, εφαρμόστηκαν τεχνικές Μόντε Κάρλο για μεγαλύτερη ευρωστία του μοντέλου. Ως εκ τούτου, υλοποιήθηκαν δύο διαφορετικά μοντέλα πρόβλεψης, ένα μοντέλο Μαρκόφ και ένα μοντέλο Μαρκόφ Μόντε Κάρλο. Για την υλοποίηση χρησιμοποιήθηκαν ηλικιακά δεδομένα (<45, 45-65, >65) του Ευρωπαϊκού Αρχείου Καταγραφής Νεφροπαθών (ERA-EDTA registry) που αφορούσαν νεοεντασσόμενους ασθενείς αλλά και ασθενείς που βρίσκονταν σε ΘΥΝΛ στην Ελλάδα την περίοδο 1998-2009. Ο σχεδιασμός μιας αλυσίδας Μαρκόφ βασίζεται στον πίνακα μετάβασης για υπολογισμό της πιθανότητας μετακίνησης του ασθενούς ανάμεσα στην Αιμοκάθαρση, την περιτοναϊκή κάθαρση, τη μεταμόσχευση και τον θάνατο. Για να υπολογιστούν οι πιθανότητες μετάβασης στην αλυσίδα Μαρκόφ, έγινε χρήση μιας επαναληπτικής τεχνικής μείωσης του σφάλματος με βάση τα ηλικιακά δεδομένα της περιόδου 1998-2006. Και τα δύο μοντέλα επαληθεύτηκαν επιτυχώς με βάση τα δεδομένα της περιόδου 2007-2009. Η πρόβλεψη του μελλοντικού αριθμού νεοεντασσόμενων ασθενών με ΤΣΧΝΑ στην Ελλάδα έγινε με διαφορετικό τρόπο σε κάθε μοντέλο. Στο μοντέλο Μαρκόφ, εφαρμόστηκαν τρία διαφορετικά σενάρια πρόβλεψης του ποσοστού επίπτωσης: χαμηλό, μεσαίο και υψηλό. Επιπλέον, σε κάθε μοντέλο ακολουθήθηκε διαφορετική προσέγγιση όσον αφορά την αύξηση του αριθμού των μεταμοσχεύσεων. Στο μοντέλο Μαρκόφ, εφαρμόστηκαν δύο σενάρια αύξησης των μεταμοσχεύσεων σε σχέση με τον αριθμό των ασθενών σε ΘΥΝΛ. Το πρώτο σενάριο βασίστηκε στην υπόθεση ότι ο μέσος αριθμός μεταμοσχεύσεων που έγιναν στην Ελλάδα κατά την περίοδο 2005-2009 θα διπλασιαστεί ως το 2020. Στο δεύτερο σενάριο θεωρήθηκε ότι η Ελλάδα θα φτάσει ως το 2020 το ποσοστό μεταμοσχεύσεων της Νορβηγίας το 2009, που ήταν το μεγαλύτερο παγκοσμίως για εκείνο το έτος. Στο μοντέλο Μαρκόφ Μόντε Κάρλο, η αύξηση του αριθμού των μεταμοσχεύσεων επιτεύχθηκε με ετήσια αύξηση κατά 1% του αριθμού των νεοεντασσόμενων ασθενών που θα έκαναν μεταμόσχευση, με αντίστοιχη μείωση του αριθμού των αιμοκαθαιρόμενων. Το μοντέλο Μαρκόφ προέβλεψε αύξηση του αριθμού των ασθενών σε ΘΥΝΛ στην Ελλάδα κατά 19.3%, 24.4% και 42.2% το 2020 σε σχέση με το 2009, ανάλογα με το εφαρμοζόμενο σενάριο επίπτωσης. Το μοντέλο Μαρκόφ Μόντε Κάρλο προέβλεψε αντίστοιχη αύξηση της τάξης του 25%. Στο μοντέλο Μαρκόφ, τα αποτελέσματα της αύξησης των μεταμοσχεύσεων έδειξαν ότι το 2020 θα υπάρξει αύξηση κατά 64.4% (πρώτο σενάριο) ή κατά 107.2% (δεύτερο σενάριο) του αριθμού των μεταμοσχευμένων ασθενών συγκριτικά με το 2009, με συνολική εξοικονόμηση 50.2 και 112.37 εκατομμύρια ευρώ αντίστοιχα, για την περίοδο 2010-2020. Τέλος, η αύξηση του αριθμού των μεταμοσχεύσεων στο μοντέλο Μαρκόφ Μόντε Κάρλο έδειξε αύξηση κατά 57.9% του αριθμού των ασθενών που ζουν με μεταμοσχευμένο νεφρό, με συνολική εξοικονόμηση 68.2 εκατομμύρια ευρώ. Τα αποτελέσματα και στα δύο μοντέλα καταδεικνύουν ότι η αύξηση του αριθμού των μεταμοσχεύσεων έναντι της αιμοκάθαρσης θα μείωνε το κόστος θεραπείας για το Σύστημα Υγείας της χώρας, ενώ ταυτοχρόνως θα βελτίωνε την ποιότητα ζωής για έναν σημαντικό αριθμό ασθενών με ΤΣΧΝΑ.

O número de pacientes com doença renal crônica está aumentando, em todo o mundo, em escala alarmante. Como resultado, observamos um elevado quantitativo de indivíduos que dependem do acesso e do tratamento dialítico para garantir sobrevida e qualidade de vida. Esse cuidado, entretanto, apresenta significativos problemas em diversas localidades do país. Ainda que uma estrutura adequada seja condição necessária, mas não suficiente, para um cuidado de qualidade, pode-se supor que aumente a probabilidade da assistência prestada ter um potencial de promover resultados em saúde mais positivos. Este estudo, descritivo e de caráter normativo, objetivou mapear os serviços de terapia dialítica existentes no município de Volta Redonda que oferecem procedimentos para o SUS e examinar sua conformidade com os padrões mínimos presentes nas diversas resoluções e demais legislações a respeito, focando em aspectos da estrutura e processo. Para tal, utilizou-se de três estratégias complementares: (a) busca de dados secundários presentes nas bases de dados nacionais e municipais; (b) entrevistas com os responsáveis técnicos pelas duas unidades existentes no município, com o responsável pela Superintendência de Controle, Avaliação e Auditoria da SMS/VR e pela Vigilância Sanitária Estadual, e (c) exame das cópias dos relatórios de vistoria sanitária realizada nos serviços nos anos de 2010 e 2011. Os resultados são apresentados em seis categorias: (1) conhecimento sobre o processo de admissão e preparo dos pacientes para entrada em Terapia Renal Substitutiva; (2) conformidade dos serviços de diálise existentes em Volta Redonda às exigências legais, desdobrando em estrutura física, parque de equipamentos, modalidades de diálise oferecida, controle e qualidade da água utilizada na diálise, atividades de controle de infecções e de proteção à saúde dos trabalhadores; (3) fluxo de encaminhamento dos pacientes em tratamento dialítico para transplante; (4) monitoramento dos indicadores de avaliação periódica dos serviços de Diálise; (5) produção assistencial desses serviços; e, por fim,(6) ações de controle e avaliação desenvolvidas junto às Unidades de Terapia Renal Substitutiva. O estudo permitiu identificar que, em diversos aspectos, os serviços de diálise de Volta Redonda estão fora de conformidade às exigências legais expressas nas diversas portarias e resoluções que tratam da estrutura e condições de funcionamento dos serviços de terapia renal substitutiva. Isso é grave e pode estar significando que os pacientes que se utilizam destes serviços possam, de alguma maneira, estar recebendo um cuidado longe do adequado. Foi também mostrada a dificuldade do serviço de Controle, Avaliação e Auditoria da SMS/VR em montar trabalho conjunto de monitoramento no cumprimento das exigências realizadas pelo órgão de vigilância estadual, que pode contribuir para melhorar a qualidade da assistência recebida pelos pacientes renais crônicos em Volta Redonda. / The number of patients with chronic kidney disease is increasing worldwide at an alarming rate. As a result has also been increasing the amount of individuals dependent on the quality and access dialysis treatment to ensure survival and quality of life. This caution, however, still presents significant problems in many parts of the country. Although an appropriate structure is necessary, although insufficient for quality care, one can assume that it increases the likelihood that the assistance be of better quality and potential to promote more positive health outcomes. This study, descriptive and normative, aimed to map the dialysis services in the city of Volta Redonda providing procedures for the NHS and examine their compliance with the minimum standards found in various resolutions and other laws on the subject, focusing on aspects of structure and process. To this end, we used three complementary strategies: (a) search for secondary data found in national databases and local (b) interviews with the technicians responsible for the two units in the municipality, with the head of the Superintendency of Control, Assessment and Audit of SMS / VR and the State Sanitary Surveillance, and (c) take copies of inspection reports carried out in health services in the years 2010 and 2011. The results are presented in six categories: (1) knowledge about the admissions process and preparation of patients for entry into Renal Replacement Therapy, (2) compliance of dialysis services in Volta Redonda existing legal requirements, unfolding in physical structure, park equipment, dialysis modalities offered, control and quality of water used in dialysis, infection control activities and health protection of workers, (3) flow of referral of patients on dialysis for transplantation, (4) monitoring of indicators periodic evaluation of dialysis services, (5) Production of health care services and, finally, (6) actions to control and evaluate the units developed with Renal Replacement Therapy. The study identified that in many ways, dialysis services in Volta Redonda are out of compliance with legal requirements expressed in the various ordinances and resolutions dealing with the structure and operating conditions of service of renal replacement therapy. This is serious and can be meaning that patients who use these services may in some way, be receiving care far from perfect. It was also shown the difficulty of the Service Control, Audit and Oversight of SMS / VR work together in setting up monitoring in fulfilling the demands made by the national surveillance state, which may contribute to improve the quality of care received by patients with chronic renal failure in Volta Redonda.

O número de pacientes com doença renal crônica está aumentando, em todo o mundo, em escala alarmante. Como resultado, observamos um elevado quantitativo de indivíduos que dependem do acesso e do tratamento dialítico para garantir sobrevida e qualidade de vida. Esse cuidado, entretanto, apresenta significativos problemas em diversas localidades do país. Ainda que uma estrutura adequada seja condição necessária, mas não suficiente, para um cuidado de qualidade, pode-se supor que aumente a probabilidade da assistência prestada ter um potencial de promover resultados em saúde mais positivos. Este estudo, descritivo e de caráter normativo, objetivou mapear os serviços de terapia dialítica existentes no município de Volta Redonda que oferecem procedimentos para o SUS e examinar sua conformidade com os padrões mínimos presentes nas diversas resoluções e demais legislações a respeito, focando em aspectos da estrutura e processo. Para tal, utilizou-se de três estratégias complementares: (a) busca de dados secundários presentes nas bases de dados nacionais e municipais; (b) entrevistas com os responsáveis técnicos pelas duas unidades existentes no município, com o responsável pela Superintendência de Controle, Avaliação e Auditoria da SMS/VR e pela Vigilância Sanitária Estadual, e (c) exame das cópias dos relatórios de vistoria sanitária realizada nos serviços nos anos de 2010 e 2011. Os resultados são apresentados em seis categorias: (1) conhecimento sobre o processo de admissão e preparo dos pacientes para entrada em Terapia Renal Substitutiva; (2) conformidade dos serviços de diálise existentes em Volta Redonda às exigências legais, desdobrando em estrutura física, parque de equipamentos, modalidades de diálise oferecida, controle e qualidade da água utilizada na diálise, atividades de controle de infecções e de proteção à saúde dos trabalhadores; (3) fluxo de encaminhamento dos pacientes em tratamento dialítico para transplante; (4) monitoramento dos indicadores de avaliação periódica dos serviços de Diálise; (5) produção assistencial desses serviços; e, por fim,(6) ações de controle e avaliação desenvolvidas junto às Unidades de Terapia Renal Substitutiva. O estudo permitiu identificar que, em diversos aspectos, os serviços de diálise de Volta Redonda estão fora de conformidade às exigências legais expressas nas diversas portarias e resoluções que tratam da estrutura e condições de funcionamento dos serviços de terapia renal substitutiva. Isso é grave e pode estar significando que os pacientes que se utilizam destes serviços possam, de alguma maneira, estar recebendo um cuidado longe do adequado. Foi também mostrada a dificuldade do serviço de Controle, Avaliação e Auditoria da SMS/VR em montar trabalho conjunto de monitoramento no cumprimento das exigências realizadas pelo órgão de vigilância estadual, que pode contribuir para melhorar a qualidade da assistência recebida pelos pacientes renais crônicos em Volta Redonda. / The number of patients with chronic kidney disease is increasing worldwide at an alarming rate. As a result has also been increasing the amount of individuals dependent on the quality and access dialysis treatment to ensure survival and quality of life. This caution, however, still presents significant problems in many parts of the country. Although an appropriate structure is necessary, although insufficient for quality care, one can assume that it increases the likelihood that the assistance be of better quality and potential to promote more positive health outcomes. This study, descriptive and normative, aimed to map the dialysis services in the city of Volta Redonda providing procedures for the NHS and examine their compliance with the minimum standards found in various resolutions and other laws on the subject, focusing on aspects of structure and process. To this end, we used three complementary strategies: (a) search for secondary data found in national databases and local (b) interviews with the technicians responsible for the two units in the municipality, with the head of the Superintendency of Control, Assessment and Audit of SMS / VR and the State Sanitary Surveillance, and (c) take copies of inspection reports carried out in health services in the years 2010 and 2011. The results are presented in six categories: (1) knowledge about the admissions process and preparation of patients for entry into Renal Replacement Therapy, (2) compliance of dialysis services in Volta Redonda existing legal requirements, unfolding in physical structure, park equipment, dialysis modalities offered, control and quality of water used in dialysis, infection control activities and health protection of workers, (3) flow of referral of patients on dialysis for transplantation, (4) monitoring of indicators periodic evaluation of dialysis services, (5) Production of health care services and, finally, (6) actions to control and evaluate the units developed with Renal Replacement Therapy. The study identified that in many ways, dialysis services in Volta Redonda are out of compliance with legal requirements expressed in the various ordinances and resolutions dealing with the structure and operating conditions of service of renal replacement therapy. This is serious and can be meaning that patients who use these services may in some way, be receiving care far from perfect. It was also shown the difficulty of the Service Control, Audit and Oversight of SMS / VR work together in setting up monitoring in fulfilling the demands made by the national surveillance state, which may contribute to improve the quality of care received by patients with chronic renal failure in Volta Redonda.

Introduction to the issue: Stay in an intensive care unit or anaesthesiology and resuscitation department has a demonstrable effect on the quality of life, whether mental, physical, or mental. A large percentage of patients experience post intensive care syndrome. The huge challenge for nursing care is to reduce this percentage and enable patients to recover in the best possible way and return to normal life of the same quality as before the hospitalization Methodology: The aim of this work is to find out how the quality of life of patients is affected after hospitalization in the intensive care unit or anaesthesiology and resuscitation department, with a proportion of acute renal failure and the need for continuous renal replacement. First, patients were evaluated with APACHE II score, SOFA and TISS 2. Next, questionnaires in which they responded to the period before hospitalization (SF 36, DEMMI, ADL, IADL) were filled, when released from ARO they went through the test of physical capability, (30s sit-up test, 6-minute walk test), further measurements when released from ICU took place (HADS, MAF, DEMMI, ADL, 30s sit-p test, 6-minute walk test), and after three months (SF 36, HADS, MAF, DEMMI, IADL, ADL 30s sit-up test, 6-minute walk test and a week of wearing a Garmin vivofit bracelet). Main...

Introduction : La mortalité associée à l’insuffisance rénale aiguë (acute kidney injury ‘’AKI’’) aux soins intensifs pédiatriques (SIP) dépasse les 50%. Des études antérieures sur la thérapie de remplacement rénal (TRR) ont fait ressortir plusieurs facteurs de risque de mortalité dont le syndrome de défaillance multiviscérale (SDMV) et la surcharge liquidienne ≥ 10 à 20% avant l’initiation de la TRR. L’objectif de cette étude était d’identifier les principaux facteurs de risque de mortalité à 28 jours après l’initiation de la TRR chez les patients atteints d’AKI aux SIP. Méthode : Il s’agit d’une étude de cohorte rétrospective aux SIP d’un centre tertiaire. Tous les enfants ayant reçus de la TRR continue ou de l’hémodialyse intermittente pour AKI, entre janvier 1998 et décembre 2014, ont été inclus. Les facteurs de risque de mortalité ont été préalablement identifiés par quatre intensivistes et deux néphrologues pédiatres et analysés à l’aide d’une régression logistique multivariée. Résultats : Quatre-vingt-dix patients ont été inclus. L’âge médian était de 9 [2-14] ans. La principale indication d’initiation de la TRR était la surcharge liquidienne (64,2%). La durée médiane d’hospitalisation aux SIP était de 18,5 [8,0-31,0] jours. Quarante patients (44,4%) sont décédés dans les 28 jours suivant l’initiation de la TRR et quarante-cinq (50,0%) avant la sortie des SIP. Le score de PELOD ≥ 20 (OR 4,66 ; 95%CI 1,68-12,92) et la surcharge liquidienne ≥ 15% (OR 9,31; 95%CI 2,16-40,11) à l’initiation de la TRR étaient associés de façon indépendante à la mortalité. Conclusion : Cette étude a permis de faire ressortir deux facteurs de risque de mortalité à 28 jours à l’initiation de la TRR : la surcharge liquidienne et la sévérité du SDMV mesurée par le score de PELOD. / Introduction: Mortality rate associated with acute kidney injury (AKI) in pediatric intensive care units (PICU) exceeds 50%. Prior studies on renal replacement therapy (RRT) have highlighted different mortality risk factors including the presence of a multiple organ dysfunction syndrome (MODS) and fluid overload ≥ 10 to 20% before starting RRT. The aim of this study was to identify most important risk factors of 28-day mortality in patients with AKI at RRT initiation in PICU. Methods: We conducted a retrospective cohort study in a tertiary care pediatric center. All critically ill children who underwent acute continuous RRT or intermittent hemodialysis for AKI between January 1998 and December 2014 were included. A case report form was developed and specific risk factors were identified by a panel of four pediatric intensivists and two nephrologists. Risk factors analysis was made using logistic regression in SPSS and SAS software. Results: Ninety patients were included. The median age was 9 [2-14] years. The most common indication for RRT initiation was fluid overload (FO) (64.2%). The median PICU length of stay was 18.5 [8.0-31.0] days. Forty of the 90 patients (44.4%) died within 28 days after RRT initiation and forty-five (50.0%) died before PICU discharge. In a multivariate logistic regression analysis, a PELOD score ≥ 20 (OR 4.66; 95%CI 1.68-12.92) and percentage of FO ≥ 15% (OR 9.31; 95%CI 2.16-40.11) at RRT initiation were independently associated with mortality. Conclusion: This study suggests that fluid overload and severity of MODS measured by PELOD score are two risk factors of 28-day mortality in PICU patients on RRT.

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