Acta Medica Croatica最新文献

Adrenocortical carcinoma is a rare entity. However, it is the most common type of cancerous adrenal gland tumor withpoor prognosis. Approximately 4 to 12 per 1 million people develop this type of tumor, which begins in the adrenal cortex.Adrenocortical carcinoma can occur at any age. Women tend to be diagnosed slightly more often than men. In most cases,the cause of cancerous adrenal gland tumor remains unknown. However, people with certain hereditary conditions have ahigher risk. Adrenocortical carcinoma can be a functional or nonfunctional tumor. If the tumor is functional, it may producehormones causing symptoms such as high blood pressure, low potassium level, heart palpitations, nervousness, feelingsof anxiety or panic attacks, excessive perspiration, diabetes, Cushing syndrome, unexplained weight gain or weight loss,weakness, abdominal stretch marks, excessive hair growth, changes in genitalia, change in libido, etc. If the tumor isnonfunctional, symptoms occur because the tumor has grown so large that it exerts pressure on the nearby organs,causing abdominal pain or a feeling of fullness. To diagnose adrenocortical carcinoma, in addition to thorough physicalexamination, the following tests are used: blood and urine tests to help determine whether the tumor is functional ornonfunctional, and imaging tests (computed tomography scan or magnetic resonance imaging). The treatment depends oncancer stage. Two major staging systems are used: the American Joint Committee on Cancer (AJCC) TNM staging systemand the ENSAT (European Network for the Study of Adrenal Tumors) staging system. Both are based on the same TNMcategories. The main types of treatment for adrenal cancer are surgery (the main treatment), chemotherapy and targetedtherapy. Radiation therapy is not used often as the main initial treatment for adrenal cancer because the cancer cells are noteasy to kill with x-rays. Radiation may be used as adjuvant therapy. By definition, adrenal incidentaloma is an asymptomaticadrenal mass detected on imaging not performed for suspected adrenal disease. In most cases, adrenal incidentalomasare nonfunctional adrenocortical adenomas, but may also represent conditions requiring therapeutic intervention (e.g.,adrenocortical carcinoma, pheochromocytoma, hormone-producing adenoma, or metastasis).

Increasing the proportion of patients with controlled hypertension implies understanding and systematic approach topatients with resistant hypertension. In the past decades, an increase in the prevalence of resistant arterial hypertension(RAH) has been observed and the incidence of this problem is becoming greater in the practice of family physicians.Patients with RAH have a higher prevalence of target organ damage as compared with patients having achieved targetblood pressure values, and their risk of an adverse cardiovascular event is tripled. RAH is defined as hypertension in whichthere is no satisfactory control of blood pressure despite compliance to lifestyle changes and taking at least three drugsin full doses, one of which has to be a diuretic. The most important risk factors for resistance to treatment are older age,obesity, smoking, excessive intake of salt and alcohol, the presence of left ventricular hypertrophy, chronic renal failure,diabetes, inadequate baroreflex pathway, chronic stress and associated mental states, use of some drugs, and all forms ofsecondary hypertension. One-fifth of patients with RAH have primary aldosteronism. Obstructive sleep apnea is a commoncause of RAH, and literature reports point to its increasing frequency. Optimal treatment involves a combination of threedrugs, one of which is a diuretic. Use of mineralocorticoid antagonist as the fourth drug has shown significant efficacy evenin patients who do not have elevated levels of aldosterone. New invasive methods of treatment include renal denervationand permanent electrical stimulation of the carotid sinus. The aim of this paper is to emphasize the importance of RAHas a cardiovascular risk factor, along with early detection and treatment at the family medicine level and timely referral toadditional procedures to treat the specific forms of RAH.

Renal anemia develops secondary to chronic kidney disease (CKD) and its incidence increases with the progression of CKD.The aim is to inform family physicians about the latest developments and ways of approaching the issue, in accordancewith national guidelines. The PubMed and Cochrane systematic reviews databases were searched for the 1996-2015 periodusing the following key words: anemia, chronic renal failure, erythropoietin, and primary health care. In addition, all relevantarticles and textbooks available were manually searched to suggest the following conclusions. The use of erythropoiesis-stimulatingagents (ESA) slows down the progression of CKD, reduces the need for blood transfusions and improves thepatient quality of life. Target hemoglobin (Hb) concentration to be permanently maintained is 110-120 g/L. Higher Hb levelsare associated with higher mortality and major cardiovascular events in dialysis patients. Target hemoglobin level shouldbe strictly individualized depending on CKD stage (both non-dialyzed and dialyzed population), age, other risks, initial andmaintenance treatment. Early recognition and appropriate correction of anemia using ESA is of utmost importance in CKDpatients. Systematic primary and secondary prevention measures along with education and professional implementationof national guidelines in daily work of family practitioners can improve medical care of patients with CKD.

The alarming rates of diabetes mellitus incidence and progression continue despite deployment of all current treatments.Kidney disease can be a particularly devastating complication, as it is associated with significant reductions in both lengthand quality of life. A variety of forms of kidney disease can be seen in people with diabetes, including diabetic nephropathy,ischemic damage related to vascular disease and hypertension, as well as other renal diseases that are unrelated todiabetes. Following an extensive PubMed search, this review provides a brief view on the screening for chronic kidneydisease (CKD) in people with diabetes, how to treat them to slow down the progression of CKD and when to refer themto specialist care. This review also emphasizes the basic challenge in treating diabetic patients, which is to shift the maincriterion from the disease-oriented to person-centered approach in the context of treating the patient as a whole.

Urinary tract infections (UTI) are the most common bacterial infections involving lower (cystitis, prostatitis) or upper(pyelonephritis, renal abscess, perinephric abscess) urinary tract. Differentiation of complicated and uncomplicated UTIis usually based on the presence of structural or functional urinary tract abnormalities, which can increase the risk oftreatment failure and development of serious complications. Factors that increase the risk are foreign bodies, stones,obstruction, neurogenic bladder, kidney transplantation, immunosuppression, and pregnancy. Complicated UTI includes aspectrum of conditions that increase the risk of treatment failure, as well as of serious complications such as bacteremiaand sepsis, perinephric abscess, renal impairment and emphysematous pyelonephritis. To avoid the potentially devastatingoutcomes, appropriate diagnostic procedures, antibiotic and surgical treatment, and appropriate follow-up are required.The incidence of complicated UTI will grow in the future due to general aging of the population, increasing incidence ofdiabetes, and ever growing number of immunocompromised and immunosuppressed patients. It is of key importance torecognize complicated UTI on time, and treat it wisely and aggressively to reduce duration of the disease and the risk ofantibiotic resistance.

Because of the increasing number of patients, chronic kidney disease (CKD) has become a significant public healthproblem. As kidney function decreases, it is necessary to introduce certain dietary modifications. The aim was to investigatewhat is the appropriate approach to diet of CKD patients, which could contribute to slowing down progression of thedisease. Dietary recommendations are individual for each patient, but also vary in the same patient depending on thestage of disease progression because special attention must be paid to appropriate intake of macronutrients (protein,carbohydrates and fats), micronutrients (sodium, potassium, calcium, phosphorus, zinc, selenium, various vitamins), andwater. In newly diagnosed patients, it is necessary to assess their nutritional status and energy requirements. It has beenshown that protein-energy malnutrition, muscle loss and cachexia are strong predictors of mortality in CKD. Comparingdifferent dietary approaches in everyday life of patients suffering from CKD, it was found that the most effective diet isMediterranean food style. Studies confirm that Mediterranean diet has a preventive effect on renal function and reducesprogression of the disease. Preventive measures, correct identification and early intervention can increase survival ofpatients and improve their quality of life. Mediterranean diet tailored to individual stages of CKD has been confirmed as thebest choice in CKD patients.

Cystic kidney diseases is a heterogeneous group of developmental, hereditary and acquired disorders that result in theoccurrence of one or more cysts on one or both kidneys, and are relatively common. Cystic kidneys can also occur as oneof various syndromes of malformations. Kidney cysts can have several classifications, depending on the properties takenin consideration. Some patients remain symptom free for life, whereas others develop serious clinical symptoms that maysometimes be life threatening. It is important to keep in mind the existing classifications, differentiate their succession,clinical course, treatment and prognosis, as well as potential complications. The objective of this paper is to presentthe most prevalent types of cysts with accompanying clinical symptoms and point out their importance, prevalence andpossible association with other serious medical conditions.

Renal tissue is sensitive to the effect of potentially nephrotoxic drugs and other substances that are available over-the-counteror can be purchased at healthy food stores or elsewhere, and harmful substances from the environment. Theharmful effects of these substances lead to the development of recognizable clinical syndromes, including acute or chronicrenal failure, tubulopathy, and proteinuria. Risk factors that influence the development of kidney disease induced by drugsare divided into those related to patient characteristics, drug characteristics, and renal function. Drugs that commonlyexhibit nephrotoxic effects are analgesics, antimicrobials, chemotherapeutics, contrast agents, immunosuppressants,herbal preparations and substances containing heavy metals. Family physician must carefully observe their patients,nurturing individual approach to drug selection and determining the dose. Renal function can quickly return to normal if thedamage is recognized on time. Recent research yields insights into the identification of new biomarkers that will contributeto early detection of drug induced kidney damage.

Prostate cancer is a common malignant tumor of the elderly, which accounts for a significant proportion of total morbiditybut very low of mortality. In Croatia, it is the second most common cancer in men. Currently, there are many doubtsconcerning screening, early detection and treatment of prostate cancer. Therefore, this article brings results of Cochranesystematic reviews (SRs) on the topic of prostate cancer published in the last eight years. In June 2016, Cochrane databaseof systematic reviews was searched using the following keywords: Systematic Reviews, and Prostate Cancer (Malignancy,Neoplasm). Inclusion criterion was publication date of the Cochrane SR or its update in the last eight years. The abstractswere initially screened and those that matched the topic were included in further analysis. Then full texts of all SRs involvedwere obtained. SRs were classified into four topics: prevention, screening, treatment and psychosocial aspects. Our searchretrieved a total of 19 Cochrane SRs on the topic of prostate cancer. Excluded were four articles that did not match thespecific topic, and the remaining 15 full texts were obtained. One of these was on screening, two on prevention, themajority, i.e. eleven were on treatment, and one on the psychosocial aspects related to prostate cancer. Based on theresults of the Cochrane SRs on prostate cancer, instead of mass/population screening, the individualized/opportunisticscreening approach should be applied in men aged 55-69, always providing full information to the patient and taking intoaccount the potential benefits and harms of this procedure.

The management of hyperglycemia in patients with chronic kidney disease (CKD) is complex, and the goals and methodsregarding glycemic control are not clearly defined. Although aggressive glycemic control seems to be advantageous inearly diabetic nephropathy, outcome data supporting tight glycemic control in patients with advanced CKD are lacking.Challenges in the management of such patients include monitoring difficulties and the complexity of available treatments.In this article, we review the current treatment options for patients with diabetes and CKD discussing all hypoglycemicagents that currently are available, as well as insulin, along with their indications and contraindications. The aim is toprovide useful information to family physicians when deciding on individualized glycemic goals and appropriate therapyfor patients with early or end stages of CKD.