NEPHROTOXIC DRUGS

Bubrežno tkivo je osjetljivo na djelovanje potencijalno nefrotoksičnih lijekova kao i drugih tvari koje su dostupne bez recepta i mogu se nabaviti u prodavaonicama „zdrave hrane“ te štetnim tvarima iz okoliša. Negativan učinak ovih tvari uzrokuje razvoj prepoznatljivih kliničkih sindroma, koji uključuju akutno i kronično bubrežno oštećenje, tubulopatije ili proteinuriju. Čimbenici rizika o kojima ovisi razvoj bubrežne bolesti inducirane lijekom dijelimo na: one vezane uz osobine bolesnika, uz osobine lijeka, te uz bubrežnu funkciju. Lijekovi koji najčešće ispoljavaju nefrotoksično djelovanje su: analgetici, antimikrobni lijekovi, kemoterapeutici, kontrastna sredstva, imunosupresivi, biljni preparati, te tvari koje sadrže teške metale. Liječnik obiteljske medicine mora pažljivo promatrati svog bolesnika, njegujući individualizirani pristup u izboru lijeka i određivanju doze. Bubrežna se funkcija može brzo oporaviti ako je oštećenje na vrijeme prepoznato. Novija istraživanja donose spoznaje o identifikaciji novih biomarkera koji će pridonijeti ranom prepoznavanju oštećenja bubrega uzrokovanog lijekovima.Renal tissue is sensitive to the effect of potentially nephrotoxic drugs and other substances that are available over-thecounter or can be purchased at healthy food stores or elsewhere, and harmful substances from the environment. The harmful effects of these substances lead to the development of recognizable clinical syndromes, including acute or chronic renal failure, tubulopathy, and proteinuria. Risk factors that infl uence the development of kidney disease induced by drugs are divided into those related to patient characteristics, drug characteristics, and renal function. Drugs that commonly exhibit 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 the damage is recognized on time. Recent research yields insights into the identifi cation of new biomarkers that will contribute to early detection of drug induced kidney damage

NEPHROTOXIC DRUGS

Bubrežno tkivo je osjetljivo na djelovanje potencijalno nefrotoksičnih lijekova kao i drugih tvari koje su dostupne bez recepta i mogu se nabaviti u prodavaonicama „zdrave hrane“ te štetnim tvarima iz okoliša. Negativan učinak ovih tvari uzrokuje razvoj prepoznatljivih kliničkih sindroma, koji uključuju akutno i kronično bubrežno oštećenje, tubulopatije ili proteinuriju. Čimbenici rizika o kojima ovisi razvoj bubrežne bolesti inducirane lijekom dijelimo na: one vezane uz osobine bolesnika, uz osobine lijeka, te uz bubrežnu funkciju. Lijekovi koji najčešće ispoljavaju nefrotoksično djelovanje su: analgetici, antimikrobni lijekovi, kemoterapeutici, kontrastna sredstva, imunosupresivi, biljni preparati, te tvari koje sadrže teške metale. Liječnik obiteljske medicine mora pažljivo promatrati svog bolesnika, njegujući individualizirani pristup u izboru lijeka i određivanju doze. Bubrežna se funkcija može brzo oporaviti ako je oštećenje na vrijeme prepoznato. Novija istraživanja donose spoznaje o identifikaciji novih biomarkera koji će pridonijeti ranom prepoznavanju oštećenja bubrega uzrokovanog lijekovima.Renal tissue is sensitive to the effect of potentially nephrotoxic drugs and other substances that are available over-thecounter or can be purchased at healthy food stores or elsewhere, and harmful substances from the environment. The harmful effects of these substances lead to the development of recognizable clinical syndromes, including acute or chronic renal failure, tubulopathy, and proteinuria. Risk factors that infl uence the development of kidney disease induced by drugs are divided into those related to patient characteristics, drug characteristics, and renal function. Drugs that commonly exhibit 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 the damage is recognized on time. Recent research yields insights into the identifi cation of new biomarkers that will contribute to early detection of drug induced kidney damage

NEPHROTOXIC DRUGS

Bubrežno tkivo je osjetljivo na djelovanje potencijalno nefrotoksičnih lijekova kao i drugih tvari koje su dostupne bez recepta i mogu se nabaviti u prodavaonicama „zdrave hrane“ te štetnim tvarima iz okoliša. Negativan učinak ovih tvari uzrokuje razvoj prepoznatljivih kliničkih sindroma, koji uključuju akutno i kronično bubrežno oštećenje, tubulopatije ili proteinuriju. Čimbenici rizika o kojima ovisi razvoj bubrežne bolesti inducirane lijekom dijelimo na: one vezane uz osobine bolesnika, uz osobine lijeka, te uz bubrežnu funkciju. Lijekovi koji najčešće ispoljavaju nefrotoksično djelovanje su: analgetici, antimikrobni lijekovi, kemoterapeutici, kontrastna sredstva, imunosupresivi, biljni preparati, te tvari koje sadrže teške metale. Liječnik obiteljske medicine mora pažljivo promatrati svog bolesnika, njegujući individualizirani pristup u izboru lijeka i određivanju doze. Bubrežna se funkcija može brzo oporaviti ako je oštećenje na vrijeme prepoznato. Novija istraživanja donose spoznaje o identifikaciji novih biomarkera koji će pridonijeti ranom prepoznavanju oštećenja bubrega uzrokovanog lijekovima.Renal tissue is sensitive to the effect of potentially nephrotoxic drugs and other substances that are available over-thecounter or can be purchased at healthy food stores or elsewhere, and harmful substances from the environment. The harmful effects of these substances lead to the development of recognizable clinical syndromes, including acute or chronic renal failure, tubulopathy, and proteinuria. Risk factors that infl uence the development of kidney disease induced by drugs are divided into those related to patient characteristics, drug characteristics, and renal function. Drugs that commonly exhibit 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 the damage is recognized on time. Recent research yields insights into the identifi cation of new biomarkers that will contribute to early detection of drug induced kidney damage

GASTROESOPHAGEAL REFLUX DISEASE – A MULTIFACETED DISEASE

Refl uks želučanog sadržaja u jednjak fi ziološki je fenomen koji se povremeno događaja kod ljudi i to najčešće nakon obroka. Gastroezofagelna refl uksna bolest (GERB) je stanje koje nastaje kada količina želučanog sadržaja nadmašuje njegovu fiziološku eliminaciju iz jednjaka i uzrokuje tegobe s pridruženim oštećenjem sluznice jednaka ili bez tog oštećenja te uzrokuje zabrinjavajuće simptome. Simptomi se smatraju zabrinjavajućima ako remete bolesnikovo opće stanje i razlog su posjete liječniku. Prevalencija GERB-a u zapadnom svijetu iznosi 10-20 %, a temelji se na procjeni pojavnosti žgaravice kao vodećeg simptoma. Dominantni simptomi su žgaravica i regurgitacija osobito nakon konzumacije obilnog i masnog obroka i visoko su specifi čni za GERB. Ekstraezofagealna refl uksna bolest (EERB) je široki spektar pojavnosti različitih simptoma povezanih s gornjim i donjim dijelom respiratornog sistema kao što su kašalj, laringitis, astma, kronična opstruktivna bolest pluća (KOPB), promuklost, sinusitis - postnazalni drip (kapajući) sindrom, upala srednjeg uha, rekurentna pneumonija i karcinom larinksa. U diferencijalnoj dijagnostici refl uksa koriste se sljedeći testovi: ezofagogastroduodenoskopija, laringoskopija i 24-satni pH monitoring. Inicijalna empirijska terapija inhibitorom protonske pumpe provodi se dva put/dan u trajanju od 1 do 2 mjeseca.Gastric content refl ux to the esophagus is a physiological phenomenon that occasionally occurs after meal. Gastroesophageal refl ux disease (GERD) is a state that appears when the quantity of gastric content surpasses its physiological elimination from the esophagus and causes diffi culties with or without associated esophageal mucosa damage, as well as alarming symptoms. The symptoms are defi ned as alarming if they disturb the patient’s well-being and are the reason for a visit to the physician. The prevalence of GERD in the Western world is 10%-20% and is based on the estimation of the heartburn incidence as the leading symptom. The dominant symptoms are heartburn and regurgitation, especially after a heavy meal, and are highly specifi c for GERD. Extraesophageal refl ux disease represents a wide range of symptoms connected to the upper and lower respiratory system, such as cough, laryngitis, asthma, chronic obstructive pulmonary disease, hoarseness, sinusitis-postnasal drip syndrome, otitis media, recurrent pneumonia and laryngeal carcinoma. The following tests are used in the refl ux differential diagnosis: esophagogastroscopy, laryngoscopy and 24-hour pH monitoring. Patients suspected to suffer from GERD are initially treated with empirical proton pump inhibitor therapy twice a day for one to two months

DIET CHARACTERISTICS IN PATIENTS WITH CHRONIC KIDNEY DISEASE

Zbog sve većeg broja, bubrežne bolesti su postale značajan javno zdravstveni problem. Slabljenjem funkcije bubrega potrebno je postupno uvoditi promjene u prehrani. Cilj rada je istražiti odgovarajući pristup u prehrani bolesnika oboljelih od kronične bubrežne bolesti (KBB) unutar zadnjih 10 godina koji bi mogao pridonijeti usporenju progresije bolesti. Preporuke prehrane su individualne za svakog bolesnika, a razlikuju se i u istog bolesnika ovisno o fazi bubrežne bolesti. Posebnu pozornost treba obratiti pravilnom unosu makronutrijenata (proteina, ugljikohidrata i masnoća), mikronutrijenata (natrija, kalija, kalcija, fosfora, cinka, selena, različitih vitamina), te vode. U novootkrivenih bolesnika neophodno je učiniti procjenu statusa uhranjenosti i energetskih potreba. Proteinsko energetska pothranjenost, gubitak muskulature i kaheksija snažni su prediktori mortaliteta u kroničnoj bubrežnoj bolesti. Usporedbom različitih prehrambenih pristupa u svakodnevnom životu oboljelog od KBB najučinkovitijim se pokazao mediteranski način prehrane, koji ima važan preventivni utjecaj na bubrežnu funkciju i smanjenje progresije same bolesti. Zaključujemo da preventivnim mjerama, pravilnim prepoznavanjem i ranom intervencijom možemo povećati preživljavanje bolesnika i poboljšati kvalitetu života. Mediteranska prehrana prilagođena pojedinim fazama KBB potvrdila se kao najbolji izbor u pristupu oboljelom od KBB.Because of the increasing number of patients, chronic kidney disease (CKD) has become a signifi cant public health problem. As kidney function decreases, it is necessary to introduce certain dietary modifi cations. The aim was to investigate what is the appropriate approach to diet of CKD patients, which could contribute to slowing down progression of the disease. Dietary recommendations are individual for each patient, but also vary in the same patient depending on the stage 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), and water. In newly diagnosed patients, it is necessary to assess their nutritional status and energy requirements. It has been shown that protein-energy malnutrition, muscle loss and cachexia are strong predictors of mortality in CKD. Comparing different dietary approaches in everyday life of patients suffering from CKD, it was found that the most effective diet is Mediterranean food style. Studies confi rm that Mediterranean diet has a preventive effect on renal function and reduces progression of the disease. Preventive measures, correct identifi cation and early intervention can increase survival of patients and improve their quality of life. Mediterranean diet tailored to individual stages of CKD has been confi rmed as the best choice in CKD patients

PATIENT WITH PEPTIC ULCER DISEASE

Ulkusna bolest je poremećaj gastrointestinalnog trakta kod kojeg dolazi do oštećenja sluznice zbog neravnoteže između zaštitnih i agresivnih mehanizama. Glavni egzogeni čimbenici u nastanku peptičkog ulkusa su infekcija bakterijom Helicobacter pylori te uzimanje ulcerogenih lijekova: nesteroidnih antireumatika (NSAR) i acetilsalicilne kiseline (ASK). Ulkusna bolest je česti razlog dolaska na pregled liječniku obiteljske medicine. Sve bolesnike s dispeptičnim smetnjama mlađe od 50 godina i bez alarmantnih simptoma potrebno je testirati na infekciju H. pylori provođenjem urejnog izdisajnog testa ili testa prisutnosti antigena u stolici, te u svih pozitivnih provesti liječenje infekcije. Bolesnike starije od 50 godina te sve one s alarmantnim simptomima potrebno je uputiti na endoskopski pregled. Kao prva linija liječenja u Hrvatskoj preporučuje se tzv. „sekvencijska“ terapija ili trojna terapija koja uključuje primjenu inhibitora protonske pumpe (IPP-a) u kombinaciji s amoksicilinom i metronidazolom. Nakon 4 tjedna od provedene eradikacijske terapije potrebno je učiniti kontrolno testiranje na infekciju H. pylori.Peptic ulcer disease is represented by a lesion in the mucosa of the digestive tract due to imbalance of its aggressive and protective mechanisms. The main external factors of the development of peptic ulcers are Helicobacter pylori infection and the use of non-steroidal anti infl ammatory drugs (NSAIDs) and acetylsalicylic acid (ASA). Symptoms of peptic ulcer disease are a common reason for visiting the family physician. All patients with symptoms of dyspepsia under the age of 50 and without the alarm symptoms should be tested whether H. pylori is present by performing the Urea Breath Test or stool antigene testing, and infection, if found, should be treated. Endoscopic examination is obligatory in patients older than 50 years and those with alarm symptoms. „Sequential therapy“ is recommended in Croatia as the fi rst-line treatment of H. pylori infection, or triple therapy that comprises applying a proton pump inhibitor (PPI) in combination with amoxicillin and metronidazole. Four weeks after eradication therapythe control testing for H. pylori should be performed

APPROACH TO A PATIENT WITH DYSPEPSIA IN FAMILY MEDICINE PRACTICE

Dispepsija je čest simptom u bolesnika koji posjećuju ordinaciju obiteljske medicine. Prevalencija u odrasloj populaciji iznosi oko 40 %. Dvije trećine bolesnika ima funkcionalnu dispepsiju. Klinička procjena, dijagnostički postupak i liječenje bolesnika ovisi o dobi, simptomima i infekciji bakterijom Helicobacter pylori. U bolesnika s dispepsijom neophodno je procijeniti mogući učinak drugih istodobnih bolesti i lijekova koje bolesnik redovito koristi. Promptna ili rana endoskopija preporučuje se bolesnicima sa simptomima alarma i starijima od 50 godina s novonastalom dispepsijom. U mlađih od 50 godina preporučena strategija je „testiraj i tretiraj“. U dijelu bolesnika liječenje se provodi supresijom kiseline. U bolesnika u kojih se ne postiže uspjeh, provodi se daljnja endoskopska dijagnostika. Ultrazvučna dijagnostika na razini primarne zdravstvene zaštite može značajno doprinijeti u dijagnostičkoj procjeni i ranom liječenju bolesnika s bolestima hepatobilijarnog trakta i pankreasa, a koji se prezentiraju simptomima dispepsije. Liječenje istodobnog psihičkog poremećaja može unaprijediti simptome dispepsije. Liječenje bolesnika koji ne odgovaraju na preporučene strategije liječenja izazov je za obiteljskog liječnika. Redoviti posjeti i psihoterapijska potpora u ovih bolesnika mogu reducirati razinu anksioznosti te ohrabriti bolesnika u liječenju prikrivenog psihološkog morbiditeta kao i u njegovim nastojanjima zdravog ponašanja.Dyspepsia is a common symptom among patients in family medicine practice. The prevalence in adult population is about 40%. Two-thirds of patients have functional dyspepsia. Clinical assessment, diagnostic procedures and treatment of patients depend on the age, symptoms and Helicobacter pylori infection. In patients with dyspepsia, it is necessary to assess the potential impact of other concurrent diseases and medications that the patient regularly uses. Prompt or early endoscopy is recommended in patients with newly detected dyspepsia older than 50 and presenting with alarming symptoms. In persons younger than 50, the recommended strategy is ‘test and treat’. In some patients, treatment is carried out by acid suppression. In patients failing to achieve success in treatment, further endoscopic diagnosis is indicated. Ultrasound diagnostics in primary care can significantly contribute to diagnostic evaluation and early treatment in patients with hepatobiliary and pancreas diseases presenting with symptoms of dyspepsia. Treatment of concurrent mental disorders can improve the symptoms of dyspepsia. Treatment of patients who do not respond to the recommended treatment strategies is a challenge for family physicians. Regular visits and psychotherapeutic support in these patients can reduce the level of anxiety and encourage the patient for treatment of psychological morbidity, as well as his efforts in healthy behavior

Medical and Psychological Parameters in Overweight and Obese Persons Seeking Treatment

The aim of the study was to analyse psychological characteristics and medical parameters in obese and overweight to identify the possible psychosocial consequences of obesity that may occur along with the numerous medical problems associated with excess body weight. Analysis was made on 296 patients (103 males and 193 females, median age 50, range 16–81) divided in three groups, depending on their Body mass index (BMI). Group I included 41 patients with BMI ranging from 25 to 29.9, group II included 170 patients with BMI from 30 to 34.9, and group III 85 patients with BM 35. We compared medical (glucose, cholesterol, triglycerides, HDL-cholesterol, systolic and diastolic blood pressure, body fat percentage) and psychological parameters (anxiety, depression, pros and cons of losing weight, self efficacy and four stages of change) in the patients included in the study. Univariate analysis has shown statistically significant difference among obese and overweight patients in goal weight, systolic and diastolic blood pressure, body fat percentage, glucose and cholesterol serum level. People with higher BMI (>30) found more advantages (pros) over disadvantages (cons) of weight loss but the level of anxiety and depression did not differ significantly among those 3 groups of patients. The results have shown that overweight and obese people have serious medical problems. They also differ in some psychological characteristics which have to be taken into consideration. Therefore, approach to these patients should be multidisciplinary, including dietary care, physical activity, psychological and medical care

INFLUENCE OF DIETARY PATTERN AND METHYLENTETRAHYDROFOLATE REDUCTASE C677T POLYMORPHISM ON THE PLASMA HOMOCYSTEINE LEVEL AMONG HEALTHY VEGETARIANS AND OMNIVORES

Povišena razina homocisteina u plazmi (Hcy) povezana je s fiziološkim i prehrambenim čimbenicima, kao i genetskim defektom enzima koji su uključeni u metabolizam Hcy. Ciljevi ove studije bili su (1) utvrditi razlike između zdravih vegetarijanca i omnivora u odnosu na biokemijske parametare, prevalenciju MTHFR genotipa i razinu Hcy, i (2) utvrditi učinke polimorfizma metilentetrahidrofolat reduktaze (MTHFR) C677T i načina prehrane na razinu Hcy u plazmi. U 47 vegetarijanaca i 53 omnivora izmjerena je razina Hcy, folata, vitamina B12, glukoze, ukupnog kolesterola, triglicerida, HDL i LDL kolesterola i kreatinina u plazmi. Polimorfizam MTHFR C677T analiziran je pomoću PCR-RFLP metode. Dobiveni rezultati su pokazali da su vegetarijanci imali niži vitamin B12, ukupni kolesterol, LDL-kolesterol i status kreatinina. Razina Hcy u plazmi bila je veća kod vegetarijanaca u usporedbi s omnivorima (14,10 ± 6,69 vs 10,49 ± 2,41 μmol/L) i negativno je korelirala sa statusom vitamina B12 i folatom. Razina plazme Hcy nije bila različita u odnosu na genotipove MTHFR C677T, ni među vegetarijancima ni omnivorima. Za razliku od MTHFR C677T polimorfizma, potvrđen je utjecaj načina prehrane na razinu Hcy u plazmi. Može se zaključiti da vegetarijanci obično imaju niži status vitamina B12 i višu razinu Hcy u plazmi. Polimorfizam MTHFR C677T nema utjecaja na razinu Hcy plazme, za razliku od prehrambenog uzorka koji ukazuje na važnost adekvatnog vitamina B12 i statusa folata u zaobilaženju mutacije.Elevated total plasma homocysteine level (Hcy) is associated with physiological and dietary factors as well as the genetic defect of enzymes involved in Hcy metabolism. The objectives of the study were to examine (1) differences between healthy vegetarian and omnivorous subjects in relation to biochemical parameters, prevalence of the MTHFR (methylentetrahydrofolate reductase) T/T genotype, and the plasma Hcy level, and (2) the effects of the MTHFR C677T polymorphism and dietary pattern on the plasma Hcy level. In 47 vegetarian and 53 omnivorous subjects the plasma level of Hcy, folate, vitamin B12, glucose, total cholesterol, triglycerides, HDL and LDL-cholesterol and creatinine were measured. MTHFR C677T polymorphisms were analyzed using the PCR-RFLP method. Obtained results have shown that vegetarians had lower vitamin B12, total cholesterol, LDLcholesterol and creatinine status. The plasma Hcy level was higher among vegetarians compared with omnivore subjects (14.10±6.69 vs. 10.49±2.41 μmol/L) and negatively correlated with vitamin B12 status and folate. The plasma Hcy level did not differ between the given MTHFR C677T genotypes among either vegetarians or omnivores. Unlike the MTHFR C677T polymorphism, the effect of dietary pattern on plasma Hcy level was confirmed. It could be concluded that vegetarians tend to have lower vitamin B12 status and a higher plasma Hcy level. The MTHFR 677C/T polymorphism has no effect on plasma Hcy level, in contrast to dietary pattern which indicates the importance of adequate vitamin B12 and folate status in bypassing the mutation