ZBRINJAVANJE BOLI PACIJENATA S KRONIČNOM BUBREŽNOM BOLESTI

Pain is a complex uncomfortable sensation caused by a multitude of etiologic factors. It is divided into many different types, differing by the mechanism of origin and the presence of other subjective sensations related to pain. The phenomenon of pain is a subjective one, with various painful stimuli being described and felt differently among individual patients. Therefore, it is often hard to quantify and accurately measure. However, one thing is for certain, regardless of its etiology, type or place of origin, and it is that pain is a disabling condition affecting an individual’s functional, social and biological status and should therefore be treated promptly and appropriately. Patients with chronic kidney disease (CKD), especially those with end stage renal disease, are often undertreated for pain, resulting in lower adherence to therapy and a higher incidence of anxiety and depression, ultimately leading to an overall lower quality of life. There are many factors included in the undertreatment of pain in this patient population, the main ones being inappropriate pain assessment and fear of prescribing pain medication due to renal function impairment affecting the pharmacokinetics of most commonly used analgesics. This review aims to educate all physicians working with CKD patients and provide an overview of the most commonly used pharmacological pain management strategies and their feasibility in treating this sensitive patient population, therefore hopefully making the current statistics of undertreated pain in CKD less grim than they currently are.Bol je složen, neugodan, osjećajni fenomen uzrokovan brojnim etiološkim čimbenicima. Razlikujemo nekoliko različitih vrsta boli ovisno o mehanizmu nastanka i prisutnosti drugih subjektivnih fenomena. Doživljaj boli je subjektivan te se percepcija i intenzitet različitih bolnih podražaja individualno značajno razlikuju. Stoga je često teško kvantifi cirati i precizno mjeriti bol. Bez obzira na etiologiju, vrstu ili mjesto nastanka bol je onemogućavajuće stanje koje utječe na funkcionalni, društveni i biološki status te se stoga treba liječiti primjereno i pravodobno. Pacijenti s kroničnom bubrežnom bolešću (KBB), poglavito oni s bubrežnom bolešću krajnjeg stadija, često pate od neadekvatno liječene boli, što dovodi do nižeg pridržavanja terapije i veće učestalosti tjeskobe i depresije, što za posljedicu ima sveukupno značajno nižu kvalitetu života. Mnogi su čimbenici uključeni u nedovoljno liječenje boli, a najvažniji su neadekvatna procjena boli i strah od propisivanja analgetika zbog toga što poremećaj bubrežne funkcije utječe na farmakokinetičke osobine brojnih analgetika. Ovim preglednim člankom želimo naglasiti važnost kontrole boli kod pacijenata s KBB-om s obzirom na trenutno poražavajuću kontrolu boli te predstaviti najčešće korištene farmakološke modalitete liječenja boli i njihovu prikladnost u liječenju ove osjetljive populacije pacijenata, sve u svjetlu postizanja što više kvalitete života pacijenata s KBB-om prema odrednicama Svjetskog dana bubrega 2022. godine

Rano podučavanje i primjena videolaringoskopije tijekom specijalizacije iz hitne medicine

The aim of this paper is to gather and evaluate available literature about using videolaryngoscopy as a training tool for novice learners and compare it to direct laryngoscopy. Search of the available literature was performed using the MEDLINE database, through the PubMed searching tool. The inclusion criteria were that papers had to be original research and participants had to be novices in the field of airway management. The studies also had to pertain to the topic of using videolaryngoscopy as a training tool, therefore all papers that evaluated performance of videolaryngoscopy in clinical applications or did not pertain to using videolaryngoscopy as a training tool were excluded from this review. Five studies were identified that fitted the inclusion criteria, all of which showed a statistically significant difference in first attempt success at endotracheal intubation in favor of videolaryngoscopy when compared to direct laryngoscopy. One of the studies also demonstrated a faster skill acquisition rate when using videolaryngoscopy. The use of videolaryngoscopy in teaching airway management to trainees (emergency medicine residents included) is a viable option and should be encouraged and researched further.Cilj ovoga rada bio je prikupiti i ocijeniti dostupnu literaturu vezanu uz primjenu videolaringoskopije kao alata za obuku početnika te ju usporediti s direktnom laringoskopijom. Pretraga dostupne literature je provedena koristeći bazu podataka MEDLINE preko tražilice PubMed. Kriteriji uključenja su bili da rad mora biti tipa izvornog istraživanja, a sudionici moraju biti početnici u polju zbrinjavanja dišnoga puta. Studije su se također trebale ticati primjene videolaringoskopije kao alata za obuku, stoga su svi radovi koji su ocjenjivali uporabu videolaringoskopije u kliničkim primjenama ili nisu opisivali primjenu videolaringoskopije kao alata za obuku isključeni iz ovoga preglednog rada. Pronađeno je pet studija koje ispunjavaju kriterije uključenja te su sve pokazale statistički značajnu razliku u uspjehu endotrahealne intubacije iz prvog pokušaja u korist videolaringoskopije u usporedbi s direktnom laringoskopijom. Jedna je od studija također prikazala bržu stopu stjecanja vještina uz primjenu videolaringoskopije. Uporaba videolaringoskopije za podučavanje zbrinjavanja dišnoga puta (među ostalim i u sklopu specijalizacije iz hitne medicine) je održiva mogućnost te bi ju se trebalo poticati i istraživati dalje

ZBRINJAVANJE BOLI PACIJENATA S KRONIČNOM BUBREŽNOM BOLESTI

Pain is a complex uncomfortable sensation caused by a multitude of etiologic factors. It is divided into many different types, differing by the mechanism of origin and the presence of other subjective sensations related to pain. The phenomenon of pain is a subjective one, with various painful stimuli being described and felt differently among individual patients. Therefore, it is often hard to quantify and accurately measure. However, one thing is for certain, regardless of its etiology, type or place of origin, and it is that pain is a disabling condition affecting an individual’s functional, social and biological status and should therefore be treated promptly and appropriately. Patients with chronic kidney disease (CKD), especially those with end stage renal disease, are often undertreated for pain, resulting in lower adherence to therapy and a higher incidence of anxiety and depression, ultimately leading to an overall lower quality of life. There are many factors included in the undertreatment of pain in this patient population, the main ones being inappropriate pain assessment and fear of prescribing pain medication due to renal function impairment affecting the pharmacokinetics of most commonly used analgesics. This review aims to educate all physicians working with CKD patients and provide an overview of the most commonly used pharmacological pain management strategies and their feasibility in treating this sensitive patient population, therefore hopefully making the current statistics of undertreated pain in CKD less grim than they currently are.Bol je složen, neugodan, osjećajni fenomen uzrokovan brojnim etiološkim čimbenicima. Razlikujemo nekoliko različitih vrsta boli ovisno o mehanizmu nastanka i prisutnosti drugih subjektivnih fenomena. Doživljaj boli je subjektivan te se percepcija i intenzitet različitih bolnih podražaja individualno značajno razlikuju. Stoga je često teško kvantifi cirati i precizno mjeriti bol. Bez obzira na etiologiju, vrstu ili mjesto nastanka bol je onemogućavajuće stanje koje utječe na funkcionalni, društveni i biološki status te se stoga treba liječiti primjereno i pravodobno. Pacijenti s kroničnom bubrežnom bolešću (KBB), poglavito oni s bubrežnom bolešću krajnjeg stadija, često pate od neadekvatno liječene boli, što dovodi do nižeg pridržavanja terapije i veće učestalosti tjeskobe i depresije, što za posljedicu ima sveukupno značajno nižu kvalitetu života. Mnogi su čimbenici uključeni u nedovoljno liječenje boli, a najvažniji su neadekvatna procjena boli i strah od propisivanja analgetika zbog toga što poremećaj bubrežne funkcije utječe na farmakokinetičke osobine brojnih analgetika. Ovim preglednim člankom želimo naglasiti važnost kontrole boli kod pacijenata s KBB-om s obzirom na trenutno poražavajuću kontrolu boli te predstaviti najčešće korištene farmakološke modalitete liječenja boli i njihovu prikladnost u liječenju ove osjetljive populacije pacijenata, sve u svjetlu postizanja što više kvalitete života pacijenata s KBB-om prema odrednicama Svjetskog dana bubrega 2022. godine

Resistant Hypertension

Prevalencija rezistentne hipertenzije (RH) iznosi između 10 – 30%, a povezana je s većim rizikom od oštećenja bubrega i kardiovaskularnog sustava. Patofiziologija RH povezana je s povišenom razinom aldosterona zbog čega važnu ulogu u terapiji imaju antagonisti mineralokortikoidnih receptora (MRA). Denervacija bubrežnih arterija (DBA) radiofrekvencijom jedna je od obećavajućih novih metoda liječenja rezistentne hipertenzije (RH), refraktorne na optimalno liječenje kombiniranom antihipertenzivnom terapijom koja uključuje 3 i više lijekova iz različitih antihipertenzivnih skupina, a od kojih jedan mora biti diuretik. Potrebno je prethodno isključiti sekundarne uzroke, neadekvatno mjerenje tlaka te nesuradljivost bolesnika.The prevalence of resistant hypertension ranges between 10 – 30%, and is associated with a higher risk of kidney and cardiovascular system damage. Pathophysiology is associated with increased levels of aldosterone, which is why mineralocorticoid receptor antagonists play a significant role in therapy. Renal sympathetic denervation with radiofrequency is a promising new method of treating resistant hypertension refractory to optimal treatment, using combined antihypertensive therapy which includes three or more drugs from different antihypertensive groups, one of which has to be a diuretic. Secondary causes, inadequate blood pressure measuring and inadequate patient’s adherence have to be previously eliminated

Diagnostic value and utility of commonly used biomarkers of cardiac and renal function in cardiorenal syndromes: a narrative review

Cardiorenal syndrome (CRS), first defined in 2004 as a consequence of the interactions between the kidneys and other circulatory departments leading to acute heart failure, has since been recognized as a complex clinical entity that is hard to define, diagnose and classify. The framework for the classification of CRS according to pathophysiologic background was laid out in 2008, dividing CRS into five distinct phenotypes. However, determining the timing of individual organ injuries and making a diagnosis of either renal or cardiac failure remains an elusive task. In clinical practice, the diagnosis and phenotyping of CRS is mostly based on using laboratory biomarkers in order to directly or indirectly estimate the degree of end-organ functional decline. Therefore, a well-educated clinician should be aware of the effects that the reduction of renal and cardiac function has on the diagnostic and predictive value and properties of the most commonly used biomarkers (e.g. troponins, N-terminal pro-brain natriuretic peptide, serum creatinine etc). They should also be acquainted, on a basic level, with emerging biomarkers that are specific to either the degree of glomerular integrity (cystatin C) or tubular injury (neutrophil gelatinase-associated lipocalin). This narrative review aims to provide a scoping overview of the different roles that biomarkers play in both the diagnosis of CRS and the prognosis of the disease in patients who have been diagnosed with it, along with highlighting the most important pitfalls in their interpretation in the context of impaired renal and/or cardiac function

Renal denervation as a terapeutic modality in a patient with resistant hypertension

Resistant hypertension (HTN) is defined as blood pressure (BP) that remains above 140/90 mmHg despite the administration of three antihyper tensive medications, including a diuretic. The sympathetic nervous system (SANS) overactivity has been proven to contribute to the development and maintenance of resistant hypertension. Renal denervation (RDN) produces inhibition of the SANS by ablating nerves distributed in the intima of renal arteries and could be a therapeutic option for resistant HTN

Spontaneous renal artery dissection possibly associated with antiphospholipid syndrome

Spontaneous renal artery dissection (SRAD) is a rare clinical event which most commonly presents with nonspecific symptoms such as acute flank pain, hypertension, fever, hematuria. It rarely occurs as an isolated, non-traumatic event and in those cases the underlying causes include atherosclerosis, fibromuscular dysplasia, collagen vascular disease and severe exertion. Only a few case reports suggest a possible connection between SRAD and antiphospholipid syndrome (APS)

Bradykinin mediated angioedema in patient using angiotensin-converting enzyme inhibitors (ACEI) presented with swelling of upper airways and body

We present a patient with ACEI induced angioedema after 5 years of therapy that caused not only swelling of mouth and upper airways but the whole body,which is an unusual clinical presentation. A 73-year old male patient was admitted to the emergency care unit with breathing difficulties due to the upper airway swelling that lasted for 2 hours.He had hypertension,diabetes mellitus, hypothyroidism,chronic renal disease and multiple myeloma.He had ACEI in his therapy for the last 5 years.The patient also had had swelling of the tongue 5 and 2 years ago.He was given corticosteroids and antihistamines which successfully resolved the edema,so allergic angioedema was diagnosed. This time he did not react to corticosteroids and antihistamines.Intubation was not possible due to tongue edema.Acute asphyxia occurred after 8.5 hours and emergency tracheotomy was performed.The swelling of upper airways and body continued to develop without the stabilization of clinical state.Because of suspected hereditary angioedema,a subcutaneous injection of icatibant was given as a lifesaving procedure.It caused the regression of the edema. ACEI were excluded from the therapy.After a week, blood analysis showed normal C1-inhibitor and C4 levels. Bradykinin mediated angioedema,including hereditary and ACEI induced forms,does not respond to conventional antihistamine and corticosteroid therapy. Also,they are not associated with urticaria. ACEI inhibit bradykinin degradation because angiotensin II is a key factor for the inactivation of bradykinin. Hereditary angioedema was suspected due to these severe symptoms and unusual clinical presentation. Type III hereditary angioedema with the normal level of C1-inhibitor is very rare but is considered as a differential diagnosis in our case

Budućnost antagonista mineralokortikoidnih receptora u liječenju dijabetičke nefropatije

Mineralocorticoid receptor antagonists (MRA) play a significant role in the treatment of resistant arterial hypertension and heart failure. There is no clinical study proving that they are the first drug of choice in the treatment of these patients. The most common limitation of the use of this group of drugs, whose most common representative is spironolactone, is hyperkalemia and sexual dysfunction, as well as gynecomastia, which is significantly less pronounced when using eplerenone, a more selective drug. Despite proven efficacy, the use of MRAs like eplerenone in patients with CKD is still limited and it is insufficiently applied in everyday practice. Finerenone, a nonsteroidal, novel, and selective antagonists of mineralocorticoid receptors shows promising differences from steroidal MRA, with a mechanism of action distinct from other agents for cardiorenal medicine in chronic kidney disease and diabetes mellitus type 2, which results in less hyperkalemia. In the FIDELIO-DKD randomized study, finerenone significantly reduced the both composite endpoints vs. placebo, suggesting that is possible postpone progression to kidney damage, thus ushering a new era in the treatment of diabetic kidney disease, which represents the most common cause of end-stage kidney disease in the world.Antagonisti mineralokortikoidnih receptora imaju važnu ulogu u liječenju rezistentne arterijske hipertenzije i srčanog popuštanja. Ne postoji kliničko istraživanje koje dokazuje da su lijek prvog izbora u liječenju ovakvih bolesnika. Najčešće ograničenje primjene lijekova iz ove skupine, čiji je najčešći predstavnik spironolakton, jesu hiperkalemija i spolna disfunkcija te ginekomastija, što je mnogo manje izraženo prilikom primjene selektivnijeg eplerenona u usporedbi sa spironolaktonom. Unatoč dokazanoj učinkovitosti i smanjenoj pojavnosti hiperkalemije u odnosu prema spironolaktonu još uvijek se eplerenon nedovoljno primjenjuje u svakodnevnoj praksi, posebno u bolesnika s dijabetičkom kroničnom bubrežnom bolesti, najčešće zbog straha od hiperkalemije. Novi nesteroidni selektivniji antagonist mineralokortikoidnih receptora finerenon pokazao je obećavajuće pozitivne ishode u kardiorenalnoj medicini, primarno prevenciju napredovanja kronične bubrežne bolesti u sklopu dijabetičke nefropatije uz mnogo manju pojavnost hiperkalemije. U randomiziranom istraživanju FIDELIO-DKD finerenon je znatno smanjio primarni i sekundarni ishod u usporebi s placebom, dovodeći do usporivanja progresije bubrežnog oštećenja u bolesnika s dijabetičkom kroničnom bubrežnom bolešću, čime je otvorena nova era liječenja dijabetičke bubrežne bolesti koja je danas najčešći uzrok završnoga stupnja bubrežne bolesti u svijetu