Kliničke praktične smjernice za perioperacijsku i poslijeoperacijsku skrb o arterijsko-venskim fistulama i umetcima za hemodijalizu u odraslih

Krvožilni pristup omogućuje hemodijalizu koja spašava život. Stoga je nužna dobra funkcija krvožilnog pristupa koja omogućuje prikladan krvni protok radi uklanjanja tvari koje se u uremiji zadržavaju u krvi bolesnika, uz istodobno sniženje rizika od sustavne infekcije na najmanju moguću mjeru. Godine 2007. Europske smjernice najbolje prakse (engl. European Best Practice Guidelines – EBPG), prethodnice trenutačne Europske najbolje bubrežne prakse (engl. European Renal Best Practice – ERBP), donijele su nacrt skupine preporuka – vodiča pri donošenju odluka o upućivanju na pregled radi krvožilnog pristupa, o procjeni i nadzoru izbora pristupa te o postupcima kod komplikacija. (1) Otad su se znatno razvili ne samo dokazi na kojima se temelje ove preporuke nego i procesi nastajanja smjernica. (2) Kao odgovor na to, ERBP je ažurirao prethodno djelo u suradnji s raznim stručnjacima iz tog područja uključujući i predstavnike Društva za krvožilni pristup (engl. Vascular Access Society – VAS), kirurge za krvožilni pristup, radiologe, medicinske sestre za dijalizu, znanstvenike, bolesnike i one koji se za njih brinu. Nastojanje da se pridržavaju sve strože metodike izrade smjernica nalagalo je određena odricanja u pogledu područja obuhvata ovih smjernica. Posljedično, one ne „pokrivaju” baš sve iste teme kao njihova prethodna verzija. Neka su područja zajednička, a neka su arhivirana da bi ustupila mjesto novim pitanjima kojima su prednost dali i pružatelji zdravstvene skrbi i oni za koje se skrbi. Odvojeno su objavljene pojedinosti postupka izbora djelokruga problematike koju su smjernice obuhvatile. (3) Nastajanje ovih smjernica slijedilo je strog proces pregleda i procjene dokaza koji se temeljio na sustavnim pregledima rezultata kliničkih istraživanja te opservacijskih podataka gdje je to bilo potrebno. Strukturirani pristup slijedio je model sustava GRADE (hrv. stupanj), koji svakoj preporuci pripisuje stupanj s obzirom na sigurnost sveukupnih dokaza te snagu. (4) Gdje je to bilo primjereno skupina za izradu smjernica unijela je nestupnjevan savjet za kliničku praksu, a koji nije proistekao iz pregleda sustavnih dokaza. Kliničke praktične smjernice iz 2019. godine specifično pokrivaju peritransplantacijske i poslijetransplantacijske aspekte arterijsko-venskih (AV) fistula i umetaka (graftova). Drugi dio, koji je bio u nastajanju kada su ove smjernice išle u tisak, pokrit će aspekte izbora krvožilnog pristupa, prijeoperacijske procjene krvnih žila i središnje venske katetere. Unatoč nedostatku dokaza velike sigurnosti za većinu područja krvožilnih pristupa, ERBP se posvetio izradi smjernica velike kakvoće, dajući smjernicu gdje god je moguće, a popis preporuka za istraživanje ondje gdje se nije moglo uputiti smjernicom. Nadamo se da će ove smjernice i one planirane pomoći stručnoj zajednici pri donošenju odluka o postupcima, postupnicima i skrbi vezanima s krvožilnim pristupima, pomoći bolesnicima i onima koji se za njih brinu da steknu uvid u problematiku te olakšati zajedničko donošenje odluka u tom području

Inhibition of adenylosuccinate lyase by 2’,3’-acyclic substrate analogs.

Adenylosuccinate lyase catalyzes the trans-elimination of fumarate from adenylosuccinate to yield AMP. The catalysis is not affected by opening the ribose ring of the substrate. The addition of aliphatic chains on the ring does not markedly affect the binding of the substrate analog, though preventing its cleavage

Physical Activity in Chronic Kidney Disease: a Plausible Approach to Vascular Calcification?

Vascular calcification (VC) is a prominent feature that affects up to 40 to 80% of Chronic Kidney Disease (CKD) patients depending on the degree of renal impairment. Though etiology and pathogenesis of the different types of VC are far from being elucidated, it is conceivable that an imbalance between promoters and inhibitors represents the condition that triggers VC deposition and progression. In addition to traditional cardiovascular risk factors, several lines of evidence suggest that specific factors may affect the arterial system and prognosis in CKD. Over the last decade, a few pharmacological strategies aimed at controlling different selected risk factors for VC have been investigated yielding conflicting results. In light of the complicated interplay between inhibitors and promoters as well as the fact that VC represents the result of cumulative and prolonged exposure to multiple risk factors, a more comprehensive risk modification approach such as lifestyle modification or physical activity (PA) may represent a valid strategy to attenuate VC deposition and progression.We herein aim at reviewing the rationale and current evidence on the potential for lifestyle modification with a specific focus on PA as a cost-effective strategy for VC treatment

A call to optimize haemodialysis vascular access care in healthcare disrupted by COVID-19 pandemic

The COVID-19 pandemic has resulted in major disruption to the delivery of both routine and urgent healthcare needs in many institutions across the globe. Vascular access (VA) for haemodalysis (HD) is considered the patient's lifeline and its maintenance is essential for the continuation of a life saving treatment. Prior to the COVID-19 pandemic, the provision of VA for dialysis was already constrained. Throughout the pandemic, inevitably, many patients with chronic kidney disease (CKD) have not received timely intervention for VA care. This could have a detrimental impact on dialysis patient outcomes in the near future and needs to be addressed urgently. Many societies have issued prioritisation to allow rationing based on clinical risk, mainly according to estimated urgency and need for treatment. The recommendations recently proposed by the European and American Vascular Societies in the COVID-19 pandemic era regarding the triage of various vascular operations into urgent, emergent and elective are debatable. VA creation and interventions maintain the lifeline of complex HD patients, and the indication for surgery and other interventions warrants patient-specific clinical judgement and pathways. Keeping the use of central venous catheters at a minimum, with the goal of creating the right access, in the right patient, at the right time, and for the right reasons, is mandatory. These strategies may require local modifications. Risk assessments may need specific "renal pathways" to be developed rather than applying standard surgical risk stratification. In conclusion, in order to recover from the second wave of COVID-19 and prepare for further phases, the provision of the best dialysis access, including peritoneal dialysis, will require working closely with the multidisciplinary team involved in the assessment, creation, cannulation, surveillance, maintenance, and salvage of definitive access