Cardiorenal syndrome, a complex pathophysiological disorder of both the heart and kidneys, is a condition in which acute or chronic damage to one organ can lead to acute or chronic dysfunction of the other organ. Depending on primary organ dysfunction and disease duration, there are five different types of cardiorenal syndrome. Type 1 cardiorenal syndrome (acute cardiorenal syndrome) is defined as acute kidney injury caused by sudden decrease in heart function. Type 2 cardiorenal syndrome (chronic cardiorenal syndrome) refers to chronic kidney disease linked to chronic heart failure. Type 3 cardiorenal syndrome (acute renocardial syndrome) is caused by acute kidney injury that leads to heart failure. Type 4 cardiorenal syndrome (chronic renocardial syndrome) includes chronic heart failure due to chronic kidney disease. Type 5 cardiorenal syndrome (secondary cardiorenal syndrome) is reversible or irreversible condition marked by simultaneous heart and kidney insufficiency, as a result of multiorgan disease such as sepsis, diabetes mellitus, sarcoidosis, amyloidosis, etc. The pathophysiological patterns of cardiorenal syndrome are extremely complicated. Despite numerous publications, perplexed physiological, biochemical and hormonal disturbances as parts of the main pathogenic mechanisms of cardiorenal syndrome remain obscure. Even though there are guidelines for the treatment of patients with heart failure and chronic kidney disease, similar guidelines for the treatment of cardiorenal syndrome are lacking. In everyday practice, it is crucial to diagnose cardiorenal syndrome and use all diagnostic and therapeutic procedures available to prevent or alleviate kidney and heart failure.

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 length and 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 to diabetes. Following an extensive PubMed search, this review provides a brief view on the screening for chronic kidney disease (CKD) in people with diabetes, how to treat them to slow down the progression of CKD and when to refer them to specialist care. This review also emphasizes the basic challenge in treating diabetic patients, which is to shift the main criterion from the disease-oriented to person-centered approach in the context of treating the patient as a whole.

Adrenocortical carcinoma is a rare entity. However, it is the most common type of cancerous adrenal gland tumor with poor 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 a higher risk. Adrenocortical carcinoma can be a functional or nonfunctional tumor. If the tumor is functional, it may produce hormones causing symptoms such as high blood pressure, low potassium level, heart palpitations, nervousness, feelings of 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 is nonfunctional, 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 physical examination, the following tests are used: blood and urine tests to help determine whether the tumor is functional or nonfunctional, and imaging tests (computed tomography scan or magnetic resonance imaging). The treatment depends on cancer stage. Two major staging systems are used: the American Joint Committee on Cancer (AJCC) TNM staging system and the ENSAT (European Network for the Study of Adrenal Tumors) staging system. Both are based on the same TNM categories. The main types of treatment for adrenal cancer are surgery (the main treatment), chemotherapy and targeted therapy. Radiation therapy is not used often as the main initial treatment for adrenal cancer because the cancer cells are not easy to kill with x-rays. Radiation may be used as adjuvant therapy. By definition, adrenal incidentaloma is an asymptomatic adrenal mass detected on imaging not performed for suspected adrenal disease. In most cases, adrenal incidentalomas are nonfunctional adrenocortical adenomas, but may also represent conditions requiring therapeutic intervention (e.g., adrenocortical carcinoma, pheochromocytoma, hormone-producing adenoma, or metastasis).

Renal tissue is sensitive to the effect of potentially nephrotoxic drugs and other substances that are available over-the-counter 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 influence 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 identification of new biomarkers that will contribute to early detection of drug induced kidney damage.

Chronic kidney disease (CKD) is one of the leading public health issues due to frequent and serious complications. Once the function of kidneys is disrupted, regardless of etiology, there are numerous factors that can speed up decrease of glomerular filtration rate, including hypertension, proteinuria and dyslipidemia. Statins are widely used in primary and secondary prevention of cardiovascular diseases in general population. Clinical advantages of statins in CKD patients are not as clear. The aim of this paper is to present lipid status in CKD patients and indications for statin therapy with the aim to reduce cardiovascular risk in this group of patients. CKD is a well-known independent risk factor in cardiovascular events, but professional associations issuing guidelines differ in the approach to treatment of dyslipidemia. The results of some studies indicate that treatment with statins may slow down the rate of kidney function reduction in patients with mild to moderate kidney damage, whereas other studies deny this effect. Furthermore, CKD patients have a higher risk of side effects, in part due to the reduced kidney excretion, polypharmacy, and numerous other comorbidities. Family physician has the role of providing preventive measures, with focus on appropriate treatment of patients with hypertension or diabetes, as the most common cause of CKD, and timely detection of CKD in initial stage.

Cystic kidney diseases is a heterogeneous group of developmental, hereditary and acquired disorders that result in the occurrence of one or more cysts on one or both kidneys, and are relatively common. Cystic kidneys can also occur as one of various syndromes of malformations. Kidney cysts can have several classifications, depending on the properties taken in consideration. Some patients remain symptom free for life, whereas others develop serious clinical symptoms that may sometimes 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 present the most prevalent types of cysts with accompanying clinical symptoms and point out their importance, prevalence and possible association with other serious medical conditions.

According to consensus definition, chronic kidney disease (CKD) includes urinary excretion of albumin >30 mg/day and/ or reduction in kidney function defined as a decrease in estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 for a period longer than three months, in the presence of kidney tissue damage verified by imaging or histologic methods. In developed world, the first cause of CKD is diabetes, followed by arterial hypertension, and the less frequent causes are inflammatory disease (glomerulonephritis, interstitial nephritis) and congenital condition (polycystic kidney disease). Currently, there is valid classification under the acronym CGA, where C stands for the cause, G for glomerular filtration rate (GFR category) and A for the level of albuminuria category. In early stages, patients usually have no symptoms but there are changes in creatinine values, estimated GFR (eGFR) reduction and presence of albuminuria, especially in patients at risk. Determining the grade of renal impairment is important because of different approaches to treatment, monitoring, expected complications, and patient education. Due to improved diagnostic methods and population aging, CKD is diagnosed ever more increasingly. Family physicians should be familiar with the basic principles of screening and diagnosis of CKD to provide them with appropriate care in collaboration with secondary and tertiary health care.

Increasing the proportion of patients with controlled hypertension implies understanding and systematic approach to patients 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 target blood pressure values, and their risk of an adverse cardiovascular event is tripled. RAH is defined as hypertension in which there is no satisfactory control of blood pressure despite compliance to lifestyle changes and taking at least three drugs in 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 of secondary hypertension. One-fifth of patients with RAH have primary aldosteronism. Obstructive sleep apnea is a common cause of RAH, and literature reports point to its increasing frequency. Optimal treatment involves a combination of three drugs, one of which is a diuretic. Use of mineralocorticoid antagonist as the fourth drug has shown significant efficacy even in patients who do not have elevated levels of aldosterone. New invasive methods of treatment include renal denervation and permanent electrical stimulation of the carotid sinus. The aim of this paper is to emphasize the importance of RAH as a cardiovascular risk factor, along with early detection and treatment at the family medicine level and timely referral to additional procedures to treat the specific forms of RAH.

Because of the increasing number of patients, chronic kidney disease (CKD) has become a significant public health problem. As kidney function decreases, it is necessary to introduce certain dietary modifications. 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 confirm that Mediterranean diet has a preventive effect on renal function and reduces progression of the disease. Preventive measures, correct identification and early intervention can increase survival of patients and improve their quality of life. Mediterranean diet tailored to individual stages of CKD has been confirmed as the best choice in CKD patients.

The management of hyperglycemia in patients with chronic kidney disease (CKD) is complex, and the goals and methods regarding glycemic control are not clearly defined. Although aggressive glycemic control seems to be advantageous in early 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 hypoglycemic agents that currently are available, as well as insulin, along with their indications and contraindications. The aim is to provide useful information to family physicians when deciding on individualized glycemic goals and appropriate therapy for patients with early or end stages of CKD.

Transplantation is sometimes the only therapeutic option to treat acute or chronic organ failure. In the care of transplant patients, there are numerous complications that are caused by powerful immunosuppressive drugs, cardiovascular, metabolic, and neoplastic diseases. These diseases are associated with significant morbidity and mortality in patients after transplantation, which will become an important part for supporting the transplant patient care. In the first year after transplantation, patients have regular contact with transplant center, and family doctor acts as a contact connecting patients with specialized centers, while also detecting and managing health problems and issues that are not related only to transplantation. After that, the role of family physicians is becoming ever more important and active in the prevention of morbidity and mortality in transplant patients by appropriate and timely intervention in detection of side effects of immunosuppressive therapy and threatening metabolic disorders. The aim of this article is to show the role of family physician in tracking the welfare of organ transplant patient.

Prostate cancer is a common malignant tumor of the elderly, which accounts for a significant proportion of total morbidity but very low of mortality. In Croatia, it is the second most common cancer in men. Currently, there are many doubts concerning screening, early detection and treatment of prostate cancer. Therefore, this article brings results of Cochrane systematic reviews (SRs) on the topic of prostate cancer published in the last eight years. In June 2016, Cochrane database of 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 abstracts were initially screened and those that matched the topic were included in further analysis. Then full texts of all SRs involved were obtained. SRs were classified into four topics: prevention, screening, treatment and psychosocial aspects. Our search retrieved a total of 19 Cochrane SRs on the topic of prostate cancer. Excluded were four articles that did not match the specific topic, and the remaining 15 full texts were obtained. One of these was on screening, two on prevention, the majority, i.e. eleven were on treatment, and one on the psychosocial aspects related to prostate cancer. Based on the results of the Cochrane SRs on prostate cancer, instead of mass/population screening, the individualized/opportunistic screening approach should be applied in men aged 55-69, always providing full information to the patient and taking into account the potential benefits and harms of this procedure.

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 UTI is usually based on the presence of structural or functional urinary tract abnormalities, which can increase the risk of treatment 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 a spectrum of conditions that increase the risk of treatment failure, as well as of serious complications such as bacteremia and sepsis, perinephric abscess, renal impairment and emphysematous pyelonephritis. To avoid the potentially devastating outcomes, 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 of diabetes, and ever growing number of immunocompromised and immunosuppressed patients. It is of key importance to recognize complicated UTI on time, and treat it wisely and aggressively to reduce duration of the disease and the risk of antibiotic resistance.

Chronic kidney disease is clearly defined as a state of damaged kidney function lasting for more than three months. Changes manifest in serum and urine pathological findings with frequent morphological changes in the kidneys and reduction in glomerular filtration. The aim is to show the possibilities of renal replacement therapy and waste related disease during dialysis treatment. The methods are based on strong evidence and guidelines. Glomerular filtration is the basis in evaluating the stage of chronic kidney disease. Based on the measures of glomerular filtration reduction, chronic kidney disease is classified into five stages, thus facilitating approach to treatment of particular groups of patients depending on the level of glomerular filtration damage. Kidney function can be replaced by dialysis or transplantation and in certain cases symptomatically if the patient refuses dialysis treatment. Malnutrition, hypertension, kidney anemia and bone-mineral disease are often present in patients with higher stages of chronic kidney disease, particularly stage 5 and kidney function replacement by dialysis. In conclusion, timely treatment reduces morbidity and mortality in patients with chronic kidney disease.

Although asymptomatic hyperuricemia is rather often in laboratory reports, it cannot be considered a disease. Despite the high prevalence of hyperuricemia in patients with arterial hypertension (AH), chronic kidney disease (CKD), cardiovascular disease (CVD) or metabolic syndrome, hyperuricemia is not confirmed as a causative factor of these disorders. The aim is to point to the latest studies of the importance of urate as a possible cardiorenal risk factor. The literature published in 2015 and 2016 was searched for the possible impact of urate level on the development of cardiorenal diseases. The PubMed, Cochrane, Medline, and UpToDate databases were searched for the literature published between November 2009 and October 2016 using the following key words: urate, hyperuricemia, cardiovascular disease, and chronic kidney disease. Causative correlation of hyperuricemia is confirmed only in disorders where deposits of monosodium urate crystals are present. Results of recent studies do not justify routine use of xanthine oxidase inhibitors in asymptomatic hyperuricemia. Some studies with small numbers of patients and short follow up report on endothelial function improvement on therapy with xanthine oxidase inhibitors. Nonpharmacological intervention by changing unhealthy lifestyle is preferred. Treatment of asymptomatic hyperuricemia in CKD is still debated, and additional studies are necessary to demonstrate the benefit of lowering urate level in CKD. Family doctors (general practitioners) should be familiar with the recommended approach to patients with asymptomatic hyperuricemia. Evidence based medicine still does not recommend target determination of serum urate level for identifying CVD and CKD risk factors. Recent studies suggest the possible effect of uric acid in cardiorenal diseases and that treatment of asymptomatic hyperuricemia with xanthine oxidase inhibitors may also be useful in CVD prevention. Additional studies are needed to prove this statement.