In this book chapter are described different types of vascular access for hemodialysis, its forms, indications, placement and complications. The chapter is dedicated to health care professionals dealing with chronic kidney disease patients undergoing hemodialysis treatment.

Accumulating data from observational studies showed that online hemodiafiltration (OLHDF) might improve survival in chronic hemodialysis (HD) patients. According to this data, the aim of our study was to investigate whether there was a difference in survival of patients treated with OLHDF compared to standard, conventional HD. We included 85 prevalent patients with end-stage renal disease (ESRD) treated with HD as a method of renal replacement therapy (RRT) for more than three months. Patients were previously treated with HD and divided into two groups: in 42 patients new treatment with OLHDF was introduced, and 43 patients were treated with HD. Both groups were followed over a period of 36 months. The study showed significantly better survival of patients treated with OLHDF, compared to the survival of patients treated with HD in the whole study population, as well as in the subgroups of diabetics, of patients who were on RRT with HD for more than five years and of the patients who were older than 65 years. In the nondiabetics, patients who were on RRT for less than five years and in the patients who were younger than 65 years, survival results in the OLHDF group were not significantly better compared to those in the HD group. As in our study, there are accumulating data from observational studies that HDF may improve survival in chronic HD patients, but new, prospective randomized trials are needed to support evidence about this hypothesis.

Health-related quality of life (HRQoL) among hemodialysis (HD) patients recently became a nephrologist's focus of interest. HRQoL is an important predictor of outcome in HD patients and need to be regularly assessed. The aim of the present study was to compare the HRQoL of chronic HD patients with general population and to analyze influencing sociodemographic and clinical factors. We included 255 prevalent HD patients from four dialysis centers. HRQoL was measured with The Medical Outcomes Study Short Form 36 Health Survey Questionnaire (SF-36). This data were compared with control group (N = 132) from the general Croatian population. Comparisons of SF-36 scale scores of HD patients regarding demographic and clinical factors (age, gender, education level, dialysis vintage and diabetes) were also performed and analyzed with a multivariate regression analysis. HRQoL in prevalent HD patients was relatively low (mean Physical Component Summary, PCS = 33.7, mean Mental Component Summary, MCS = 43.0) and was lower compared to the control group from the general population in all HRQoL domains, PCS and MCS scores. Almost 53% of the HD patients had the critical score PCS < 43 + MCS < 51 as the predictor of death and hospitalization. Better HRQoL was revealed in the patients < 65 years old, males, patients with higher educational level and in the patients on maintenance HD less than one year. Age was the only statistically significant predictor of PCS and MCS. Developments of HD technology, treatment of comorbidities, continuous patients' education, social and psychological support and use of other renal replacement modalities, especially kidney transplantation, may improve the HRQoL in these patients.

In patients with end-stage chronic renal disease who are treated with regular hemodialysis, the vascular access is mandatory. It can be achieved through the catheter for hemodialysis or through construction of arteriovenous (AV) fistula and arteriovenous (AV) graft. Vascular access may be temporary or permanent. Temporary access to the bloodstream includes the appropriate placement of a catheter into one of the central veins (internal jugular, subclavian or femoral). Puncture is performed percutaneously, and it is recommended that the vein is previously visualised by ultrasound. For temporary access, non-tunneled catheters are commonly used. Permanent access to the bloodstream can be achieved using the AV fistula or AV graft, and so-called tunneled or, uncommonly used, nontunneled catheter into one of the central veins. Complications of the vascular access are numerous. Complications of the AV fistula and AV graft are stenoses, thromboses, aneurysms, pseudoaneurysms, cardiovascular complications, infections, and peripheral ischemia of the distal extremity. Complications of catheter for hemodialysis include hematoma at the site of puncture, accidental arterial puncture, inadequate position of the catheter, pneumothorax, hematothorax, hematopericard, thrombosis and infection. For catheter locking at the time of disuse heparin is used most commonly, but recently citrate solutions of different concentrations are being used as well. Adequate catheter care will allow its long-term use.

Currently, more than a million patients worldwide are supporting renal function by dialysis as a treatment of choice in the End-stage Renal Disease. Hemodialysis is one of the modalities of renal replacement therapy. Hemodialysis removes nitrogenous and other waste products, corrects electrolyte, water and acid abnormalities by diffusion, convection and ultrafiltration. Hemodialiysis membranes which are presently in use are the synthetic membranes of high biocompatibility (low-flux for conventional hemodialysis and high-flux for hemodiafiltration). Dialysate is a solution of purified water and electrolytes and is used for balancing a composition of blood. Hemodiafiltration is hemodialysis modality that combines principles of hemodialysis and hemofiltration (diffusion and convection) to enhance removal of both, high and low molecular weight uremic toxins. Online hemodiafiltration (OLHDF) offers production of substitution fluid in dialysis machine from fresh dialysate, that’s why the technique of OLHDF is simplified to use and economically acceptable. There are many clinical advantages of OLHDF, some of them are: lower mortality risk, higher delivered dialysis dose, correction of malnutrition, anti-inflammatory effect, improvement of blood pressure and hemodynamic stability, better control of hyperphosphatemia, anemia and greater biocompatibility. Despite of numerous clinical advantages, OLHDF is not still widely in use in maintenance hemodialysis patients, mainly because of the higher price of high permeable filters. Although, any dialysis modality, regardless of performance and efficiency will only partially restore integrity of renal function, OLHDF seems to offer the most physiological way to enhance the removal of uremic toxins and improvement of many comorbidities that are renal patients faced with. OLHDF is a step forward to gold standard in renal replacement treatment.

Danas se u svijetu vise od milijun bolesnika lijeci dijalizom kao terapijom izbora u zavrsnom stadiju kronicne bubrežne bolesti. Hemodijaliza je jedan od postupaka nadomjestanja bubrežne funkcije. Procesima difuzije, konvekcije i ultrafiltracije odstranjuju se uremijski toksini i visak tekucine, nadomjestaju tvari koje su u manjku, te ispravljaju poremecaji ravnoteže elektrolita i acidobazne ravnoteže. Membrane dijalizatora koje se danas upotrebljavaju su sintetske membrane visoke biokompatibilnosti (niskoprotocne, koje se koriste za standardnu hemodijalizu i visokoprotocne, koje se koriste za hemodijafiltraciju – HDF). Dijalizat ili dijalizna tekucina je otopina tocno određenog sastava, slicna ljudskoj plazmi, a koristi se za uravnoteženje sastava tjelesnih tekucina. HDF je hemodijalizna procedura koja kombinira principe hemodijalize i hemofiltracije kako bi omogucila bolje odstranjenje molekula srednje i velike molekulske težine. Zbog brojnih mogucnosti koje pruža online pripremljena supstitucijska tekucina, online hemodiafiltracija – OLHDF mnogo je prakticniji nacin HDF. Brojne su prednosti OLHDF, a neke od njih su: smanjena stopa smrtnosti, veca doza isporucene dijalize, ispravak pothranjenosti, protuupalni ucinak, bolja kontrola krvnog tlaka i hemodinamske stabilnosti, bolja kontrola razine fosfora u krvi, bolji utjecaj na ispravak anemije te veci stupanj biokompatibilnosti. Primjena OLHDF zbog svojih brojnih prednosti poželjna je u svih bolesnika lijecenih hemodijalizom, međutim, zbog visoke cijene, primjena je za sada jos uvijek ogranicena i slabo zastupljena. OLHDF osigurava najpovoljniji fizioloski profil uklanjanja srednjih i velikih molekula, te poboljsanje brojnih patoloskih stanja koja pogađaju bolesnike lijecene hemodijalizom. Zato OLHDF predstavlja nov korak prema zlatnom standardu u lijecenju dijalizom.

Acute renal failure (ARF) is still a considerable factor in hospital morbidity and mortality. This clinical condition occurs in up to 25% of critically ill patients. Mortality in these patients varies widely depending on the cause. ARF in the context of a large pericardial effusion and pericardial tamponade has not often been reported. This paper presents a case of life-threatening pericardial tamponade and a consecutive rapid onset of ARF. Successful treatment with pericardiocentesis was performed, which was followed by restitution of renal function.

Povoljan prometni položaj rijecke luke, duga pomorska tradicija i sve intenzivnija ulaganja u tehnologiju prekrcaja izdvojili su rijecku luku izvan nacionalnih okvira te je smjestili u red priznatih luka na važnim pomorskim pravcima. U ovome radu analiziran je kontejnerski promet rijecke luke u razdoblju od 2000. do 2008. godine i ujedno prikazano stanje kontejnerskog prometa u konkurentskim lukama Kopar i Trst. Dan je osvrt na tendencije razvitka kontejnerskog prometa luke Rijeka te je opisan Rijeka Gateway projekt kao najvažniji projekt razvoja rijecke luke i utjecaja koji on ostvaruje na cijelu regiju.