Delay in funding of tolvaptan for polycystic kidney disease in Aotearoa New Zealand.

Autosomal dominant polycystic kidney disease (ADPKD) is the fifth most common cause of end stage kidney disease (ESKD) in Aotearoa New Zealand. Identification of two genes, PCKD1 and PCKD2, which cause the majority of this disease, has played a key role in the development of DNA-sequence molecular diagnostics. ADPKD is characterised by the formation and growth of multiple cysts within the kidney, with some but not all patients progressing to ESKD. The diagnosis of ADPKD is based on the presence of family history, and radiological imaging although increasingly genetic testing is being used for screening and diagnosis. Once diagnosed, standard management of ADPKD includes laboratory monitoring of chronic kidney disease (CKD) parameters, lowering of blood pressure, and a high fluid intake. Over the last decade much research has been undertaken for targeted therapies for ADPKD; however, despite funding of these medications overseas since May 2015, and applications to Te Pataka Whaioranga, The Pharmaceutical Management Agency (PHARMAC), these therapies remain unavailable to New Zealanders resulting in an increased burden of disease to individuals and the whanau and financial cost to the health system.

A consensus statement on the use of angiotensin receptor blockers and angiotensin converting enzyme inhibitors in relation to COVID-19 (corona virus disease 2019).

There has been a lot of speculation that patients with coronavirus disease 2019 (COVID-19) who are receiving angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) may be at increased risk for adverse outcomes. We reviewed the available evidence, and have not found this to be the case. We recommend that patients on such medications should continue on them unless there is a clinical indication to stop their use.

Difficult Hypertension Clinic Utilizing a Nurse Specialist: A Cost-Efficient Model for the Modern Era?

In the modern era in New Zealand, there has been a lack of specialist hypertension clinics where family practitioners might refer patients with difficult-to-treat or resistant hypertension. A new specialist referral hypertension clinic was established in 2009 at North Shore Hospital, Auckland, employing a model of care where much of the follow-up work is done by a nurse specialist. The authors review data from the first 1000 patients discharged from the clinic. Mean (treated) blood pressure improved by -26/12 mm Hg over an average of three visits, two thirds of which were to nurse specialist clinics. The authors propose this as a cost-efficient model that could easily be duplicated in other centers.

Ambulatory vs office blood pressure monitoring in renal transplant recipients.

Hypertension is common following renal transplantation and has adverse effects on cardiovascular and graft health. Ambulatory blood pressure monitoring (ABPM) is better at overall blood pressure (BP) assessment and is necessary to diagnose nocturnal hypertension, which is also implicated in poor outcomes. The authors performed a retrospective analysis of 98 renal transplant recipients (RTRs) and compared office BP and ambulatory BP recordings. ABPM revealed discordance between office BP and ambulatory BP in 61% of patients, with 3% caused by white-coat and 58% caused by masked hypertension (of which 33% were caused by isolated nocturnal hypertension). Overall, mean systolic BP was 3.6 mm Hg (0.5-6.5) and diastolic BP was 7.5 mm Hg (5.7-9.3) higher via ambulatory BP than office BP. This was independent of estimated glomerular filtration rate, proteinuria, transplant time/type, and comorbidities. A total of 42% of patients had their management changed after results from ABPM. ABPM should be routinely offered as part of hypertension management in RTRs.

Malignant hypertension: a preventable emergency.

The Waitemata Hypertension Clinic Database 2009-2012 (Auckland, New Zealand) was searched for patients meeting the definition of Malignant Hypertension. Eighteen of 565 patients met the criteria. All patients had essential hypertension which was either undiagnosed, untreated or undertreated. Most cases responded satisfactorily to standard drug therapy, but a number were left with significant chronic kidney disease. Malignant hypertension is a life-threatening disease which should be entirely preventable with regular blood pressure checks in primary care.

Nurse titration clinics to achieve rapid control of blood pressure.

AIMS: To assess the effectiveness of a new hypertension clinic (in Auckland, New Zealand) using clinical nurse specialist appointments for drug titration. METHODS: A new hypertension clinic was established at Waitemata District Health Board (DHB) in August 2010 using an initial registrar clinic appointment followed by fortnightly clinical nurse specialist appointments for drug titration. 50 GP-referred patients were prospectively audited and their outcomes compared to 50 patients seen in the physician hypertension clinic. RESULTS: The comorbidities of the two groups were similar. 52-66% had the metabolic syndrome by IDF criteria. The mean number of clinic visits to discharge was not significantly different. The mean number of antihypertensive drugs at discharge was the same (2.8) for both clinics. There were significant reductions in systolic and diastolic blood pressures in both clinics, with a mean discharge blood pressure of 131/78 in the nurse clinic group. CONCLUSIONS: Nurse titration clinics are as effective as physician-only appointments in rapidly achieving target blood pressures.

Effect of antimicrobial locks for tunneled hemodialysis catheters on bloodstream infection and bacterial resistance: a quality improvement report.

BACKGROUND: Catheter-restricted antimicrobial lock (AML) use reduces catheter-associated bloodstream infection (CA-BSI) in clinical trial settings, but may not be as effective in clinical settings and may increase bacterial resistance. DESIGN: Quality improvement report analyzed using a cross-sectional time series (unbalanced panel) design. SETTING & PARTICIPANTS: The study cohort comprised all prevalent adults treated with hemodialysis through a tunneled catheter for any, but not necessarily all, of the time from January 1, 2003, to June 30, 2006, in Manukau City, New Zealand (135,346 catheter-days, 404 tunneled catheters, 320 patients). QUALITY IMPROVEMENT PLAN: Catheter-restricted AMLs (heparin plus gentamicin) for all tunneled catheters from July 1, 2004. MEASURES: Repeated observations of CA-BSI, hospitalization, tunneled catheter removal, and death from CA-BSI analyzed by using generalized estimating equations with a single level of clustering for each tunneled catheter and patterns of bacterial resistance analyzed by using simple descriptive statistics. RESULTS: AML use was associated with reductions in rates of CA-BSI and hospitalization for CA-BSI by 52% and 69% for patients with tunneled catheters locked continuously with AMLs since their insertion compared with those with tunneled catheters that were not, respectively. AML exposure also was associated with a trend to increased gentamicin resistance amongst coagulase-negative staphylococci isolates, a pattern similar to that observed for BSIs in our general hemodialysis population in which tunneled catheters were not the source of BSI, but different from that in the general non-end-stage renal disease population in the region. LIMITATIONS: This is an uncontrolled observational study and cannot prove causality. The follow-up period of 18 months is longer than for other studies, but still too short to definitely answer whether AML use drives bacterial resistance. CONCLUSIONS: A change to use of AMLs may improve clinical outcomes; however, additional study of associated bacterial resistance is needed before AML use becomes standard care.

Establishment of a Difficult Hypertension Clinic in Whangarei, New Zealand: the first 18 months.

A Difficult Hypertension Clinic was established at Whangarei Hospital (Whangarei, Northland, New Zealand) in March 2006 in response to a perceived need amongst general practitioners. The experience with the first 150 patients is reviewed. Mean BP at referral was 162/89 mmHg, and mean number of antihypertensive drugs was 2.49. Mean BP at discharge from the Difficult Hypertension Clinic was 138/78 mmHg and mean number of antihypertensive drugs 3.16. The commonest cause of hypertension resistance was underprescription of diuretics. Secondary or contributory causes of hypertension were identified in 28 (19%) of patients, and white coat hypertension in three (2%). The Difficult Hypertension Clinic established in our hospital is an effective model for achieving clinical targets and care recommended in evidence-based guidelines.

Subcutaneous black fungus (phaeohyphomycosis) infection in renal transplant recipients:three cases.

We describe three cases of subcutaneous phaeohyphomycosis developing in the lower limbs of renal transplant recipients shortly after transplantation. Each case presented with dark-colored nodules that subsequently ulcerated. Histopathologic examination revealed dematiaceous fungal hyphae with a surrounding granulomatous reaction. The fungi were subsequently identified as Alternaria alternatum in two cases and Phialophora richardsiae in one case. In one case, the lesions resolved during a prolonged (6-month) course of itraconazole without the requirement for surgical excision. In the other two cases, combined medical and surgical treatment resulted in cure. A review of the literature on phaeohyphomycosis is presented.