Previously, management of hypertension has concentrated on lowering elevated blood pressure. However, the target has shifted to reducing absolute cardiovascular (CV) risk. It is estimated that two in three Australian adults have three or more CV risk factors at the same time. Moderate reductions in several risk factors can, therefore, be more effective than major reductions in one. When managing hypertension, therapy should be focused on medications with the strongest evidence for CV event reduction, substituting alternatives only when a primary choice is not appropriate. Hypertension management guidelines categorise angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) interchangeably as first-line treatments in uncomplicated hypertension. These medications have different mechanisms of action and quite different evidence bases. They are not interchangeable and their prescription should be based on clinical evidence. Despite this, currently ARB prescriptions are increasing at a higher rate than those for ACEI and other antihypertensive classes. Evidence that ACEI therapy prevents CV events and death, in patients with coronary artery disease or multiple CV risk factors, emerged from the European trial on reduction of cardiac events with perindopril in stable coronary artery disease (EUROPA) and Heart Outcomes Prevention Evaluation (HOPE) trials respectively. The consistent benefit has been demonstrated in meta-analyses. The clinical trial data for ARB are less consistent, particularly regarding CV outcomes and mortality benefit. The evidence supports the use of ACEI (Class 1a) compared with ARB despite current prescribing trends.

PURPOSE:The purpose of this study is to examine the effect of the presence of tunnelled vascular catheter (TVC) on physician referral and surgeon review and operating patterns and ultimately time of creation of permanent haemodialysis (HD) access.METHODS:A retrospective analysis of TVC and arteriovenous fistulae (AVF) databases in 2010. Physician referral time and surgical time to operation were compared between patients commencing HD with TVC and a control group who commenced HD with AVF.RESULTS:The AVF group (n = 27) commenced HD with an AVF and TVC group (n = 49) commenced HD via a TVC. Time from physician referral to surgeon review in the AVF vs. TVC group was 29 vs. 35 days (p = 0.6). Time from surgeon review to access creation was 43 vs. 50 days (p = 0.4). However, in the TVC group, the time from TVC insertion to physician referral to a surgeon was an additional 109 ± 20 days. Subgroup analysis of 11 TVC patients (23%) presenting at end stage without AVF (crash starters) had a TVC to physician referral time of 103 ± 75 days, physician referral to surgeon review of 14.4 ± 4 days and surgeon review to AVF of 67 ± 23 days.CONCLUSIONS:The presence of a TVC is associated with a significant delay (>3 months) before physicians make a referral for surgeon review. There was no surgeon-related delay to access creation related to the presence of a TVC.

Aim Percutaneous renal biopsy (PRB) remains the gold standard for the diagnosis of renal disease; however, the tissue yield which relates to the optimal needle size used for native-kidney biopsies has not been clearly established. Our study compares the sample adequacy and complication rates using 16 gauge (G) and 18 gauge (G) automatic needles on native kidney PRB. Methods A retrospective analysis was performed of native-kidney biopsies at two centres, one exclusively using 16G and the other exclusively using 18G needles. All samples were assessed by a single centralized pathology service. We compared patient characteristics, indications, diagnoses, adequacy of tissue samples, and complications. Results A total of 934 native-kidney biopsies were performed with real time ultrasound guidance: 753 with Bard Max Core 16Gx16cm needles, and 181 with Bard Magnum 18Gx20cm needles. The median (range) of total glomeruli count per biopsy was higher in the 16G group compared with the 18G group (19 (0-66) vs 12 (0-35), P<0.001), despite having fewer cores per biopsy (2 (0-4) vs 3 (1-4), P<0.001). The 16G group provided a greater proportion of adequate biopsy samples (94.7% vs 89.4%, P=0.001). There was no significant difference in the frequency of total complications between the 16G and 18G groups (3.7% vs 2.2%, P=0.49). Conclusion This retrospective study demonstrates 16G needles provide more glomeruli, more diagnostically adequate renal tissue, with fewer cores without a significant increase in complications compared with 18G needles. Based on these observations, 16G needles should be considered as the first line option in native-kidney PRB.

BACKGROUND High-sensitivity cardiac troponin T (hs-cTnT) is a biomarker used in diagnosing myocardial injury. The clinical utility and the variation of this biomarker over time remain unclear in hemodialysis (HD) and peritoneal dialysis (PD) patients. We sought to determine whether hs-cTnT concentrations were predictive of myocardial infarction (MI) and death and to examine hs-cTnT variability over a 1-year period. METHODS A total of 393 nonacute HD and PD patients (70% HD and 30% PD) were followed in a prospective observational study for new MI and death. RESULTS Median hs-cTnT was 57 ng/L (interquartile range, 36-101 ng/L) with no observed difference between HD and PD patients (P = 0.11). Incremental increases in mortality (P = 0.024) and MI (P = 0.001) were observed with increasing hs-cTnT quartiles. MI incidence increased significantly across quartiles in both HD and PD patients (P = 0.012 and P = 0.025, respectively), whereas mortality increased only in HD patients (P = 0.015). For every increase of 25 ng/L in hs-cTnT, the unadjusted hazard ratio (HR) was 1.10 for mortality in the whole group (95% CI, 1.04-1.16, P = 0.001) and 1.16 for MI (95% CI, 1.08-1.23, P < 0.001). Adjusted HR for mortality was 1.07 (95% CI, 1.01-1.15, P = 0.04) and 1.14 for MI (95% CI, 1.06-1.22, P < 0.001). Changes in hs-cTnT from baseline concentrations after 1 year were minimal (55 ng/L vs 53 ng/L, P = 0.22) even in patients who had an MI (P = 0.53). CONCLUSIONS hs-cTnT appears to have a useful role in predicting MI and death in the dialysis population. Over a 1-year period concentrations remained stable even in patients who sustained a new cardiac event.

Introduction and Aims: Hemoglobin (Hb) stability with C.E.R.A. once-monthly (QM) was evaluated in high risk patients with chronic kidney disease (CKD) on dialysis switched from shorter-acting erythropoiesis-stimulating agents (ESAs).Methods: Adult CKD patients on dialysis were converted to C.E.R.A. QM to achieve a target Hb of 10.0-12.0g/dL (5 studies), 10.5-12.5 g/dL (3 studies), 11.0-12.5 g/dL and 11-13 g/dL (one study each).High risk (HR) and low risk (LR) subgroups were defined on the basis of therapy parameters before switching: epoetin or darbepoetin alfa dose (=8000 IU or 40 μg, respectively), average Hb at screening (below the 40% percentile [P60] for LR).The ratio of dose and achieved Hb at screening >P60 (HR), or Hb fluctuation >P60 (HR) were defined by the same parameters.Cardiovascular (CV) risk groups were defined by pre-existing cardiac risk factors (diabetes or cardiac disorder), or through >P60 N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels.Treatment switchover was followed by a 16-week titration and an 8-week evaluation period.Hb parameters, dosing and safety in the evaluation period were compared.Results: Patients (N=1577); median age 63 (range: 19-93) years were classified into HR/LR subgroups as shown in the table.Evaluation of therapy-related subgroups showed generally significantly higher mean Hb values for the LR subgroups.The largest difference (0.4 g/dL) was seen for subgroups by dose/Hb, while subgroups by Hb fluctuation showed no difference.The difference seen for the HR/LR screening Hb group represented a reduction from 1.2 g/dL difference at screening to 0.3 g/dL after the switch to C.E.R.A.There was less variation in mean Hb levels for the HR/LR subgroups by CV risk factors.Hb stability (mean Hb within target range or change from baseline =1 g/dL) was similar across all subgroups.Mean required C.E.R.A. dose QM was higher for all HR groups than the LR counterparts, with significant differences for four of the comparisons.As expected, significantly higher frequencies of cardiac and vascular SAEs were seen in HR versus LR patients for NT-proBNP (HR/LR, 5.7/1.9;p<0.004 for cardiac SAEs) and baseline risk factors (4.6/2.0;p<0.02 for cardiac SAEs; 4.9/1.3;p=0.0004 for vascular SAEs).Conclusions: The pooled analysis in dialysis patients shows that C.E.R.A. QM maintains stable Hb levels in all HR patients as well as in patients with prevailing CV risk factors.