Dialysis patients more likely to receive PCa treatment

Nephrologists Lag in SGLT2i Prescribing

The specialists accounted for only 1.26% of prescriptions from May 2021 to April 2022

NEPHROLOGISTS’ USE of sodiumglucose cotransporter-2 inhibitors (SGLT2is) has risen substantially from 2015 to 2022, but they account for only a small fraction of prescriptions for the drugs, according to investigators.

Studies have demonstrated that SGLT2is substantially slow kidney function decline and decrease cardiorenal mortality. Clinical guidelines recommend these drugs as first-line therapies for most patients with CKD. Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend using SGLT2 inhibitors for all patients with diabetic CKD.

Using the IQVIA National Prescription Audit, which captures about 93% of US retail prescription dispensing activity, Rishav Adhikari, MD, and colleagues at Johns Hopkins University School of Medicine in Baltimore, Maryland, analyzed SGLT2i prescription data from January 2015 to April 2022. During that time, nephrologists’ monthly prescriptions for SGLT2is increased 35-fold, but still accounted for only 1.26% of total prescriptions in the final 12 months of the study period (May 2021 to April 2022) compared with 56% of primary care physicians, Dr Adhikari and colleagues reported in a poster presentation.

In the final 12 months, endocrinologists accounted for 11-fold more SGLT2i prescriptions than nephrologists.

On a per-physician basis, nephrologists accounted for 21 prescriptions per physician in the final 12 months of the study period, whereas endocrinologists, primary care physicians, and cardiologists accounted for 316, 28, and 18 prescriptions per physician, respectively.

“Nephrologists must recognize current gaps in CKD management, particularly the underutilization within their field of evidence-based [SGLT2is], and should adjust clinical practices to close those gaps,” the authors concluded.

After dapagliflozin received a Food and Drug Administration approved indication for CKD, nephrologists have predominantly used that drug. They prescribed it more frequently than nonnephrologists (52% vs 28% of prescriptions), Dr Adhikari’s team reported.

Overall, use of SGLT2 inhibitors among nephrologists “notably accelerated following publication of favorable renal outcomes trials,” the investigators wrote.

“Deploying [SGLT2is] will require a focused and coordinated effort across the medical specialties that manage patients with cardiorenal diseases, including an enhanced role for the nephrologist,” they concluded.

A separate study presented at the conference also found low prescribing of SGLT2is by nephrologists. Tripti Singh, MD, of the University of Wisconsin in Madison, and colleagues analyzed responses from 153 nephrologists who participated in an online survey. A minority of respondents (33.6%) said they prescribe SGLT2is to more than 50% of their patients who meet requirements for the drugs. The survey identified barriers to prescribing the drugs, the most common being the cost of the medications or high copays (34% of respondents), lack of experience or comfort in prescribing the drugs (29%), and lack of time and personnel to manage the side effects (11%).

Survey responses revealed that professional guidelines (29%), readily available medical knowledge through social media (26%), and participation in professional conferences (18%) were the mechanisms that have helped the most in prescribing SGLT2is. ■

Cost is a barrier to prescribing the medications, a study shows.

AKI Common After Radical Cystectomy

ACUTE KIDNEY injury (AKI) and acute kidney disease (AKD) are common complications of radical cystectomy for muscle-invasive bladder cancer (MIBC), according to the findings of a recent study.

Investigators identified hypertension at baseline as a unique risk factor for these complications.

Francesco Trevisani, MD, of IRCCS Ospedale San Raffaele in Milan, Italy, and colleagues studied 280 patients (258 men and 22 women) who underwent radical cystectomy for MIBC. AKI and AKD developed in 51.4% and 37.5% of patients, respectively, the investigators reported in a poster presentation. Both AKI and AKD occurred in 23.6% of patients, whereas 13.9% of patients experienced AKD, but not AKI. Surgical approach was not a factor.

Baseline hypertension was present in 63% of patients with AKI and AKD compared with 46% of patients without AKI and AKD, according to the investigators.

The authors concluded that AKI and AKD are frequent side effects from radical cystectomy for MIBC and require the nephrological counseling immediately after the procedure to monitor for onset of both complications.

Of the 280 patients, 209 (75%) underwent open surgery and 71 (25%) had robotic surgery, and 44 (16%) received neoadjuvant chemotherapy. In addition, 35 patients (12%) had type 2 diabetes, 153 (55%) had hypertension, and 18 (6.4%) had ischemic heart disease. ■

PCa Treatment More Likely in Dialysis Patients

PATIENTS on dialysis are more likely to be treated for prostate cancer versus non-dialysis patients and kidney transplant recipients, new findings suggest.

Using the Surveillance, Epidemiology and End Results (SEER)-Medicare database, Nagaraju Sarabu, MD, of University Hospitals in Cleveland, Ohio, and colleagues studied 272 men with low-risk prostate cancer: 42 patients on dialysis, 20 kidney transplant recipients, and 210 patients without end-stage kidney disease (ESKD). The non-ESKD group had significant 73% decreased odds of curative treatment compared with the dialysis group, the investigators reported in a poster presentation. None of the kidney transplant recipients died from prostate cancer.

“Dialysis patients, who are more likely to die of other causes, are paradoxically more likely to be treated for low-risk prostate cancer,” the authors concluded. “Active surveillance should be performed in this population, and should not preclude transplant eligibility.” ■

Bicarbonate Therapy May Up CKD Risk

BICARBONATE therapy may increase the risk for incident chronic kidney disease (CKD) and death among US veterans with normal kidney function.

The finding is from a study of a national cohort of 238,313 US veterans with an estimated glomerular filtration rate of 60 mL/min/1.73 m2 or higher and urinary albumin creatinine ratio less than 30 mg/g at baseline. Of these, 2992 were incident bicarbonate users. In a propensity scorematched cohort of 5968 patients, bicarbonate therapy was significantly associated with a 2.8- and 2.3-fold increased risk for incident CKD and death, respectively, Hanwen Wang, MD, of Tibor Rubin VA Medical Center in Long Beach, California, and colleagues reported. ■