Vaginal delivery increases risk for SUI surgery

Incremental Hemodialysis Is Not Associated With Higher Death Risk

This approach could lower costs compared with conventional HD, data suggest

THE RISK FOR DEATH is comparable between incremental and conventional hemodialysis (HD) in patients with sufficient residual kidney function (RKF), investigators report.

Emma Caton, MSc, of the University of Hertfordshire in the United Kingdom, and colleagues performed a systematic review of 22 cohort studies, 2 randomized controlled trials (RCTs), 1 non-randomized controlled trial, and 1 pre-post study involving a total of 101,476 adults receiving HD. Included studies had a low to moderate risk of bias.

In a meta-analysis of 18 studies, mortality risk did not differ significantly between groups receiving incremental HD (1-2 sessions per week) and conventional HD (at least 3 sessions per week), the investigators reported in Nephrology Dialysis Transplantation.

Clinical circumstances guided the decision to initiate incremental HD in 18 studies, whereas socioeconomic pressures forced the decision in 8 studies. Mortality risk was nonetheless comparable after sensitivity analyses excluding patients receiving incremental HD due to factors such as lack of income, insurance, or proximity to a dialysis center.

According to data from the 2 RCTs, incremental HD also is significantly associated with a 69% reduced risk of hospitalization compared with conventional HD, the investigators reported.

Too few studies assessed vascular access complications, fluid overload, hyperkalemia, acidosis, loss of residual kidney function, symptom scores, and quality of life to make definitive conclusions. Four studies estimated the costs of both regimens and suggested that incremental HD may be cost-saving.

According to Caton’s team, “the findings from this review lend support to the safety of incremental HD as a treatment for ESKD and highlight the potential for this method to be implemented as an alternative to standard care in patients with sufficient RKF.”

Additional randomized controlled trials are still needed to determine the safety and efficacy of incremental vs conventional HD.

Among the studies considered in the review was the first prospective randomized trial of incremental versus conventional HD. The results, published in Kidney International in 2021, demonstrated that incremental HD appears safe and cost-saving in patients with adequate RKF. The trial, by Enric Vilar of Lister Hospital, East and North Herts NHS Trust, Hertfordshire, UK, and colleagues, included 55 incident HD patients with a urea clearance of 3 mL/min/1.73 m2 or higher. They randomly assigned patients to conventional or incremental HD schedules for 12 months. Incremental HD involved twice-weekly sessions; standard HD consisted of thrice-weekly sessions. The groups had similar RKF at baseline. At 6 months, the groups did not differ significantly with respect to urea clearance and body surface area-corrected glomerular filtration rate slope. ■

Meta-analysis also revealed a lower risk of hospitalization vs conventional HD

Vaginal Delivery Ups Risk for SUI, POP Surgery

WOMEN HAVE the highest risks for stress urinary incontinence (SUI) surgery and pelvic organ prolapse (POP) surgery after their first vaginal childbirth, according to new study findings presented at the International Continence Society’s 2022 annual meeting (ICS 2022) in Vienna, Austria.

Using the 2010-2017 Swedish National Quality Register of Gynecological Surgery, investigators identified 59,415 women aged 45 years and older who had SUI or POP surgery. The vast majority of women who underwent SUI surgery (93.1%) had 1 or more vaginal deliveries, whereas just 2.6% had C-sections, and 4.3% were never pregnant. POP surgery showed a similar pattern: 97.8% of patients had 1 or more vaginal deliveries, whereas 0.4% had C-sections, and 1.9% were never pregnant.

The vaginal delivery group had a significant 22% and 28% higher risk for SUI and POP surgery, respectively, compared with the age-matched general female population, Jennie Larsudd-Kåverud, MD, of Gothenberg Continence Research Center at the University of Gothenberg in Sweden reported on behalf of her team. In contrast, the never-pregnant and C-section groups had significant 69% and 74% lower risks for SUI surgery and 26% and 99.6% lower risks for POP surgery, respectively.

In absolute terms, the risk for POP surgery was highest in the vaginal delivery group (2.1%) and lowest in the C-section group (0.09%) — a 23-fold difference.

The first vaginal delivery carried the highest absolute risks: a 6.0-fold increased risk for POP surgery and a 3.0-fold risk of SUI surgery. Compared with the first vaginal delivery, the second vaginal birth carried a quarter of the risk for POP surgery and a tenth of the risk for SUI surgery.

“The result of the present study did not support the assumption that one or more pregnancies in themselves may cause long-term effects on the pelvic floor leading to POP and SUI surgery,” Dr Larsudd-Kåverud concluded in a study abstract.

Previous studies have demonstrated an association between vaginal deliveries and an increased risk for pelvic floor disorders. For example, a study of 1528 women showed that, compared with spontaneous vaginal deliveries, C-sections were associated with a significant 54%, 49%, and 72% lower risk for SUI, overactive bladder, and POP, respectively, in adjusted analyses, whereas operative vaginal delivery was associated with significant 75% and 88% higher risk for anal incontinence and POP, respectively, Joan L. Blomquist, MD, of the Greater Baltimore Medical Center in Baltimore, Maryland, and colleagues reported in a 2018 paper published in JAMA. The study population included 778 women who had C-sections, 565 who had spontaneous vaginal deliveries, and 185 who had operative vaginal deliveries. ■

Budesonide May Ease IgA Nephropathy

BUDESONSIDE IMPROVES the urinary protein-to-creatinine ratio (UPCR) and maintains estimated glomerular filtration rate (eGFR) in adult patients with IgA nephropathy (IgAN), according to interim results from a phase 3 randomized clinical trial (RCT).

“This is the first phase 3 RCT to show treatment benefits of this magnitude with a drug that we postulate may target the underlying pathophysiology of IgAN,” Brad H. Rovin, MD, of Ohio State University Wexner Medical Center in Columbus, and colleagues reported in Kidney International.

In Part A of the double-blind NefIgArd trial, researchers randomly assigned 199 patients with IgAN and persistent proteinuria despite stable, optimized renin angiotensin system blockade to budesonide (16 mg/d) or placebo for 9 months. At baseline, median UPCR was 1.26 g/g and median proteinuria was 2.26 g/24 hours (58% had proteinuria of 2 g or more in 24 hours). Median eGFR was 55 mL/min/1.73 m2 .

The budesonide formulation was Nefecon, a corticosteroid hypothesized to target mucosal B-cells in the ileum, including the Peyer’s patches, which are responsible for the production of galactose-deficient IgA1 antibodies (Gd-Ag1) causing IgAN.

At 9 and 12 months, 24-hour UPCR was a significant 27% and 48% lower, respectively, in the budesonide vs placebo group, Dr Rovin’s reported. In addition, eGFR at 9 months was preserved in the budesonide group with a decrease from baseline of 0.17 vs 4.04 mL/min/1.73 m2 in the placebo group.

Treatment-emergent adverse events (TEAEs) occurred in 86.6% of the budesonide group and 73.0% of the placebo group. Most TEAEs were mild to moderate (1% severe) and reversible, the investigators reported. The most common TEAEs in the budesonide group were hypertension, peripheral edema, muscle spasms, and acne. Infection occurred in 39.2% of the budesonide and 41.0% of the placebo group. ■

More PSA Screening Tied to Lower mPCa Incidence

BY JOHN SCHIESZER IN A LARGE STUDY of men receiving care at Veterans Health Administration (VHA) medical centers, investigators found that facilities with higher PSA screening rates had lower subsequent rates of metastatic prostate cancer (mPCa).

Over the past 12 years, conflicting data and changes in clinical practice guidelines have led to a drop in PSA screening rates across the country, the investigators noted. PSA screening rates declined in the VHA system from 47% in 2005 to 37% in 2019, with declines observed across all ages and races. The incidence of mPCa rose from 5.2 cases per 100,000 men in 2005 to 7.9 per 100,000 in 2019.

Each 10% increase in PSA screening rate was significantly associated with a 9% decrease in the incidence of metastatic prostate cancer 5 years later, the investigators reported. Each 10%

increase in long-term non-screening rates (the percentage of patients who missed screenings 3 years in a row) was significantly associated with an 11% increase in the incidence of metastatic prostate cancer 5 years later.

Alex K. Bryant, MD, a radiation oncology resident physician at the University Michigan Rogel Cancer Center in Ann Arbor, and colleagues reported study findings at the 2022 American Society for Radiation Oncology annual meeting in San Antonio, Texas. Study results were published concomitantly in JAMA Oncology.

The new data can be used to inform shared decision making about the potential benefits of PSA screening in men who wish to reduce their risk of metastatic prostate cancer, Dr Bryant and colleagues concluded.

Dr Bryant and colleagues analyzed data from all men aged 40 years or older receiving care at 128 facilities in the VHA health system from January 1, 2005 to December 31, 2019. The cohort grew from 4,678,412 men in 2005 to 5,371,701 men in 2019.

“The study appears to be carefully done, and the main takeaways likely generalize to men outside the national VA health system,” said Roman Gulati, MS, of the Fred Hutchinson Cancer Research Center in Seattle, Washington, where he is a designer, developer, and analyst of statistical models for investigating population impacts of national clinical practice patterns and cancer control policies. “Although the results are unsurprising, studies like this one are invaluable for understanding real-world trends in new cancer diagnoses,”

Douglas M. Dahl, MD, Chief of the Division of Urologic Oncology at Massachusetts General Hospital Cancer Center and Associate Professor of Surgery at Harvard Medical School, both in Boston, said the VHA population is a good way to capture evidence across a national health system in the United States. The results are consistent with other data showing the detrimental impact of the US Preventive

Each 10% increase in PSA screening was associated with a 9% lower mPCa rate.

PSA screening

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Services Task Force (USPSTF) 2012 grade D recommendation against PSA screening.

“Metastatic [prostate cancer] rates have been on the rise since then after decades of progress,” Dr Dahl said. “I think a new and really important finding is the 3-year gap in screening also being tied to increased metastatic rate. This is so relevant to the COVIDrelated disruptions in early detection which will also likely show downstream negative effects. We are seeing so many men with aggressive tumors who unfortunately did not get routine medical care due to the pandemic.”

While the USPSTF changed back to a grade C recommendation, Dr Dahl said significant damage occurred. “Much of the foundation for recommendations against screening are no longer valid,” Dr Dahl said. “It used to be that any abnormal PSA automatically meant a biopsy. Now, we have MRI done prior to biopsy, which results in differentiating very well between those who need biopsy and those who don’t.”

The use of transperineal biopsy has nearly eliminated the risk of serious infections or bleeding due to biopsy, according to Dr Dahl. With MRI guidance, he said biopsies are substantially more accurate in making a diagnosis so appropriate treatment or surveillance can be tailored to the situation. “It used to be any diagnosis of prostate cancer automatically meant aggressive treatment,” he said. “Now, a large cohort of our patients are monitored instead of having treatment. This is widely accepted and found to be safe.” ■