Renal & Urology News - Jan/Feb 2017 Issue

J A N U A R Y/F E B R U A R Y 2 017

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V O L U M E 16 , I S S U E N U M B E R 1

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© NATALIE SCHENKER-AHMED, PHD, AND DAVID S. KAROW, MD, PHD

Prostate MRI May Have AS Benefit Better detection of significant PCa observed

BY JODY A. CHARNOW MAGNETIC RESONANCE imagingultrasound fusion (MRI/fusion) targeted prostate biopsy may improve detection of clinically significant tumors in prostate cancer patients on active surveillance (AS) undergoing confirmatory biopsy, researchers reported at the Society of Urologic Oncology 17th annual meeting in San Antonio, Texas.

“We observed that 70% of AS patients have MRI-detectable lesions, the majority of which are consistent with low-grade disease,” senior author J. Kellogg Parsons, MD, MHS, a urologic

IN THIS ISSUE 10

Preoperative use of 5-ARIs may reduce blood loss during TURP

15

Studies validate new prostate cancer grading system

16

Obesity is associated with an elevated risk for BPH

19

Robotic radical nephrectomy increasingly used for RCC

24

Metformin use found to decrease prostate cancer risk Serious infections raise ESRD risk in SLE patients.

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oncologist and professor of surgery at the University of California San Diego in La Jolla, told Renal & Urology News.

“MRI/fusion targeted biopsy in patients with PI-RADS 4 and 5 lesions was superior to systematic biopsy for the detection of clinically significant disease, suggesting that MRI and selective, targeted biopsy of PI-RADS 4 and 5 lesions should be considered in AS patients.”

In a study of 356 AS patients, a team led by Dr. Parsons and first author Zachary Hamilton, MD, who presented study findings, compared MRI/ fusion targeted biopsy (TB) to standard

MRI SCANS SHOWING a suspicious prostate lesion (boundary outlined at upper left).

transrectal ultrasound (TRUS)-guided systematic biopsy (SB) for detecting Gleason 3 + 4 = 7 or higher disease. A total of 195 patients (58%) underwent prostate MRI after the initial diagnostic biopsy. Of these, 138 (71%) had prostate lesions detectable on MRI.

After implementation of TB in May 2014, 42 AS patients underwent confirmatory MRI/fusion TB: 9 (21.4%), 19 (45.2%), 7 (16.7%), and 7 (16.7%) with PI-RADS 2, 3, 4, and 5 lesions, respectively. MRI-guided biopsy of the continued on page 11

In-Office Biopsy Researchers Establish Normal of Renal Masses Testosterone Reference Range Safe, Efficacious BY NATASHA PERSAUD the Journal of Clinical Endocrinology & OFFICE-BASED ultrasound-guided renal mass biopsy (RMB) is a safe and efficacious procedure for managing appropriately selected patients with small renal masses, according to investigators.

“It potentially offers improved dynamic characterization of solid renal mass, greater convenience to patients, as well as cost savings,” a team led by Chirag N. Dave, MD, of the Beaumont Health System in Royal Oak, Michigan, concluded in a paper published online ahead of print in Urology.

Dr. Dave and his colleagues studied a retrospective cohort of 108 patients who underwent office-based continued on page 11

RESEARCHERS HAVE established a reference range for normal total testosterone levels using values harmonized by the Steroid Hormone Standardization Program at the Centers for Disease Control and Prevention (CDC) in Atlanta.

For healthy, non-obese men aged 19 to 39 from Europe or the United States, the harmonized normal range of total testosterone is 264 to 916 ng/dL, a range that corresponds to the 2.5th to 97.5th percentile, investigators reported in a paper published online ahead of print

Metabolism. Values below the 2.5th percentile indicate hypogonadism.

Lack of a universally accepted testosterone threshold has made accurate diagnosis of hypogonadism difficult.

“Well-defined reference ranges are at the heart of clinical practice and without them clinicians can make erroneous diagnoses that could lead to patients receiving costly, lifelong treatments that they don’t need or deny treatments to those who need them,” lead researcher Shalender Bhasin, MD, continued on page 11

CALCIPHYLAXIS LINKED TO LOW VITAMIN K

The vitamin has a role in inhibiting vascular calcification PAGE 22

4 Renal & Urology News

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Study Characterizes GU Injuries in the U.S. Military THE LARGEST and most comprehensive review of military genitourinary (GU) injuries to date found that 1367 U.S. service members (SMs) deployed as part of Operation Iraqi Freedom/ Operation Enduring Freedom suffered at least 1 GU injury, according to investigators.

In a retrospective cross-sectional study, a team led by Steven J. Hudak, MD, of the San Antonio Military Medical Center in Fort Sam Houston, Texas, found that 1000 SMs (73%) suffered injuries involving the external genitalia, including the scrotum (760, 55.6%), testes (451, 33.0%), penis (423,

31%), and/or urethra (125, 9.1%). In addition, 502 (36.7%) suffered at least 1 severe GU injury, with 146 men suffering the loss of 1 or both testes, the investigators reported in The Journal of Urology (2017;197:414-419)..

“Deployment related GU trauma is a uniquely devastating injury which has

become increasingly common during the recent wars in Iraq and Afghanistan,” the researchers wrote. “GU injury related urinary, sexual and reproductive dysfunction is likely to be highly disruptive during the challenging course of recovery after complex polytrauma, especially for young SMs.” n

www.renalandurologynews.com JANUARY/ FEBRUARY 2017

Renal & Urology News 5

Serious Infections More Likely in CKD Patients PATIENTS WITH CHRONIC kidney disease (CKD) are at elevated risk for hospitalization and death due to infection, a new study suggests.

In a study of 9697 white and black individuals aged 53 to 75 years who participated in the ARIC (Atherosclerosis Risk in Communities) study, both lower

estimated glomerular filtration rate (eGFR) and higher urinary albumin-tocreatinine ratio (ACR) were associated with increased risks of infection-related hospitalization and infection-related death, Kunihiro Matsushita, MD, PhD, of Johns Hopkins Bloomberg School of Public Health in Baltimore, and col-

leagues reported online ahead of print in the American Journal of Kidney Diseases.

The findings have important clinical implications for infection prevention programs, such as those involving vaccination and prevention of healthcare-acquired infections, they noted.

“Currently, albuminuria is not taken

into account in this context. Thus, our results suggest that these programs could be expanded to include persons with less severely decreased kidney function, including those with elevated albuminuria,” Dr. Matsushita and colleagues wrote.

Of the 9697 individuals, 2701 were hospitalized with infection and 523 subsequently died within 30 days of discharge during 13.6 years of follow up. Compared with an eGFR of at least 90 mL/min/1.73 m2 , an eGFR of 15 to 29, 30 to 59, and 60–89 mL/min/1.73 m2 was associated with a 2.6, 1.5, and 1.07 times increased risk for infection-related hospitalization, respectively. An eGFR of 15 to 29 and 30 to 59 mL/min/1.73 m2 was associated with a 3.76 and 1.62 times increased risk of infection-related death, respectively.

Lower eGFR, higher ACR increase the risk of infection-related death, a study found.

Albuminuria of any degree also was associated with increased risks. The risks for infection-related hospitalization were 2.30, 1.56, and 1.34 times higher with ACRs above 300, 30 to 299, and 10 to 29 mg/g, respectively, compared with an ACR below 10 mg/g as a reference. Risks of death from infection were elevated 3.44, 1.57, and 1.39 times, respectively.

The investigators adjusted for a range of relevant demographic and clinical factors such as body mass index, smoking, diabetes, chronic obstructive pulmonary disease, cancer, and steroid use.

The findings were consistent among infection types, including pneumonia, kidney and urinary tract infections, bloodstream infections, and cellulitis.

Bloodstream infections showed the greatest hazard ratios among patients with an eGFR of 15 to 29 mL/min/1.73 m2 or an ACR above 300 mg/g. These values were associated with a 3-fold and 3.7-fold higher risk of bloodstream infection, respectively, compared with reference values.

Dr. Matsushita and colleagues cited uremic toxins and oxidative stress as potential mechanisms increasing infection risk among CKD patients.

With respect to study limitations, the researchers noted that the study involved CKD patients aged 53 to 75, so the results possibly may not apply to younger or older patients. n

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Contents

JANUARY/ FEBRUARY 2017 ■ VO L U M E 1 6 , I S S U E N U M B E R 1

Urology 15

ONLINE

this month at renalandurologynews.com

New Prostate Cancer Grading System Validated Two recently published studies demonstrated that a simpler 5-tier system can reliably predict survival outcomes.

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Benign Prostatic Hyperplasia Linked to Obesity Abdominal obesity and high serum leptin levels increase the risk of high-volume BPH, according to researchers.

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Chemotherapy Used for More UTUC Cases From 2004 to 2013, the proportion of patients who underwent nephroureterectomy and received adjuvant chemotherapy increased from 7.4% to 13.1%.

Clinical Quiz Take our latest quiz at renalandurologynews.com/ ClinicalQuiz

25

Standard 12-Core Prostate Biopsy Needed Despite Negative MRIs In a study, prostate MRI missed 13% of high-grade prostate tumors eventually revealed by standard transrectal ultrasoundguided 12-core biopsy.

Answer correctly and you will be entered to win a $50 American Express gift card.

Congratulations to our recent winners: December: Rohit Gupta, MD January: Chandra Mohan, MD

Nephrology 5

HIPAA Inadequate attention to business associate agreements can bring hefty fines.

Job Board Be sure to check our latest listings for professional openings across the United States.

9

Annual Dialysis Conference Long Beach, CA March 11–14 European Association of Urology London, UK March 24–28 National Kidney Foundation 2017 Spring Clinical Meetings Orlando, FL April 18–22 American Transplant Congress Chicago April 29–May 3 American Urological Association Annual Meeting Boston May 12–16 American Society of Clinical Oncology Annual Meeting Chicago June 2–6 European Renal Association-European Dialysis and Transplant Association 54th Congress Madrid June 3–6 Canadian Urological Association Annual Meeting Toronto June 24–27

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Obesity Ups ESRD Risk in Living Kidney Donors In a study, end-stage renal disease was 86% more likely to develop in individuals with a BMI of 30 kg/m2 or higher.

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ACP Publishes New Gout Guidelines The guidelines recommend using corticosteroids as first-line treatment when these agents are not contraindicated.

22

Calciphylaxis, Low Vitamin K Linked An enzyme that inhibits vascular calcification depends on the vitamin for conversion to its active form, a study found.

News Coverage Visit our website for daily coverage of the National Kidney Foundation’s 2017 Spring Clinical Meetings (April 18–22).

Serious Infections More Likely in CKD Patients Lower estimated glomerular filtration rate and higher albumin-to-creatinine ratio are associated with an increased risk of infection-related hospitalization and death, researchers report.

CALENDAR

There is no doubt that MRI-targeted biopsy is

better than a random TRUS biopsy, but it is imperfect.

See our story on page 25

Departments 8

From the Medical Director Nephrology potentially facing a manpower crisis

10

News in Brief Use of 5-ARIs may reduce blood loss during TURP

26

Practice Management How to recognize and avoid physician burnout

8 Renal & Urology News

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FROM THE MEDICAL DIRECTOR EDITORIAL ADVISORY BOARD

Nephrology in Crisis: Trainees in Short Supply

F

ewer medical graduates are applying for nephrology fellowship training, and I see this as a workforce crisis. Today, of more than 400 fellowship positions across the nation, some 40% remain unfilled when match results are announced in December of each year.

More than half of training programs have had at least one unfilled position. The workforce crisis in nephrology could have a domino effect on many aspects of patient care.

The United States has some 8000 adult and 500 pediatric nephrologists who are engaged in patient care or related positions. Each year, some 300 to 400 young physicians complete nephrology training and enter the market and a similar number of senior nephrologists retire.

The annual median nephrologist income ranges from $180,000 to $240,000, which is not very different from average internist income in this country but, believe it or not, it is 50% to 100% lower than the median income of a nephrologist in Canada, although it is higher than in Germany, United Kingdom, and Japan.

The rise of the hospitalist field and its relatively luxurious income and work hours has affected subspecialty training in internal medicine.

Many internal medicine residency graduates tend to conveniently embark on a hospitalist position without any interest in a subspecialty.

In nephrology, revenues appear to have declined by 5%–10% or more over the years. Many nephrology groups tend to hire nurse practitioners (NPs) and physician assistants (PAs) for such responsibilities as weekly dialysis clinic rounds. This has likely resulted in diminished demand for nephrologists.

With regard to a shortage of new doctors entering nephrology, I believe we have reached the nadir. In coming years, we should see increasing interest in nephrology. Ongoing growth in the dialysis population from better patient survival will improve nephrology job security and entice many hospitalists to return to subspecialty practice—including nephrology—after a few years of a training gap.

Efforts should be directed at making nephrology more appealing. This can be done by strengthening sub-fellowships in kidney transplantation, glomerulonephritis, interventional nephrology, and even certification in dialysis therapy and techniques (as in Japan). Adding combined fellowships in critical care, rheumatology, and endocrinology can result in more triple board-certified nephrologists. Combined medicine/ pediatric residency graduates should be encouraged to consider dual fellowships in nephrology for children and adults to expand the pool of quadruple board-certified nephrologists. Together, we can make nephrology even more popular than before.

Medical Director, Urology

Medical Director, Nephrology

Robert G. Uzzo, MD, FACS G. Willing “Wing” Pepper Chair in Cancer Research Professor and Chairman Department of Surgery Fox Chase Cancer Center Temple University School of Medicine Philadelphia

Kamyar Kalantar-Zadeh, MD, MPH, PhD Professor & Chief Division of Nephrology & Hypertension University of California, Irvine School of Medicine Orange, Calif.

Urologists

Nephrologists

Christopher S. Cooper, MD Director, Pediatric Urology Children’s Hospital of Iowa Iowa City

Anthony J. Bleyer, MD, MS Professor of Internal Medicine/Nephrology Wake Forest University School of Medicine Winston-Salem, N.C.

R. John Honey, MD Head, Division of Urology, Endourology/Kidney Stone Diseases St. Michael’s Hospital University of Toronto

David S. Goldfarb, MD Professor, Department of Medicine Clinical Chief New York University Langone Medical Center Chief of Nephrology, NY Harbor VA Medical Center

Stanton Honig, MD Department of Urology Yale University School of Medicine New Haven, CT J. Stephen Jones, MD, FACS President, Cleveland Clinic Regional Hospitals & Family Health Centers Professor & Horvitz/Miller Distinguished Chair in Urological Oncology Jaime Landman, MD Professor of Urology and Radiology Chairman, Department of Urology University of California Irvine

Edgar V. Lerma, MD, FACP, FASN, FAHA Clinical Associate Professor of Medicine Section of Nephrology Department of Medicine University of Illinois at Chicago College of Medicine, Chicago Allen Nissenson, MD Emeritus Professor of Medicine The David Geffen School of Medicine at UCLA, Chief Medical Officer, DaVita Inc.

James M. McKiernan, MD Assistant Professor of Urology Columbia University College of Physicians and Surgeons New York City

Rulan Parekh, MD, MS Associate Professor of Pediatrics and Medicine University of Toronto

Kenneth Pace, MD, MSc, FRCSC Assistant Professor Division of Urology St. Michael’s Hospital University of Toronto

Robert Provenzano, MD Chief, Section of Nephrology St. John Hospital and Medical Center Detroit

Ryan F. Paterson, MD, FRCSC Assistant Professor Division of Urologic Sciences University of British Columbia Vancouver, Canada

Robert S. Rigolosi, MD Director, Regional Hemodialysis Center Holy Name Hospital, Teaneck, N.J.

Renal & Urology News Staff Editor Web editor Production editor Group art director, Haymarket Medical Production manager Production director Circulation manager National accounts manager Group Publisher Editorial director

Kam Kalantar-Zadeh, MD, MPH, PhD Chief, Division of Nephrology & Hypertension, Professor of Medicine, Pediatrics and Public Health, University of California Irvine School of Medicine.

Csaba P. Kovesdy, MD Chief of Nephrology Memphis VA Medical Center Fred Hatch Professor of Medicine University of Tennessee Health Science Center, Memphis

Jody A. Charnow Natasha Persaud Kim Daigneau Jennifer Dvoretz Brian Wask Kathleen Millea Grinder Paul Silver William Canning Chad Holloway Kathleen Walsh Tulley

Senior VP, medical journals & digital products

Jim Burke, RPh

CEO, Haymarket Media Inc.

Lee Maniscalco

Renal & Urology News (ISSN 1550-9478) Volume 16, Number 1. Published bimonthly by Haymarket Media, Inc., 275 7th Avenue, 10th Floor, New York, NY 10001. Periodicals postage paid at New York, NY, and an additional mailing office. The subscription rates for one year are, in the U.S., $75.00; in Canada, $85.00; all other foreign countries, $110.00. Single issues, $20.00. www.renalandurologynews.com. Postmaster: Send address changes to Renal & Urology News, c/o DMD Data Inc., 2340 River Road, Des Plaines, IL 60018. Copyright: All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means (electronic, mechanical, photocopying, recording, or otherwise) without the prior written permission of Haymarket Media, Inc. Copyright © 2017.

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Renal & Urology News 9

Obesity Ups ESRD Risk in Living Kidney Donors OBESITY IS A risk factor for end-stage renal disease (ESRD) among living kidney donors (LKDs), new findings suggest.

In a study of 119,769 living kidney donors in the United States, Jayme E. Locke, MD, MPH, of the University of Alabama at Birmingham, and colleagues found that individuals who were obese at the time of donation had a significant 86% increased risk of ESRD compared with their non-obese counterparts in adjusted analyses, according to a paper published online ahead of print in Kidney International. The investigators adjusted for age, sex, ethnicity, blood pressure, baseline estimated glomerular filtration rate, and relationship to recipient.

In addition, each 1-unit increment in body mass index (BMI) above 27 kg/ m2 was associated with a significant 7% increased risk of ESRD.

Allopurinol May Benefit The Kidneys ALLOPURINOL treatment for hyperuricemia may improve kidney function, researchers reported.

In a study of patients at the VA New York Harbor Healthcare System, Aneesa Krishnamurthy, DO, of SUNY Downstate Medical Center in Brooklyn, New York, and colleagues compared 50 men with hyperuricemia (defined as a serum uric acid level greater than 7 mg/dL) newly started on allopurinol with a control group of 50 hyperuricemic men not treated with allopurinol and matched by age, race, and estimated glomerular filtration rate (eGFR). The average follow-up was 3.4 years.

On average, patients treated with a mean 221 mg/day dose of allopurinol achieved a significant 11.9 mL/min/1.73 m2 higher eGFR compared with controls, Dr. Krishnamurthy’s team reported in a paper published online ahead of print in the Journal of Clinical Rheumatology. The allopurinol group had a significant 0.10 mg/ dL lower final creatinine level than controls after adjusting for initial creatinine level and age. ■

Dr. Locke and colleagues commented that their study is the first national study to examine risk for ESRD among a cohort of obese living kidney donors.

The study population, identified using the Scientific Registry of Transplant Recipients, consisted of 20,588 obese donors (BMI of 30 kg/m 2 or above),

58,004 non-obese donors (BMI below 30 kg/m 2), and 41,177 donors whose BMI was not known. The maximum follow-up was 20 years. The estimated incidence of ESRD 20 years after donation was 93.9 per 10,000 for obese donors compared with 39.7 per 10,000 for non-obese donors, a significant

difference between the groups.

“These data have important implications for donor selection, predonation management of living donor candidates, and informed consent discussions with obese persons considering living donation,” the investigators concluded. ■

10 Renal & Urology News

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News in Brief

Please visit us at www.renalandurologynews.com for the latest news updates from the fields of urology and nephrology

Short Takes Post-Transplant Kidney Stones Characterized

Medicine in St. Louis, Missouri, reported

The incidence of kidney stones in pa-

Endourology. The most common types

tients following kidney transplantation

of benign pathology were oncocytoma

is estimated to be 1%, according to

(66 patients, 51.2%), angiomyolipoma

a new systematic review and meta-

(37 patients, 28.7%), and complex

analysis of 21 studies with 64,416

cysts (10 patients, 7.8%). In multivari-

kidney transplant recipients.

ate analysis, low body mass index, low

online ahead of print in the Journal of

The mean time to diagnosis of kidney

R.E.N.A.L. score, and low preoperative

stones after transplantation was 28

creatinine predicted benign histology,

months, Wisit Cheungpasitporn, MD, of

according to the investigators.

Mayo Clinic in Rochester, Minnesota, Journal of Transplantation (2016;6:790-

Black Gout Sufferers Have Worse HRQoL

797). Calcium-based stones were the

Blacks with gout have significantly

most common type of stone (67% of

worse health-related quality of life

cases), followed by struvite stones

(HRQoL) compared with whites, Jasvin-

(20%), and uric acid stones (13%).

der A. Singh, MD, of the University of

and colleagues reported in the World

Alabama at Birmingham, and col-

Benign Disease Found In 14% of PN Cases

leagues reported in Rheumatology (2017;56:103-112).

Approximately 1 in 7 patients who

In a 9-month prospective cohort

undergo partial nephrectomy (PN) for

study of 167 patients with gout (107

presumed renal cell carcinoma (RCC)

whites and 60 blacks), researchers

have benign histology, a study found.

found that blacks had significantly

In a series of 916 patients who

higher median baseline serum urate

underwent PN for renal masses from

levels (9.0 vs. 7.9 mg/dL). Compared

2007 to 2015, 129 (14.1%) had a

with whites, blacks had worse HRQoL

final diagnosis of benign disease, Tyler

scores on 3 SF-36 domains: the men-

Marques Bauman, BS, and colleagues

tal component summary and 2 of the 5

at Washington University School of

Gout Impact Scale components.

Bladder Cancer in 2017 The American Cancer Society has released its annual estimates of the number of new cancer cases and deaths that will occur in the United States. Here are the statistics for bladder cancer.

80,000 60,000

79,030

n Both sexes n Male

60,490

n Female

40,000 20,000 0

18,540

Estimated new cases

16,870

12,240

4,630

Estimated deaths

Source: Siegel RL, Miller KD, Jemal A. (2017), Cancer Statistics, 2017. CA: A Cancer Journal for Clinicians, 67:7–30.

Aortic Calcification in CKD Patients Linked to Nutrition N

utritional status is associated with abdominal aortic calcification (AAC) in patients with chronic kidney disease, researchers in Japan concluded in a paper published online ahead of print in the Circulation Journal.

In a study that enrolled 323 asymptomatic CKD and not on dialysis, Kazuhiro Harada, MD, and colleagues at Nagoya University Graduate School of Medicine in Nagoya, Japan, evaluated AAC using the aortic calcification index (ACI) determined on non-contrast computed tomography. They evaluated nutrition status using the geriatric nutritional risk index (GNRI) and divided patients into 3 groups according to GNRI tertile. The median aortic calcification index (ACI) decreased significantly with increasing GNRI tertile (15.5%, 13.6%, and 7.9%).

GNRI correlated significantly with ACI on multivariate analysis. In addition, low GNRI and high C-reactive protein (CRP) were significantly associated with severe AAC compared with high GNRI and low CRP.

Use of 5-ARIs May Reduce Blood Loss During TURP T

reatment with 5-alpha reductase inhibitors (5-ARIs) prior to transurethral resection of the prostate (TURP) may reduce operative blood loss and prostatic microvessel density (MVD), new findings suggest.

In a prospective, double-blind study, Ankur Bansal, MD, and Aditi Arora, MD, of Janak Surgicare Centre in Pitiala, Punjab, India, enrolled 450 men with benign prostatic hyperplasia who planned to undergo TURP and randomized them into 3 groups of 150 patients each. Group 1 received placebo, group 2 received finasteride 5 mg/day, and group 3 received dutasteride 0.5 mg/day for 4 weeks prior to TURP. The finasteride and dutasteride recipients had significantly less mean blood loss than the placebo group (168.7 and 162.4 mL vs. 265.3 mL, respectively) the researchers reported online ahead of print in the Journal of Endourology. They also had less prostatic and suburethral MVD. A higher proportion of men in the placebo group than in the finasteride and dutasteride groups required blood transfusion (9.3%, 2.7% and 2.0%, respectively).

Long-Term BoNT-A Therapy Compliance Low Among Men I

ntravesical injections of botulinum toxin A (BoNT-A) can be an effective treatment for men with overactive bladder (OAB) symptoms, but only a quarter of men comply with the treatment long term, according to a single-center retrospective study.

Mohammad S. Rahnama’I, MD, of Zuyderland Medical Centre in Heerlen, The Netherlands, and colleagues evaluated a heterogeneous group of 88 male patients with OAB treated with BoNT-A. The mean follow-up was 69 months.

Twenty-two patients (25%) continued BoNT-A treatment at last follow-up, the investigators reported in a paper published online ahead of print in Neurourology and Urodynamics. Of those who discontinued treatment, 35 had insufficient effect and 27 had tolerability issues. Four patients stopped treatment for reasons unrelated to BoNT-A.

www.renalandurologynews.com JANUARY/ FEBRUARY 2017

Prostate MRI benefit continued from page 1

14 patients with PI-RAD 4-5 lesions resulted in upgrading for 12 (85.7%). By comparison, of 106 patients who underwent confirmatory SB, 30 (28.3%) had their cancer upgraded.

The study revealed a significantly higher rate of disease upgrading associated with PIRADS 4-5 lesions when compared with PI-RADS 1-3 lesions (85.7% vs 14.3%) and TRUS-guided SB (85.7% vs 28.3%). Additionally,

In-office renal biopsies continued from page 1

­ ltrasound-guided RMB from April u 2010 to October 2015. The study population had a median age of 69.5 years.

The patients had a median renal mass size of 3.3 cm. Biopsy results showed that 72 patients (66.7%) had renal cell carcinoma, 14 (13%) had benign renal parenchyma, 11 (10.2%) had angiomyolipoma, 2 (1.9%) had lymphoma, and 3 (2.8%) had other disease. Biopsy findings initially were non-diagnostic for 14 (13%) of the 108 patients. The non-diagnostic rate fell to 8 (7.4%) after including patients who were rebiopsied.

Twenty-eight patients underwent observation, whereas 79 (73.2%) underwent surgery or ablative therapy. Final pathologic findings were concordant with biopsy results in 64 (98.4%) of 65 cases.

Of the 108 patients, 3 (2.9%) experienced a Clavien grade I complication.

“All complications were recognized in the 1-hour postprocedure observational

PI-RADS 4-5 lesions were significantly and independently associated with 16-fold increased odds of upgrading on repeat biopsy. Upgrading of disease was significantly associated with a nearly 5.8-fold increased odds of progression to definitive local therapy.

Although the study by Dr. Parsons and his colleagues suggests that MRI/fusion can improve the care of patients on AS, a separate study presented at the meeting showed that adding MRI/fusion to the standard 12-core biopsy significantly increased the number of PCa patients

deemed ineligible for AS based on currently available selection criteria. In a study of 100 PCa patients eligible for AS based on a 12-core standard biopsy and meeting at least 1 of 7 sets of AS criteria, a team led by Bruno Nahar, MD, and Sanoj Punnen, MD, of the University of Miami Miller School of Medicine, found that the proportion of men who became ineligible for AS after adding MRI/ fusion findings ranged from 10.3% to 40.7%. They concluded that AS criteria need to be updated to reflect the increased use of MRI/fusion biopsy. n

Renal & Urology News 11

Aggressive PCa Diagnoses Are Declining THE DIAGNOSIS OF high Gleason score prostate cancer (PCa) in the United States is declining among all races, data presented at the Society of Urologic Oncology 17th annual meeting in San Antonio, Texas, suggest.

Using the Surveillance, Epidemiology and End Results (SEER) database,

period and no patients were admitted to the hospital or required additional intervention related to their biopsy.”

Fellowship-trained urologists with experience in percutaneous renal access and advanced laparoscopic or robotic procedures performed the biopsies. All patients had a suspicious mass revealed

Final pathology was concordant with biopsy results in 64 (98.4%) of 65 cases. on ultrasound, computed tomography, or magnetic resonance imaging. Patients were asked to hold all anticoagulant medications for 1 week prior to biopsy.

All patients received an oral narcotic (10 mg hydrocodone) and sedative (diazepam) 1 hour pre-procedure. Clinicians continuously monitored patients for response to verbal commands.

The investigators noted that numerous studies have demonstrated that same-day hospital-based outpatient renal biopsy is safe and is most commonly followed by a 6–8 hour observation period. “At our institution, after reviewing the literature regarding techniques of RMB, we felt that office biopsies for renal masses by urologists were a natural progression, technically feasible, and safe for select patients,” they wrote.

Dr. Dave’s team cited a recent study published in the Journal of Endourology (2016;30 Suppl 1:S28-S33) showing the cost savings associated with officebased versus hospital-based radiology setting. Including facility, pathology, and professional fees, the cost was $4598 for hospital-based biopsy compared with $2129 for office-based biopsy, a cost savings of $2469, according to the study.

“We plan to study cost comparisons at our private practice and local institution and anticipate similar substantial cost savings,” the authors stated. n

a team at Saint Louis University in Missouri led by Sameer Siddiqui, MD, examined the effect of the 2008 and 2012 guidelines issued by the U.S. Preventive Services Task Force (USPSTF) stating there was insufficient evidence to support PCa screening.

The study included 337,504 men diagnosed with PCa from 2008 to 2013.

The investigators categorized Gleason score (GS) as low (GS 2–6), intermediate (GS 7), and high (GS 8–10).

From 2008 to 2013, the incidence of GS 8–10 disease (per 100,000 men) decreased from 21.7 to 19.4 among white men, 39.5 to 33.7 among black men, 22.8 to 19.0 for Hispanic men, and 17.7 to 13.8 among Asian/Pacific islanders. The trend suggests decreased diagnosis of aggressive PCa following issuance of the USPSTF guidelines, according to the investigators.

Over the 6-year study period, black men had the highest cumula-

Testosterone range continued from page 1

of Brigham and Women’s Hospital in Boston, stated in a press release.

Dr. Shalender and his team examined total testosterone values from 9054 community-dwelling men within 4 ­ cohorts in the United States and Europe:

The reference range is based on healthy, non-obese men aged 19 to 39 years. the Framingham Heart Study, European Male Aging Study, Osteoporotic Frac­ tures in Men Study, and the Male Sibling Study of Osteoporosis. Serum samples from 100 men from each cohort were

sent to a CDC laboratory for analysis by a higher-order liquid chromatography tandem mass spectrometry method.

Normalizing equations based on the CDC’s benchmarks were applied to all locally measured testosterone values across the 4 cohorts. The investigators also determined age-specific reference ranges for the 4 cohorts and overall.

The investigators found that differences in testosterone ranges among cohorts largely ensued from assay variation. “Without harmonized reference ranges and standardized assays, tests can lead to misdiagnoses and unfortunately this happens every day around the world,” co-author Hubert Vesper, PhD, of the CDC, stated in the release. “Now we have a reference range for testosterone, and it’s important that we take this into consideration in the tests that clinicians and patients depend on for accurate diagnoses.”

Among the strengths of the study, testosterone tests were performed in the morning, minimizing the influence of testosterone fluctuations throughout the day. The cohorts largely included white men, however, so future studies involving multiple ethnicities and different world regions are needed to confirm the accuracy of the testosterone ranges for these populations. The investigators recommend further evaluation of the reference range in future trials.

The study leaves some unresolved issues, the researchers noted. Among them is whether the reference sample should include only the healthy nonobese men or if it should include the entire population of men aged 19 to 39 years. Obesity and comorbid conditions affect levels of circulating testosterone, so inclusion of obese men and those with comorbidities could distort the reference ranges, the investigators explained. n

tive incidence of low Gleason score cancer (76.2 per 100,000), followed by white men (52.9 per 100,000), the researchers reported in a poster presentation. The cumulative incidence of high Gleason score cancer was 37.5 and 21.0 per 100,000 for black and white men, respectively.

The annual percentage change (APC) declined significantly among all races for low GS cancer (−8.9% for whites, −8.6% for blacks, -8.6% for Hispanics, and −8.7% for Asian/ Pacific Islanders) and intermediate GS cancer (−8.6%, −6.5%, −9.2%, and −9.9% respectively). The APC for high GS cancer declined significantly for blacks and Hispanics (−3.5% and −4.4%, respectively), but did not change significantly among whites and Asian/Pacific islanders. n

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Radium-223 Reduces Skeletal-Related Admissions RADIUM-223 REDUCES the number of hospitalizations for symptomatic skeletal events among patients with castration-resistant prostate cancer (CRPC) who have bone but no visceral metastases, according to a new study.

In a post-hoc analysis of the randomized, phase 3 ALSYMPCA (Alpharadin

in Symptomatic Prostate Cancer Patients) trial involving 901 patients, Christopher Parker, MD, and colleagues, compared the effect of radium-223 and placebo on hospitalizations before and after a first symptomatic skeletal event. They defined an event as the need for external beam radiation therapy for bone pain,

symptomatic pathologic vertebral or non-vertebral bone fractures, spinal cord compression, or tumor-related orthopedic surgical intervention.

The investigators previously reported that radium-223 offered a survival advantage and was associated with 34% and 35% lower odds of a first and second

skeletal event, respectively. Now they report that fewer patients who received radium-223 as 6 monthly injections had a hospitalization within a year of treatment initiation (37.0% vs 45.5%). The number of hospitalizations per patient was similar for treated and untreated patients, however (0.69 vs 0.79), possibly due to the 1-month difference in follow-up times.

Radium-223 recipients spent fewer days on average in the hospital (4.44 vs 6.68). This trend was similar for radium-223 recipients before the first symptomatic skeletal event (2.35 vs 3.36 days) and after it (7.74 vs 9.19 days), the investigators reported online ahead of print in the European Journal of Cancer.

All told, the data suggest that radium-223 not only provided a survival benefit, but also delayed skeletal events and reduced hospital stays, potentially improving health-related quality-oflife in patients with CRPC accompanied by symptomatic bone metastases, Dr. Parker and colleagues concluded. n

Statins May Slow CKD Progression STATINS MAY HAVE renoprotective effects in patients with early-stage chronic kidney disease (CKD).

In a retrospective observational study involving 14,497 CKD patients, Eun Yeong Cho, MD, of Gachon University of Gil Medical Center, Incheon, Republic of Korea, and colleagues compared 1955 statin users and 12,542 non-users. They also propensity score-matched 858 statin users with 858 non-users.

Statins had a significant beneficial effect on the doubling of serum creatinine and all-cause mortality, but only among patients with an estimated glomerular filtration rate (eGFR) of 30 mL/min/1.73 m2 or higher, the researchers reported in PLoS One 2017;12(1):e0170017.

In these patients, statin use was associated with a 25.6% and 23.3% decreased likelihood of a doubling of serum creatinine in the unmatched and matched patients, respectively, RAYA16AGRX4627_Brief_PI_V2_1_r3_FSU.indd 1

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and a 34.5% and 46.3% decreased likelihood of all-cause mortality.n

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Healthy Diet May Prevent Renal Stones DIET RICH in fruit and vegetables and low in meat consumption may prevent development of kidney stones, according to a new study.

Pietro Manuel Ferraro, MD, of Catholic University of the Sacred Heart, in Rome, Italy, and colleagues identified 6308 kidney stone cases during more than 3 million person-years of follow up in their analysis of 3 major cohorts. Consuming more non-dairy, animal protein was associated with 15% and 20% greater odds of kidney stones, respectively, in the all-male Health Professionals Follow-Up Study and the all-female Nurses’ Health Study I, the researchers reported in a paper published online ahead of print in the Clinical Journal of the American Society of Nephrology. A higher animal protein-to-potassium ratio, which approximates dietary acid load, was associated with higher risks of kidney stones, independent of its constituents.

Vegetable protein intake did not appear to influence kidney stone risk, whereas dairy protein might have a mixed effect, according to the investigators.

Greater potassium intake was associated with 33% to 56% lower risks of kidney stones in all 3 cohorts. Higher dietary potassium intake was associated with higher urine citrate, pH, and volume—all conditions unfavorable to stone formation.

These results were not modified by age, body mass index, diabetes, hypertension, thiazide medications, or calcium supplements, Dr. Ferraro and colleagues reported. The researchers also accounted for dietary intake of fluids, alcohol, calcium, sodium, fructose, oxalate, and phytate.

“Our data suggest that diets rich in fruits and vegetables as well as diets with a relative abundance of fruits and vegetables compared with animal protein may represent effective interventions to prevent kidney stone formation,” Dr. Ferraro’s group concluded.

A 2009 study of the same cohorts showed that an eating plan similar to that prescribed by the Dietary Approaches to Stop Hypertension (DASH) study, which included high amounts of produce and low intake of red and processed meats, was associated with decreased stone risk (J Am Soc Nephrol 2009;20:2253-2259). n

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Proposed Prostate Cancer Grading System Validated Simpler 5-tier system predicts cancer-specific and overall mortality

BY JODY A. CHARNOW TWO RECENTLY published studies demonstrate that a proposed simpler 5-tier grading system for prostate cancer (PCa) can reliably predict survival outcomes.

In the new system, PCa patients are placed into 1 of 5 prognostic grade groups based on Gleason score and other criteria, with grade group 1 indicating the most favorable prognosis and grade group 5 the least favorable.

In a large population-based study of PCa patients, Grace L. Lu-Yao, PhD, of Thomas Jefferson University in Philadelphia, and colleagues found that the risk of PCa-specific mortality (PCSM) approximately doubled with each grade group increase. The system predicted PCSM regardless of treatment received or clinical stage at diagnosis, the researchers reported. In a separate study, Misop Han, MD, of Johns Hopkins Medical Institutions in Baltimore, Maryland, demonstrated that the grading system can predict all-cause mortality and PCSM following radical prostatectomy (RP) among on men with Gleason score 8–10 disease based on both biopsy and RP Gleason scores (GS).

The results of both studies were published online ahead of print in European Urology.

In the new grading system, GS 6 cancers are placed into grade group 1 and GS 7 cancers are subdivided into 3 + 4 and 4 + 3 disease. GS 3 + 4 cancers are associated with significantly better

prognoses than GS 4 + 3 cancers and are placed into grade group 2 and 3, respectively. The new system also subdivides GS 8–10 cancers into GS 8 and GS 9–10 cancers.

Using the Surveillance, Epidemiology and End Results (SEER) database, Dr. Lu-Yao’s team identified 331,320 PCa patients who had primary and secondary Gleason patterns diagnosed during January 2006 to December 2012. The cumulative incidence of 7-

The World Health Organization in 2016 formally accepted the new grading system. year PCSM after RP was 0.43%, 0.48%, 0.80%, 2.13%, and 4.57% for grade group 1 to 5, respectively. Among men who underwent RP, those in Grade Groups 2 to 5 had a 1.13, 1.87, 5.03, and 10.92 times increased risk of PCSM compared those in grade group 1.

The primary strength of the study was the large population-based sample size with racially diverse populations that reflect real world experiences, Dr Lu-Yao and colleagues stated. Major limitations include short follow up and the lack of PSA data at diagnosis. In addition, the investigators were not able to determine whether patients received active surveillance, watching waiting, androgen-deprivation therapy, or adjuvant therapy.

New Grading System At a Glance • Patients are placed into 1 of 5 grade groups, with grade group 1 indicating the most favorable prognosis and grade group 5 the least favorable • Classification is based on Gleason score and other criteria • Patients with Gleason score 6 cancers are placed into grade 1 • Gleason score 7 cancers are subdivided into 3 + 4 and 4 + 3 disease and placed into grade group 2 and 3, respectively.

• Gleason score 8 and 9–10 disease, which have commonly been lumped together, are treated separately and placed into grade group 4 and 5, respectively.

Source: Pierorazio PM, Walsh PC, Partin AW, Epstein JI. Prognostic Gleason grade grouping: data from the modified Gleason score system. BJU Int 2013;111:753-760.

In the other study, Dr. Han and colleagues evaluated the significance of distinguishing GS 8 and GS 9–10 in terms of long-term survival outcomes for both the preoperative setting using biopsy GS and the postoperative setting with RP GS. The study included 721 men with biopsy GS 8–10 and 1047 with RP GS 8–10. Compared with men who had GS 8 disease, men with GS 9–10 disease had later RP year and higher pathologic stage, Dr. Han’s team reported. Among men with biopsy GS 8–10, 115 died (82 due to PCa) with a median follow-up of 3 years. Of men with RP GS 8–10, 221 died (151 due to PCa) with median follow-up of 4 years.

For both biopsy and RP GS, men with GS 9–10 disease had a significant 2-fold higher risk of PCa-related death than those with GS 8 disease in multivariable analysis, Dr. Han’s group reported. Men with biopsy and RP GS 9–10 disease had a significant 1.9 times and 1.6 times increased risk of all-cause mortality, respectively, compared with men who had biopsy and RP GS 8 disease.

In a discussion of study limitations, the investigators said they relied on retrospective data collection at a single institution. Consequently, the findings are sensitivity to selection bias and might not be generalizable. The researchers also noted that information about adjuvant and salvage therapy was not included in multivariable analyses.

In an editorial accompanying the report by Dr. Lu-Yao and colleagues, Jonathan I. Epstein, MD, of The Johns Hopkins Medical Institutions in Baltimore, who along with colleagues proposed the new grading system in 2013, noted that the World Health Organization formally accepted the new system in 2016. In addition, Dr. Epstein wrote, the grading system was accepted by the College of American Pathologists and will be included in the 8th edition of American Joint Committee on Cancer staging manual, which effectively means the grading system will be included in virtually all pathology reports within the United States once adherence to the guidelines is mandated at the beginning of 2017. n

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Benign Prostatic Hyperplasia Linked to Obesity INCREASING ABDOMINAL obesity and serum leptin levels are associated with increased prostate volume, according to a new study.

Jae Hung Jung, MD, of Yonsei University Wonju College of Medicine in Wonju, Korea, and colleagues studied 571 men who underwent urologic examination, including serum PSA measurement and transrectal ultrasonography, and completed the International Prostate Symptom Score questionnaire. Men with a mean prostate volume of less than 30 mL, at least 30 but less than 40 mL, and 40 mL or more (high-volume benign prostatic hyperplasia, BPH) had a mean waist circumference of 86.62, 87.45, and 89.80 cm, respectively; mean body mass index (BMI) of 24.38, 24.62, and 25.67 kg/m2; mean leptin levels of 2.66, 2.61, and 3.58 µg/L; 18.28, 16.62, and 18.22 kg of body fat; and 2.49, 2.52, and 2.88 kg of visceral fat, respectively.

Abdominal obesity, high serum leptin levels increase risk of high-volume BPH. In adjusted analyses, increases in these variables were significantly associated with increasing odds of highvolume BPH. The highest quartile of serum leptin and adiponectin levels were significantly associated with 3.5-fold increased odds and 68.5% decreased odds of high-volume BPH, respectively, compared with the lowest quartiles, the researchers reported in the International Neurourology Journal (2016;20:321-328).

For the study, the investigators obtained baseline data from the Korean Genome and Epidemiology Study on Atherosclerosis Risk of Rural Areas in the Korean General Population.

The likely biologic mechanism by which obesity may promote BPH seems to be insulin resistance, the investigators explained. Chronic elevation of insulin is associated with increased availability of insulin-like growth factor-1 (IGF-1). “Insulin has been suggested to stimulate tumorigenesis by inducing IGF-1 synthesis and activating insulin and IGF-1 receptors, which often are overexpressed in cancer cells,” Dr. Jung and colleagues wrote. “Moreover, insulin and IGF-1 interactions with ­ athways may downstream ­signaling p

impact the growth of hormonally driven tumors, such as prostate cancer; they may also stimulate BPH.” The investigators also stated that insulin may influence transcription of genes involved in sex hormone metabolism. These genes alter the androgen to estrogen ratio and circulating level

of sex hormone-binding globulin, the researchers explained. “Such alterations in the testosterone to estrogen ratio in prostate tissue may contribute to BPH development.”

Chronic inflammation and oxidative stress also may explain the link between obesity and BPH, the investi-

gators noted. “Increased BMI is associated with adipocyte hypertrophy and death, which cause excessive cytokine production and leukocyte recruitment,” Dr. Jung’s team explained.

“These inflammatory changes in the tissue may provide a pro-neoplastic microenvironment.”

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Although the study has a number of limitations, “we believe that obesity management and prevention may be a novel target for the prevention of BPH,” the researchers stated.

The new findings build on previous studies linking obesity with BPH. In a study examining risk factors for incident symptomatic BPH among 5667 participants in the placebo arm of the Prostate Cancer Prevention

Trial, investigators found that each 0.05 increase in waist-to-hip ratio was associated with a 10% increased risk for total and severe BPH, according to findings published in The Journal of Urology (2007;177:1395-1400).

In a paper published in the Journal of Clinical Endocrinology and Metabolism (2006;91:2562-2568), researchers reported that increasing BMI was associated with increased age-adjusted

odds of BPH. Compared with normalweight men (BMI less than 25 kg/m2), overweight men (BMI 25–29.9 kg/m2), obese men (BMI 30-34 kg/m2), and severely obese men (BMI 35 kg/m2 or higher) had 41%, 27%, and 3.5-fold increased odds of BPH. In addition, a meta-analysis published in European Urology (2008;53:1228-1235) showed that moderate to vigorous physical activity was associated with a decreased

Renal & Urology News 17

risk for BPH or lower urinary tract systems (LUTS). The meta-analysis included 11 studies that included a total of 43,083 men. Of these studies, 8 were eligible for pooled analyses.

Compared with sedentary individuals, men who engaged with light, moderate, and heavy physical activity had 30%, 26%, and 26% decreased odds of BPH or LUTS, respectively, the investigators reported. n

B:10.25”

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ESRD Risk Factors in IgAN Patients Identified CERTAIN CLINICAL and pathologic factors predict which patients with IgA nephropathy (IgAN) are at higher risk for progressing to end-stage renal disease (ESRD) within 10 years, according to Chinese researchers.

Danhua Shu, MD, and colleagues at First Affiliated Hospital of Wenzhou

Medical University in China compared 50 IgAN patients who had a renal survival time of less than 10 years (ESRD cases) with 100 IgAN patients who had a renal survival time of more than 10 years (controls).

The patients were B:7.25” diagnosed with primary IgAN from T:7” 1997 to 2012.

S:7”

At the time of biopsy, cases had significantly higher frequencies of Oxford classification M1 (50% or more mesangial hypercellularity), S1 (presence of segmental glomerulosclerosis) and T1 and T2 disease (greater than 25% and 50% tubular atrophy/ interstitial fibrosis, respectively) com-

pared with controls, the investigators reported in a paper published online ahead of print in BMC Nephrology.

In addition, cases had a lower mean estimated glomerular filtration rate (eGFR, 57.3 vs. 95.7 mL/min/1.73 m2), higher mean levels of serum creatinine (1.4 vs. 0.9 mg/dL), uric acid (UA, 8.0 vs 5.7 mg/dL), total cholesterol (207.7 vs. 184.6 mg/dL), and 24-hour urine protein (2.9 vs. 0.8 g/day). Cases also had lower mean hemoglobin (Hb) levels (12.2 vs. 12.9 g/dL) and a greater proportion of patients with hypertension (62.0% vs. 47.0%).

In multivariate analysis, only M1 (and low eGFR at biopsy and elevated time-averaged UA level and low timeaveraged Hb level during follow-up emerged as independent risk factors for ESRD, according to the researchers.

Predictors of renal failure in 10 years include M1 disease, low eGFR at biopsy.

B:10.25”

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T:10”

“In summary, patients with pathological assessment of M1, T1 or T2, an impaired renal function, abnormal blood biochemical parameters and hypertension at biopsy should be paid more attention, and therapies aiming to keep UA and Hb levels under control and reduce urinary protein during the follow-up are highly recommended,” Dr. Shu and colleagues wrote.

In the current study, T score did not have a marked role in multivariate analysis, but it correlated with most variables in the study, Dr. Shu’s team stated.

Combined with other study findings, they hypothesize that M1 score may be a risk factor for ESRD progression in the Chinese population.

Hyperuricemia can cause both mechanical and inflammatory damage to the kidneys. Although urinary protein was not identified as a risk factor for renal failure in multivariable analysis, it has long been recognized as important to renal outcomes, according to the investigators.

The researchers noted that the retrospective design of the study was a limitation. They also acknowledged a selection bias. The patients enrolled in the study were those who followed up in their hospital long-term, so they might not be fully representative of the general population. n

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Robotic Radical Nephrectomy for RCC On the Rise USE OF ROBOTIC radical nephectomy (RRN) to treat stage 1 renal cell carcinoma (RCC) is on the rise in the United States, investigators reported at the Society of Urologic Oncology 17th annual meeting in San Antonio, Texas.

Using the National Cancer Database, Matthew Bream, MD, and colleagues at Case Western Reserve University in Cleveland identified 15,756 patients undergoing minimally invasive radical nephrectomy (RN)—either robotic radical nephrectomy (RRN) or laparoscopic RN (LRN)—for localized T1 RCC from 2010 to 2013. During the 4-year study period, 25% of these patients underwent RRN, with the proportion of

SHPT Raises Risk of Renal Graft Loss SECONDARY hyperparathyroidism and increased fractional excretion of phosphate predict graft loss in kidney transplant (KT) recipients, data show.

Following kidney transplantation, fibroblast growth factor 23 normally returns to baseline within 1 year, but hyperparathyroidism persists in most KT patients, Sinee Disthabanchong, MD, and colleagues at Mahidol University in Bangkok, Thailand noted. Consequently, serum phosphate remains relatively low in association with increased serum calcium and urinary phosphate excretion when compared with patients who have chronic kidney disease.

Dr. Disthabanchong’s team prospectively followed 273 kidney transplant patients for an average of 71.4 months. Death-censored graft loss occurred in 41 patients (15%).

In adjusted analyses, only increased parathyroid hormone (PTH) and fractional excretion of phosphate (FePi) remained associated with graft failure, the investigators reported online ahead of print in Clinical and Experimental Nephrology. Adjusted survival curves showed that PTH levels above 90 pg/mL and FePi above 20% were associated with a significantly higher risk of graft loss compared with lower values. ■

cases treated with RRN increasing significantly over time from 18% in 2010 to 31% in 2013, Dr. Bream’s group stated in a poster presentation.

On multivariable analysis, patients treated at academic hospitals had significant 29% higher odds of undergoing RRN compared with those treated at

community hospitals, the investigators reported. Patients with tumor size of 4 cm or less and those who underwent retroperitoneal lymph node dissection had significant 25% and 86% higher odds, respectively, of undergoing RRN. The RRN and LRN groups were similar with respect to perioperative

quality indicators and conversion to open surgery.

“With similar perioperative quality outcomes and increased attention to health care costs, RRN may face greater scrutiny as a surgical option for localized RCC,” Dr. Bream and his colleagues concluded. ■

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ACP Publishes New Gout Guidelines

Corticosteroids should be considered as first-line therapy when these drugs are not contraindicated

BY JODY A. CHARNOW NEW EVIDENCE-BASED guidelines for managing gout released by the American College of Physicians (ACP) recommend that clinicians choose corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), or colchicine to treat patients with acute gout and use low-dose rather than high-dose colchicine when prescribing this drug to treat acute gout.

The guidelines, published in January in the Annals of Internal Medicine, (2017;166:58-68), also recommend that clinicians discuss benefits, harms, costs, and individual preferences with patients before initiating urate-lowering therapy (ULT), including concomitant prophylaxis, in patients with recurrent gout attacks. The guidelines recommend against initiating ULT in most patients after a first gout attack and in patients with infrequent attacks.

“High-quality evidence showed that corticosteroids, NSAIDs, and colchicines are effective treatments to reduce pain in patients with acute gout,” Amir Qaseem, MD, PhD, MHA, of ACP, and coauthors wrote on behalf of the ACP’s Clinical Guidelines Committee.

“Gout symptoms are mostly caused by inflammatory reaction to the deposition of urate crystals, which results from an increase in serum urate level above it saturation point in the blood.”

Corticosteroids first Corticosteroids should be considered as first-line therapy in patients without contraindications because these drugs generally are a safe and a low-cost treatment option, the guidelines state.

With regard to the use of low-dose colchicine for acute gout, the guidelines state that moderate-quality evidence suggests that lower doses of the medication (1.2 mg followed by 0.6 mg 1 hour later) are as effective as higher dosing (1.2 mg followed by 0.6 mg/hour for 6 hours). Higher dosing should not be used—especially in patients with chronic kidney disease (CKD)—due to toxicity.

Upcoming News

Evidence was insufficient for goutspecific dietary advice or therapies to improve symptomatic outcomes, according to the guidelines.

With respect to monitoring serum uric acid levels in gout sufferers, the guideline committee said evidence “was insufficient to conclude whether the benefits of escalating urate-lowering therapy to reach a serum urate target (‘treat-to-target’) outweigh the harms associated with repeated monitoring and medication escalation.”

Although studies have demonstrated an association between lower urate levels and fewer gout flares, the studies did not establish that ULT rather than other patient characteristics caused the decrease in flares, Dr. Qaseem and coauthors wrote.

“Further, even if urate-lowering therapy does reduce gout flares, these studies do not help us understand the tradeoff between the magnitude of benefit and the harms and costs incurred by treatment and monitoring,” they

The guidelines state evidence for treating to target serum urate levels is insufficient. stated. “Thus, we remain uncertain about the value of a treat-to-target strategy compared with a strategy of basing treatment intensity on minimizing of symptoms.”

In this regard, the ACP guidelines differ from recommendations in American College of Rheumatology (ACR) guidelines (Arthritis Care Res (Hoboken);20 12;64:1431-1446), which recommend that the goal of ULT is to achieve a serum uric acid target, at a minimum, of less than 6 mg/dL in all gout case scenarios. ACR also recommends that “the target serum urate should be lowered sufficiently to durably improve signs and symptoms of gout, including palpable and visible tophi detected by physical examination, and that this may

Key Guideline Statements The new American College of Physicians gout management guidelines recommend: • Choosing corticosteroids, nonsteroidal anti-inflammatory drugs, or colchicine to treat acute gout • Using low-dose rather than high-dose colchicine when prescribing this drug for acute gout • Discussing with patients the benefits, harms, costs, and individual preferences before starting urate-lowering therapy (ULT), including for concomitant prophylaxis, for recurrent gout attacks • Not initiating long-term ULT in most patients following a first gout attack or in those with infrequent attacks.

Source: Qaseem A et al. Management of acute and recurrent gout: A clinical practice guideline from the American College of Physicians. Ann Int Med 2017;166:58-68.

involve therapeutic serum urate-lowering to below 5 mg/dL.”

Potential shortcomings In an accompanying editorial, Tuhina Neogi, MD, PhD, of Boston University School of Medicine and Ted R. Mikuls, MD, MSPH, of the University of Nebraska Medical Center in Omaha, pointed out potential shortcomings of the treat-to-avoid-symptoms approach suggested in the ACP guidelines.

“With this strategy, providers might consider suppressive anti-inflammatory therapy or treatment of each flare as a sufficient strategy without addressing underlying hyperuricemia,” Drs. Neogi and Mikuls wrote. “When patients never receive ULT or receive inappropriately low doses, ongoing urate deposition occurs, leading to progression of tophaceous deposits, further joint damage, and functional limitations.”

Commenting on the ACP guidelines, gout specialist Anthony J. Bleyer, MD, professor of nephrology at Wake Forest School of Medicine in WinstonSalem, North Carolina, told Renal &Urology News: “The current ACP guidelines fail to address gout prevention in patients with chronic kidney disease. This is unfortunate, as CKD is the most common cause of gout, and

the prevalence of gout increases markedly with worsening stages of CKD. Specifically, prescribing allopurinol in the setting of CKD is a major concern.”

The 2012 ACR guidelines, Dr. Bleyer said, better address this area, stating allopurinol at doses even greater than 300 mg/day can be used “in renal impairment” provided there is adequate patient education of possible adverse risks and that there is regular monitoring for drug sensitivity. Unfortunately, he said, this recommendation is based on suboptimal evidence, and it is important that physicians read this recommendation in its entirety when deciding on allopurinol dosing for their patients. Febuxostat is much more expensive, but it has been well studied and shown to be well tolerated with eGFR values as low as 15 ml/min/1.73m2, according to Dr. Bleyer, who is a member of the Renal & Urology News editorial advisory board.

“It is clear that both sets of guidelines prefer allopurinol—due to cost—even though febuxostat is better studied and does not have as severe adverse effects as allopurinol,” Dr. Bleyer said. “In the end, issues of safety versus cost must be discussed with the patient when prescribing allopurinol versus febuxostat in CKD.” ■

Renal & Urology News will be covering the European Association of Urology 2017 Congress in London, March 24–28. Go to www.renalandurologynews.com for daily reports on noteworthy studies.

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Calciphylaxis, Low Vitamin K Linked An enzyme that inhibits vascular calcification depends on the vitamin for conversion to its active form

BY JODY A. CHARNOW VITAMIN K DEFICIENCY may have a role in the development of calciphylaxis, a rare but frequently fatal condition in dialysis patients, according to newly published study findings.

The vitamin is an essential cofactor on which gamma-glutamylcarboxylase depends to convert inactive uncarboxylated matrix gla protein (ucMGP) to its active carboxylated form (cMGP), a potent inhibitor of vascular calcification. In a study comparing 20 hemodialysis (HD) patients with calciphylaxis (cases) and a group of 20 HD patients without calciphylaxis matched by age, sex, race, and warfarin use (controls), a team led by Sagar U. Nigwekar, MD, of Massachusetts General Hospital in Boston, found that the fraction of total MGP that was carboxylated was significantly lower in cases than controls (0.58 vs. 0.69). Each 0.1 unit reduction in relative cMGP concentration was associated with a greater than 2-fold increased

risk of calciphylaxis, Dr Nigwekar and his colleagues reported online ahead of print in Journal of the American Society of Nephrology. The prevalence of vitamin K deficiency was higher among cases compared with controls (90% vs.

50%). In multivariable analysis, vitamin K deficiency was associated with lower relative cMGP concentration.

“Our novel findings motivate examination of vitamin K supplementation to optimize MGP carboxylation as a potential preventive and/or therapeutic approach for calciphylaxis,” Dr. Nigwekar and his colleagues concluded.

The investigators acknowledged that, because of their study’s small sample size, confirmation of their findings in larger case-control studies is needed.

In an interview with Renal & Urology News, Dr. Nigwekar observed: “Cal­ci­ phy­laxis is a devastating disease with limited understanding of its pathogenesis and no effective treatment. Our present study links vitamin K deficiency

Chemotherapy Used for More UTUC Cases

Among patients who did not receive chemotherapy, male patients were more likely than female patients not to receive it based on risk factors (49.0% vs 39.2%) and women were more likely than men to refuse chemotherapy (60.8% vs 51.0%).

NAC and AC use varied by geographic location. In the Northeast, Southeast, West, and Midwest, clinicians used NAC in 1.7%, 1.0%, 2.6%, and 1.4% of cases, respectively, and AC in 12.4%, 10.5%, 10.6%, and 11.3% of cases, respectively. NAC and AC use also varied by type of hospital. For example, NAC use was highest at academic centers (2.7% of cases) and lowest in community hospitals (0.5%).

Patients who did not receive chemotherapy lived a median 11 miles from their treatment center compared with 19.5 miles for patients received NAC and 40.4 miles for those receiving both NAC and AC, according to the researchers.

“We are encouraged that the trend in NAC is increasing, but there is a lot of room for improvement, not only within the community, but at academic centers as well,” Dr. McCormick told Renal & Urology News. “The results, especially in regard to patient refusal and distance traveled for treatment, have created new questions which we are excited to investigate further.” n

USE OF neoadjuvant and adjuvant chemotherapy for upper tract urothelial carcinoma (UTUC) is increasing in the United States, but it remains uncommon and inconsistent among different patient populations and treatment centers, researchers concluded in a presentation at the Society of Urologic Oncology 17th annual meeting in San Antonio, Texas.

Using information from the National Cancer Database, Benjamin McCormick, MD, and colleagues at the University of North Carolina in Chapel Hill found that the proportion of UTUC patients who underwent nephroureterectomy and received neoadjuvant chemotherapy (NAC) rose from 0.6% during 2004– 2007 to 1.5% during 2008–2010 and 2.7% during 2011–2013. The proportion who received adjuvant chemotherapy (AC) increased from 7.4% to 12.6% and 13.1% during those periods, respectively.

The study included 2,018 patients who underwent nephroureterectomy during 2004–2007, 2,118 during 2008– 2010, and 2,320 during 2011–2013.

Sagar U. Nigwekar, MD

with the development of calciphylaxis.

This study also identifies matrix gla protein, a vitamin K dependent protein, as a target for future strategies to prevent and/or treat calciphylaxis. We and others have previously reported that warfarin, a vitamin K antagonist, is a risk factor for ­calciphylaxis. The

­ resent study provides biological explap nation for that association as we demonstrate impaired activity of matrix gla protein in patients with calciphylaxis.”

The researchers cited case reports of calciphylaxis in patients who have conditions that predispose to vitamin K deficiency, such as Crohn’s disease, alcoholic cirrhosis, and history of gastric bypass surgery.

Last year in the same journal (2016;27: 3421-3429), Dr. Nigwekar and colleagues published the findings of a large case-control study showing that warfarin use at HD initiation was associated with greater than 3-fold odds of calciphylaxis. The study compared 1030 HD patients with calciphylaxis matched by age, sex, and race to 2060 HD patients without calciphylaxis. The median period between HD initiation and development of calciphylaxis was 925 days. The mortality rates were 27% and 45% at 6 and 12 months after diagnosis of calciphylaxis, respectively. n

Active Surveillance Criteria For PCa May Need Updating ADDING MAGNETIC resonance imaging-

University of California-San Francisco

ultrasound (MRI-US) fusion prostate

(UCSF), the Prostate Cancer Research

biopsy to the standard 12-core

International Active Surveillance (PRIAS)

prostate biopsy significantly increases

project, the Royal Marsden Hospital,

the number of prostate cancer (PCa)

Memorial Sloan Kettering Cancer Center

patients who would be deemed

(MSKCC), and the University of Miami.

ineligible for active surveillance using currently available selection criteria,

After adding MRI-US fusion biopsy cores, the proportion of men who

according to study findings reported at

became ineligible for AS varied depend-

the Society of Urologic Oncology 17th

ing on the criteria, ranging from 10.3%

annual meeting in San Antonio, Texas.

using the Royal Marsden criteria, which

As a result, active surveillance (AS)

is a very inclusive criteria, to 40.7%

criteria need to be updated to reflect

using the University of Miami criteria,

the increased use of MRI-US fusion

which uses more strict criteria to select

prostate biopsy, investigators led by

patients for AS. The proportions were

Bruno Nahar, MD, and Sanoj Punnen,

17.0%, 21.1%, 26.3%, 33.3%, and

MD, at the University of Miami Miller

38.5% for the University of Toronto,

School of Medicine, concluded in a

UCSF, MSKCC, Johns Hopkins, and

poster presentation.

PRIAS criteria, respectively.

The investigators studied 100 PCa

“Criteria that incorporated an absolute

patients who were eligible for active

maximum number of cores positive (usu-

surveillance (AS) based on a 12-core stan-

ally 2) had the highest rates of ineligibil-

dard prostate biopsy and meeting at least

ity after adding the fusion cores,” Drs.

1 of 7 sets of AS criteria (Johns Hopkins

Nahar and Punnen told Renal & Urology

University, the University of Toronto, the

News in a joint statement by email. n

24 Renal & Urology News

JANUARY/ FEBRUARY 2017 www.renalandurologynews.com

Initial Degarelix Use Found to Improve PSA-PFS PATIENTS WITH metastatic or highrisk prostate cancer (PCa) treated with degarelix have improved PSA progression-free survival compared with those treated with luteinizing hormonereleasing hormone (LHRH) agonists, investigators reported at the European Society for Medical Oncology 2016

that included men with PSA relapse or high-risk PCa. The investigators defined PSA progression-free survival (PSAPFS) as death from any cause or PSA recurrence (2 consecutive increases of at least 50% 2 or more weeks apart and at least a 5 ng/mL increase from nadir).

They defined high-risk PCa as baseline

congress in Copenhagen. The finding is from a pooled analysis of data from patients in the Americas, Europe, and Asia. Neal Shore, MD, National Urology Research Director for 21st Century Oncology in Myrtle Beach, South Carolina, and collaborators pooled data from 2 pivotal phase 3 randomized trials

PSA level greater than 20 ng/mL or Gleason score 8–10; they defined metastatic PCa by baseline TNM staging.

The study population included 60 patients from the Americas, 97 from Europe, and 224 from China. The patients were randomly assigned 193 patients to receive the gonadotropinreleasing hormone (GnRH) degarelix and 188 to receive an LHRH agonist (leuprolide or goserelin).

Patients who received degarelix had significantly improved PSA-PFS compared with those treated with an LHRH agonist, regardless of geographic region.

Compared with European patients, however, Chinese and American patients had a significant 52% and 74% decreased risk for PSA-PFS, respectively, Dr. Shore’s group reported.

“These results suggest delay of disease progression with initial use of a GnRH antagonist as compared with LHRH agonists across global regions,” the investigators concluded in their study abstract. n

Antidiabetic Drug Use May Cut PCa Risk USE OF ANTIDIABETIC drugs is associated with a reduced risk of prostate cancer (PCa), according to paper published online ahead of print in the Scandinavian Journal of Urology.

In a study of 78,615 men in the Finnish Randomized Study of Screening for Prostate Cancer, Antti Haring, MD, of the University of Tampere in Tampere, Finland, and colleagues found that antidiabetic drug users had a 15% lower overall PCa risk compared with non-users. PCa screening did not affect the association, the investigators reported.

Among antidiabetic drug users, metformin decreased overall PCa risk by 19%. Results also showed that use of sulphonylureas was associated with a 2-fold increased risk of metastatic PCa. The investigators found no association between use of thiazoledenediones or insulin and PCa risk.

“As sulphonylureas stimulate insulin secretion, the results suggest that hyperinsulinemia may be a risk factor for PCa,” the researchers concluded. n

Cosmos Communications K

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www.renalandurologynews.com

JANUARY/ FEBRUARY 2017

Renal & Urology News 25

Infections May Up ESRD Risk in SLE Kidney failure more likely in systematic lupus erythematosus patients hospitalized for infection INFECTION-RELATED hospitalizations are associated with a significantly higher risk for end-stage renal disease (ESRD) in patients with systemic lupus erythematosus (SLE), data show.

In a nationwide cohort study of 7326 SLE patients in Taiwan, patients who had 1, 2 or 3 or more infectionrelated hospitalizations had a 2.7, 4.0-, and 5-fold increased risk for ESRD, respectively, compared with patients who had no hospitalizations for infection, Chien-Hung Lin, MD, of the National Yang-Ming University in Taipei, and colleagues reported online ahead of print in Nephrology Dialysis Transplantation.

The association between infectionrelated hospitalization and ESRD was especially strong for patients with juvenile-onset SLE. For example, those with 3 or more infection-related hospitalizations had a 14-fold increased risk.

Patients with SLE have a higher risk of infection than the general population,

New Findings Support PCa Cryoablation PRIMARY WHOLE gland cryoablation for prostate cancer (PCa) based on targeted biopsy-proven cancer mapping, achieves acceptable oncologic and functional outcomes at 5 years, investigators reported at the Society of Urologic Oncology 17th annual meeting in San Antonio, Texas.

Alfredo Maria Bove, MD, and colleagues at the University of Southern California in Los Angeles studied 102 patients undergoing whole gland cryoablation for localized PCa. At entry, imagebased cancer mapping using staging biopsy guided by transrectal ultrasound and Doppler were digitally documented.

All procedures were performed under TRUS guidance with individualized cryoneedle delivery based on preoperative cancer mapping. The researchers defined biochemical failure as post-treatment PSA level above 0.2 ng/mL and a PSA nadir + 2 (the Phoenix definition).

The median follow-up was 5 years.

Patients had a median age of 71 years and median PSA level of 7.5 ng/mL.

Infection-Related Hospitalizations in SLE Patients The rate of infection-related hospitalizations among patients with systemic lupus erythematosus varies according to the age at SLE onset, a study found.

50 40 30

39%

37.5% 27.7%

20 10 0

Juvenile <18 years

Adult

18–50 years

Late

>50 years

Age at Onset Source: Lin C-H, et al. Infection-related hospitalization and risk of end-stage renal disease in patients with systemic lupus erythematosus: a nationwide population-based study. Nephrol Dial Transplant 2016; published online ahead of print.

and infection is the leading cause of mortality in these patients, followed by cardiovascular complications, the investigators noted.

“The clinical implications of our results are that serious infection has a close relationship with ESRD, a major

The clinical stage was T1c in 48% of men, T2 in 44%, and T3 in 8%). The D’Amico group risk was low in 24% of men, intermediate in 50%, and high in 26%. In 65 patients (66%) PSA declined to below 0.2 ng/mL. The estimated biochemical failure-free survival (EBFFS) rate was 84% by the Phoenix definition.

Complications developed in 13 patients (12.7%). The incontinence rate was 4%.

Potency recovered in 12% of patients.

The researchers compared the cryoablation cohort with 102 men who underwent open radical prostatectomy (RP), matching the patients by preoperative PSA level, Gleason score, and clinical stage. The 5-year EBFFS, based on patients who had a posttreatment PSA level above 0.2 ng/mL, was 39% for the cryoablation cohort and 79% for the RP cohort, a statistically significant difference between the groups. Metastases developed in 5 (5%) of the cryoablation patients and 4 (4%) of the RP patients. Eight cryotherapy and 12 RP patients required salvage treatment.

Dr. Bove and colleagues concluded that cryoablation “for PCa using indi vidualized cryoneedle delivery based on biopsy-proven cancer mapping achieved acceptable oncologic and functional outcomes with low rates of incontinence and complications.” ■

complication of SLE, and that implementation of measures that seek to reverse the trend of infectious complications in SLE are mandatory,” the investigators wrote.

Using Taiwan’s National Health Insurance Research Database for the

period 2000–2011, the investigators identified patients with newly diagnosed SLE and no history of ESRD. During a mean follow-up of 8.1 years, ESRD developed in 316 (4.3%) of the 7326 SLE patients. Male patients had a significant 56% higher risk for ESRD. Among the patients with different types of infectious complications, those with septicemia/bacteremia had the greatest risk for ESRD compared with patients who had no infection-related hospitalizations.

The rate of infection-related hospitalizations was 37.5% among patients with juvenile-onset SLE, 39% among those with late-onset SLE, and 27.7% among those with adult-onset SLE, the investigators reported. “The very young and very old SLE patients may be more predisposed to infections because hypocomplementemia and low concentrations of protective antibodies are more common in these groups,” they explained. ■

Standard 12-Core Prostate Biopsy Needed Despite Negative MRIs STANDARD 12-CORE prostate biopsies

Medicine in St. Louis defined the

should continue to be performed in

negative predictive value (NPV) of

men despite the absence of suspi-

prostate MRI at their institution and the

cious prostate lesions on magnetic

characteristics of men with clinically

resonance imaging (MRI) scans,

significant cancer (Gleason 7 or higher

investigators reported at the Society

PCa) but a negative MRI.

of Urologic Oncology 17th annual

They studied 84 men with nega-

meeting in San Antonio, Texas. In a

tive prostate MRI who subsequently

study, they found that prostate MRI

underwent standard template TRUS

missed 13% of high-grade prostate

biopsy. The group consisted of 39

tumors that were revealed by subse-

biopsy-naïve patients, 30 patients who

quent standard template transrectal

had a previous negative biopsy, and 15

ultrasound (TRUS) 12-core biopsy.

patients on active surveillance (AS).

“There is no doubt that MRI-targeted

Results showed that MRI had an

biopsy is better than a random TRUS

NPV of 87% for Gleason 7 or higher

biopsy, but it is imperfect,” said lead

PCa, which the investigators said is

investigator Eric Kim, MD. “Currently,

in line previously published studies.

optimal cancer detection requires both

The only predictor of Gleason 7 or

targeted and systematic biopsy. As

higher cancer among negative MRI

MRI interpretation and other imaging

patients was an increasing Prostate

modalities, such as PET [positron

Cancer Prevention Trial risk calculator

emission tomography], improve, sys-

estimate for high-grade PCa. Dr. Kim’s

tematic biopsy may not be needed.”

group reported finding no significant

Dr. Kim and his colleagues at Washington University School of

differences in NPV between patients based on prior biopsy status. ■

26 Renal & Urology News

JANUARY/ FEBRUARY 2017

www.renalandurologynews.com

Practice Management Physician burnout is common, but strategies for managing stress can help to prevent or alleviate it BY TAMMY WORTH when you are dealing with burnout vacation is not a cure, Dr. Drummond said. Taking a day or week will give you a break from the stress, but if you do not start taking new actions when you return from your vacation, the downward spiral of burnout will simply resume when you return.

Causes According to Dr. Drummond, these are the top 5 categories of stress that cause physician burnout: 1. The inherently stressful nature of working with sick and dying people and their family members.

2. The daily job-specific stresses associated with doctors’ practices, such as call rotations, electronic medical records, and dealing with staff, only add to the challenges for physicians.

3. Bad leadership. Nothing burns out a good doctor faster than a bad leader. This is true in all professions. “We are only now learning

Exhaustion, low energy, increases in absenteeism, and drops in productivity are among the signs of burnout.

Proc 2015;90:1600-1613) was over 50%”, said Dr. Drummond, the CEO and founder of TheHappyMD.com, a physician coaching and training company focused on burnout prevention.

What burnout looks like Want to recognize burnout in yourself or your staff? You will begin to feel (or see in others) exhaustion, low energy, and significant drops in productivity.

You may become cynical or sarcastic and venting more frequently about patients and their problems. Another sign is increased absenteeism. But

On The Web

it applies in medicine, too, as large employed physician groups form around the country.”

4. Problems at home that compromise physicians’ ability to recharge their energy.

5. The “deny your own humanity” conditioning drilled into doctors in medical school coupled with the underlying workaholic, superhero personalities of many physicians.

“Docs will show up to work sick and know they are a danger to patients because they don’t want to be perceived as weak or not pulling their

© THINKSTOCK

D

ike Drummond, MD, offers an adage of how medical school nearly molds physicians for burnout. It is common in surgery residency programs that when a chief resident leaves the hospital after the day shift, he tells the intern on duty, ‘You can call tonight if you need me, but remember that calling me is a sign of weakness.’ When Dr. Drummond recalls this common story, , he chuckles, even though he is not really joking.

Medical students absorb several flavors of conditioning as they become doctors. They become Lone Ranger, superhero, and workaholics, following the prime directives of “the patient comes first” and “never show weakness,” he said. Not only do doctors deal with sick people all day in a high-stress atmosphere, but they feel they cannot reach out for assistance when they need it. It is no wonder that the prevalence of burnout among U.S. physicians in a recent study (Mayo Clin

A feeling of being unable to reach out for assistance may contribute to physician burnout.

weight.,” Dr. Drummond said. “No other profession has this attitude about self-care and wellness.”

A second major component to burnout is isolation, which Dr. Drummond said could be handled by making structural changes within an organization. “You can build social networks, regular social gatherings and re-build the person to person connections physicians had back in the days of the smaller, physician controlled provider groups. These human connections can reinforce the message that you aren’t in this alone,” he said.

Fixing it Dr. Drummond cautions not to think of burnout as a “problem” that can be fixed with a single solution. Instead, burnout is a classic dilemma, a perpetual balancing act that you will always have to manage. Individuals can work to find strategies that help them manage stress, such as meditation, yoga, or journaling. If your problems are homebased, work to solve those so they do not spill over into your job.

Physicians did not go into the medical profession to do administrative tasks like dealing with regulations, information technology, and documentation, said Jessica Sweeney-Platt, executive director of physician performance research at athenahealth, based in Watertown, Massachusetts, a firm that provides cloud-based services for healthcare and point-of-care mobile apps. Muddling through this all day, or taking it home after a long day, takes away from their sense of control, she said.

To reduce the burden, she recommends giving as much of this work as possible to the front desk, medical assistants and others. For instance, if a patient needs immunizations or a test performed, have an assistant do the chart prep work and tee up the orders.

That way the doctor can just confirm the orders and move on. Even before the visit, plan as much as possible and have it ready so doctors are not doing as much chart work afterwards. ■ Tammy Worth is a freelance medical journalist based in Blue Springs, MO.

Want to improve your practice? Look for our tips on how to handle equipment issues, adjust to EHRs, comply with HIPAA, and more at www.renalandurologynews.com/practice.