14 Renal & Urology News
WINTER 2022
www.renalandurologynews.com
Predictors of NMIBC Upstaging Identified Risk factors include advanced age and lymphovascular invasion, and other histologic features PATHOLOGIC UPSTAGING among patients with nonmuscle-invasive bladder cancer (NMIBC) is more likely among older patients and those with lymphovascular invasion (LVI) and other histologic features, according to recent study findings presented at the 22nd Annual Meeting of the Society of Urologic Oncology. The findings are from a study of 8620 patients with NMIBC who underwent radical cystectomy (RC), of whom 3100 (36%) were upstaged. Age 80 years or older was significantly associated with 1.6-fold greater odds of upstaging compared with age less than 60 years, Ahmed Elshabrawy, MD, and colleagues from UT Health San Antonio in Texas, reported in a poster presentation. LVI was significantly associated with 7.7-fold greater odds of upstaging compared with no LVI. Sarcomatoid and squamous histologies were signifi-
LN Remission Lowers Fetal Loss Risk Rate WOMEN WITH LUPUS nephritis (LN) who have a complete renal remission prior to pregnancy tend to experience good fetal outcomes and less LN relapse, a new study finds. Investigators analyzed the pregnancy outcomes of 158 pregnancies in 155 Chinese patients with LN. Of these, 130 patients had achieved complete renal remission (CRR) and a systemic lupus erythematosus disease activity index 2000 (SLEDAI-2K) of 4 or lower prior to pregnancy, and 25 patients had not. CRR was defined as proteinuria less than 0.5 g/24 h, no active urinary sediment, serum albumin 35 g/L or higher, and normal serum creatinine. The remission group had significantly lower rates of LN relapse (11.3% vs 72.0%), LN relapse in early pregnancy (3.0% vs 44.0%), fetal loss (5.3% vs 20.0%), and premature birth (23.3% vs 48.0%) compared with the control group. The odds of LN relapse significantly increased 11.2- and 5.2-fold in patients with a pre-pregnancy CRR duration of less than 18 months and anti-C1q antibody positivity, respectively, Weixin
cantly associated with 1.4- and 6.4-fold greater odds of upstaging, respectively, compared with urothelial disease. The study also identified predictors of RC, which included younger age, male gender, treatment at academic medical centers, and the presence of LVI and
Pathologic upstaging is associated with significantly worse survival, data show. istologic variants. Compared with h patients younger than 60 years, those aged 80 years or older had 76% lower odds of RC. Male vs female sex was significantly associated with 22% greater odds of RC. Treatment at academic medical centers was significantly associated
Hu, MD, and colleagues from Jinling Hospital, Nanjing University School of Medicine in China, reported in Nephrology Dialysis Transplantation. The odds of fetal loss significantly increased 9.3-fold with anti-phospholipid antibody positivity, and the odds of premature birth significantly increased 3.9-fold with a prednisone dosage of 12.5 mg/d or higher during pregnancy. Age older than 30 years was an independent risk factor for both preeclampsia and premature birth. Current guidelines for the management of pregnancy in LN patients are mostly based on patients with SLE, but the risk of LN relapse during pregnancy is 2- to 3-fold higher in LN, the investigators noted. According to Dr Hu’s team, “our study showed that LN patients with complete renal remission for more than 18 months were associated with good pregnancy outcomes and lower LN relapse during pregnancy.” For immunosuppression during pregnancy, the remission group received prednisone (82.7%), prednisone plus a calcineurin inhibitor (7.5%), or prednisone plus azathioprine (4.5%). Fewer patients in the control group received prednisone alone (28.0%), and more received prednisone plus a calcineurin inhibitor (56.0%) or plus azathioprine (12.0%). Medications contraindicated in pregnancy were discontinued. ■
with 7.2-fold greater odds of RC. The presence of LVI, compared with its absence, was significantly associated with 4.0-fold greater odds of RC. Pure urothelial vs variant histology was significantly associated with 60% lower odds of RC. Upstaged patients had significantly lower 5-year overall survival compared with patients who were not upstaged (40% vs 71%). Positive surgical margins and neuroendocrine or sarcomatoid variants were significantly associated with higher death risks. “On a nationwide level, predictable adverse pathological features are associated with pathological upstaging,” the investigators concluded in their poster. This upstaging is associated with significantly poor overall survival, especially in patients with non-organ-confined disease, they noted. “These features should be considered when counseling patients regarding
early radical cystectomy,” they wrote. The lower odds of RC among older patients observed in the current study can be attributed to multiple factors, said senior author Ahmed M. Mansour, MD. For example, the procedure is associated with greater morbidity among older patients, he explained. Thus, older patients might opt for other treatment. In a paper published recently in Urologic Oncology (2021;39:236.e9-236. e20), he and his colleagues reported findings from a study of 74,159 patients with muscle-invasive bladder cancer showing that 5.4% refused RC despite physician recommendations. On multivariate analysis, predictors of RC refusal included advanced age (80 years or older vs younger than 60 years), Black race, and female sex. Median survival after RC was 40.4 vs 12.5 months in refusal group, according to the investigators. ■
Dyskalemias Before Hemodialysis Sessions May Increase Mortality LOW AND HIGH serum potassium levels
The study included 1117 incident
before hemodialysis (HD) sessions are
HD patients older than 18 years from
associated with an increased risk for
the Netherlands Cooperative Study on
death, according to a recent prospec-
the Adequacy of Dialysis. Researchers
tive study of adult patients new to HD.
followed up patients from their first
Predialysis levels of 4.0 mmol/L or
HD treatment until death, transplanta-
lower and levels higher than 6.0 mmol/L
tion, switch to peritoneal dialysis, or a
are associated with 1.4- and 1.3-fold
maximum of 10 years.
increased risks for 6-month all-cause
At baseline, the study population
mortality, respectively, in adjusted analy-
had a mean age of 63 years; 58% of
ses compared with an optimum level
patients were men, 26% smoked, 24%
of about 5.1 mmol/L, Esther N.M. de
had diabetes, and 32% had cardiovas-
Rooijj, MD, of Leiden University Medical
cular disease. The mean serum potas-
Center in Leiden, The Netherlands, and
sium level was 5.0 mmol/L. In addition,
colleagues reported in Kidney Medicine.
7% had low subjective global assess-
“If proven causal, the clinical implica-
ment scores. The median residual kid-
tion of these results is that potassium-
ney function was 3.5 mL/min/1.73m2.
lowering therapy should be used
A total of 555 deaths occurred during
with caution in hemodialysis patients
10 years of follow-up.
with normal or low serum potassium
The authors noted that, to their knowl-
level before the dialysis session,” the
edge, their study is the first to include
investigators reported. “Furthermore,
only incident HD. “All previous studies
as low predialysis serum potassium
investigating the relation between
could result from malnourishment, the
predialysis serum potassium and death
associated mortality risk emphasizes
included mainly prevalent hemodialysis
the importance of preventing nutritional
patients, thus being susceptible to
disorders in hemodialysis patients.”
survivor bias,” they wrote. ■
