16 minute read
From the Editor
Contents
JULY/AUGUST 2021 ■ VOLUME 20, ISSUE NUMBER 4
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Urology
7 Obesity May Lower mCRPC Death Risk A study found that obesity was signi cantly associated with a 29% and 35% decreased risk of all-cause and cancer-speci c mortality.
9 Metformin Possibly Bene cial in Advanced Prostate Cancer In a randomized controlled trial, use of the drug in combination with standard of care delayed development of castrationresistant disease.
22 Nocturnal Polyuria Highly Prevalent in the US By one measure, nocturnal polyuria was present in 39.1% of men and 49.9% of women, a study found.
32 Pandemic’s Legacy: Innovations in Cancer Care and Research What clinicians have learned from their experiences during the COVID-19 crisis may change how they manage patients.
Nephrology
8 Hospitalizations May Predict ESKD Risk Intermediate and high utilizers have a 1.5- and 1.8-fold higher risk of end-stage kidney disease compared with low utilizers, data show.
22 Living Donor Transplantation Declining The proportion of patients undergoing living donor kidney transplantation decreased from 37% in 2010 to 29% in 2019, according to the investigators.
23 Switching to Twice-Weekly HD Can Be Done Safely Converting selected patients from thriceweekly to twice-weekly hemodialysis resulted in no signi cant changes in potassium, phosphorus, hemoglobin, or parathyroid hormone levels, a study found.
31 Intradialytic Cycling Has CV Bene ts In a study, exercise cycling during hemodialysis sessions was associated with a reduction in left ventricular mass.
Our member institutions pivoted to telehealth
very quickly. Clinicians worked together to gure out clinical pathways to minimize risk and maximize bene t. CALENDAR
American Urological Association
Annual Meeting Las Vegas, Nevada September 10–13
International Continence Society
Annual Meeting Melbourne, Australia October 12–15
American Society for Radiation Oncology (ASTRO)
Annual Meeting Chicago, IL October 24–27
American Society of Nephrology
Kidney Week San Diego, CA November 2–7
Large Urology Group Practice Association
Annual Meeting Chicago, IL November 12–13
Society of Urologic Oncology
Annual Meeting Orlando, FL December 1–3
35
Departments
2 From the Editor The pandemic has opened new research frontiers
6 News in Brief Burnout af icts 47% of urology residents
35 Ethical Issues in Medicine Promote a “just culture” to improve patient safety
36 Practice Management Bluetooth-connected devices are a potential target for hackers
FROM THE EDITOR
Health Care Interrupted: Research Frontiers Beckon
For years after the COVID-19 pandemic ends, researchers from every academic discipline will probe the long-term effects of the crisis. Sociologists, anthropologists, and psychologists surely will examine how months of social isolation affected human behavior. Economists will analyze the pandemic’s influence on the stock market and consumer spending patterns and the effect of the trillions of dollars the federal government spent to buttress the economy and provide financial relief for households. And medical researchers will study the clinical consequences of the pandemic, especially the ramifications of delayed care.
For a few months early in the pandemic, states across the nation mandated the cessation of non-urgent medical services, bringing routine screening and testing to a halt or nearly so. Even when the mandates lifted, patients remained reluctant to make emergency department visits or regular in-person doctor appointments out of fear of contracting COVID-19. This interruption in care raises a number of important research questions. Did the delay in routine screening and testing result in an increase in the number of patients presenting with more advanced cancers, as some investigators have predicted? Does a delay of a few months in performing such services as surveillance cystoscopies for patients with bladder cancer or per-protocol PSA tests for men on active surveillance for prostate cancer make a difference in outcome? Can clinicians safely prolong the interval between these and other such services to make patients’ lives easier and reduce health care costs?
Telehealth will be another area ripe for scientific inquiry. Unable to have non-urgent in-person encounters with patients, clinicians across specialties turned en masse to telehealth. This migration to virtual encounters was facilitated by the Centers for Medicare & Medicaid Services, which allowed Medicare to pay physicians and other health care providers for telehealth visits at the same rate as regular in-person visits and under a broader range of circumstances. Will the increased prominence of telehealth during the pandemic remain after the crisis ends? What is the level of patient and physician acceptance of telehealth? How does telehealth impact the physician-patient relationship?
To lower the risk of COVID-19 transmission, some dialysis facilities tested a strategy of converting patients who met certain criteria from thrice-weekly to twice-weekly in-center hemodialysis sessions (a controversial topic in nephrology) or to home hemodialysis. Physicians have switched from intravenous to oral drugs and from shorter- to longer-duration injection formulations of drugs to reduce the number of in-person visits. How did these strategies work out? If outcomes were not adversely affected, could these approaches be used more widely?
These are only a sampling of the numerous research questions likely to be explored. The answers could change the practice of medicine.
Jody A. Charnow
Editor
EDITORIAL ADVISORY BOARD
Medical Director, Urology
Robert G. Uzzo, MD, MBA, 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 Urologists
Christopher S. Cooper, MD
Director, Pediatric Urology Children’s Hospital of Iowa Iowa City
R. John Honey, MD
Head, Division of Urology, Endourology/Kidney Stone Diseases St. Michael’s Hospital University of Toronto
Stanton Honig, MD
Department of Urology Yale University School of Medicine New Haven, CT
J. Stephen Jones, MD
Chief Executive Officer Inova Health System Falls Church, VA Professor and Horvitz/Miller Distinguished Chair in Urologic Oncology (ret.) Cleveland Clinic Lerner College of Medicine Cleveland
Jaime Landman, MD
Professor of Urology and Radiology Chairman, Department of Urology UC Irvine School of Medicine Orange, CA
James M. McKiernan, MD
John K. Lattimer Professor of Urology Chair, Department of Urology Director, Urologic Oncology Columbia University College of Physicians and Surgeons New York
Kenneth Pace, MD, MSc
Assistant Professor, Division of Urology St. Michael’s Hospital University of Toronto Vancouver, Canada Medical Director, Nephrology
Kamyar Kalantar-Zadeh, MD, PhD, MPH
Professor & Chief, Division of Nephrology, Hypertension & Kidney Transplantation UC Irvine School of Medicine Orange, CA
Nephrologists
Anthony J. Bleyer, MD, MS
Professor of Internal Medicine/Nephrology Wake Forest University School of Medicine Winston-Salem, NC
David S. Goldfarb, MD
Professor, Department of Medicine Clinical Chief New York University Langone Medical Center Chief of Nephrology NY Harbor VA Medical Center
Csaba P. Kovesdy, MD
Chief of Nephrology Memphis VA Medical Center Fred Hatch Professor of Medicine University of Tennessee Health Science Center Memphis
Edgar V. Lerma, MD
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. Denver
Rulan Parekh, MD, MS
Associate Professor of Pediatrics and Medicine University of Toronto
Robert Provenzano, MD
Associate Professor of Medicine Wayne State University School of Medicine Detroit Vice President of Medical Affairs, DaVita Healthcare Denver
Robert S. Rigolosi, MD
Director, Regional Hemodialysis Center Holy Name Hospital Teaneck, NJ
Renal & Urology News Staff
Editor Jody A. Charnow Web editor Natasha Persaud Production editor Kim Daigneau Group creative director Jennifer Dvoretz Production manager Brian Wask Vice president, sales operations and production Louise Morrin Boyle National accounts manager William Canning Editorial director, Haymarket Oncology Lauren Burke Vice president, content, medical communications Kathleen Walsh Tulley Chief commercial officer James Burke, RPh President, medical communications Michael Graziani Chairman & CEO, Haymarket Media Inc. Lee Maniscalco
News in Brief
Please visit us at www.renalandurologynews.com for the latest news updates from the fields of urology and nephrology
Short Takes
Survey: Burnout Afflicts 47% of Urology Residents
A recent survey found that 47% of US urology residents, including 65% of second-year residents, met criteria for professional burnout, investigators reported in Urology.
In addition, 17% of the 415 survey respondents regretted their overall career choice, according to Kevin Kim, MD, MPH, of Mayo Clinic in Rochester, Minnesota, and colleagues. The crosssectional study examined urology residents’ responses to the 22-item Maslach Burnout Inventory and questions about career and specialty choice regret from the 2019 American Urological Association census.
Regarding unmet needs, 62% of respondents prioritized the ability to attend personal health appointments, with the majority experiencing difficulty in attending such appointments.
HP Laser Lithotripsy Not More Effective
Both low-power (LP) and high-power (HP) laser lithotripsy are associated with similar results, according to a recent systematic review and metaanalysis that included 6403 patients.
The pooled stone-free rate was 82% and 81% among patients treated with LP and HP laser lithotripsy, a team led by Olivier Traxer, MD, of AssistancePublique Hôpitaux de Paris, Hôpital Tenon, Sorbonne Université, Paris, reported online ahead of print in the Journal of Endourology. Complication rates did not differ between the procedures. Mean operative time was significantly faster for HP procedures (32.9 vs 62.7 minutes). Mean stone volume was significantly larger in the LP group (2604 vs 1217 mm3).
FDA Approves Once-Daily Torsemide Formulation
The Food and Drug Administration in June approved Soaanze, a once-a-day improved formulation of the oral loop diuretic torsemide, for the treatment of edema associated with heart failure or renal disease in adults. It provides a longer duration of peak effects without causing excessive urination, according to a press release from Sarfez Pharmaceuticals, the drug’s maker.
The formulation has an extended duration of action that lasts approximately 6 to 8 hours, with a peak effect that occurs within the first 4 hours.
CKD in Patients With Cancer
A study by investigators in Romania found that the prevalence of chronic kidney disease (CKD) among patients with cancer is higher than that of the general population, and the prevalence varies by cancer type, as shown below.
48.7%
34.1%
20.0% 19.6%
9.9% 8.8% 7.1%
NMIBC Therapies Vary in Side Effects, Tolerability
Patient-reported side effects and tolerability of various intravesical therapies for nonmuscle-invasive bladder cancer differ significantly, according to survey findings published in Urology.
A team led by Brian R. Lane, MD, of Spectrum Health Hospital System in Grand Rapids, Michigan, analyzed responses to 592 completed surveys filled out by patients prior to repeat instillation of full-dose and high-dose bacillus CalmetteGuérin (BCG) and gemcitabine. Patients reported symptoms of any kind in 463 surveys (78%), the most common being bladder symptoms (59%), fatigue (52%), body aches (26%), and hematuria (18%).
Patients were able to hold full-dose BCG, reduced-dose BCG, and gemcitabine for the protocol-specified duration 87%, 95%, and 71% of the time, respectively. The prevalence, severity, and duration of body aches were highest with gemcitabine, whereas the prevalence and duration of hematuria were higher with BCG. Reduced-dose BCG had the lowest prevalence, severity, and duration of fatigue.
MRAs May Decrease Death Risk in Dialysis Patients
Mineralocorticoid receptor antagonists (MRAs) appear to lower mortality risks in patients receiving dialysis without substantially increasing the risk for hyperkalemia, investigators reported in the Clinical Journal of the American Society of Nephrology.
Chih-Chin Kao, MD, of Taipei Medical University Hospital in Taipei, Taiwan, and colleagues conducted a systematic review and meta-analysis of MRA trials published up to 2020. The review included 13 trials of spironolactone and 1 trial of eplerenone and involved a total of 1309 patients on dialysis for kidney failure (mean age 53-70 years). MRA use was significantly associated with a 59% lower risk for cardiovascular mortality and a 56% lower risk for all-cause mortality, according to researchers. In a meta-analysis of 7 of the trials, the MRA group had a nonsignificant 12% increased risk for hyperkalemia compared with the control group.
Adjuvant Nivolumab Improves Outcomes in High-Risk UC
Adjuvant nivolumab following radical surgery for high-risk muscle-invasive urothelial carcinoma (UC) is associated with improved disease-free survival compared with placebo, according to study findings published in the New England Journal of Medicine.
Researcher randomly assigned 353 patients to receive nivolumab 240 mg intravenously and 356 to receive placebo every 2 weeks for 1 year. All patients had undergone radical surgery within 120 days of randomization. The median disease-free survival in the intention-to-treat population was 20.8 months with nivolumab and 10.8 months with placebo, Dean F. Bajorin, MD, of Memorial Sloan Kettering Cancer Center in New York City, and colleagues reported. The proportion of patients who were alive and disease-free at 6 months was 74.9% with nivolumab and 60.3% with placebo. Nivolumab was significantly associated with a 30% decreased risk for disease recurrence or death compared with placebo.
NMIBC Recurrence Not Tied to Smoking
Investigators find a lack of an association in a cohort of mostly patients with high-risk disease
SMOKING IS A known risk factor for bladder cancer, but a recent study suggests that smoking status is not significantly associated with recurrence of nonmuscle-invasive bladder cancer (NMIBC) among patients managed with photodynamic enhanced (blue light) cystoscopy.
The study included 723 adults with NMIBC (11.5% with primary and 88.5% with recurrent NMIBC). Almost 73% of patients had high-risk disease, 52.6% were former smokers, and 12.7% were smokers at the time of entry into the multi-institutional registry used for the study.
Of the 723 patients, 259 (35.8%) experienced recurrence during a 3-year study period. The 1- and 3-year probability of recurrence was 19% and 44%, respectively, Richard S. Matulewicz, MD, of New York University Grossman School of Medicine in New York City, and colleagues reported online in Urologic Oncology. After adjusting for clinical and demographic factors, smokers were not at significantly increased risk for recurrence compared with never smokers.
Still, the importance of smoking cessation should not be dismissed, according to the investigators.
“Our findings should not be used to minimize the need for urologists to educate and counsel smokers who are diagnosed with bladder cancer,” Dr Matulewicz’s team cautioned. “Smoking cessation is critically important given the myriad health benefits of smoking cessation and all urologists should be screening for tobacco use during visits and improving how they help patients quit.”
The latest study is not the first to provide evidence that smoking cessation after NMIBC diagnosis has no significant effect on disease recurrence. A prospective study of 722 patients with NMIBC (103 never smokers, 266 former smokers, 186 continuing smokers, 150 former smokers who started again, and 17 who quit smoking after diagnosis) showed that smoking cessation after diagnosis did not decrease recurrence risk compared with continued smoking (Cancer Causes Control. 2018;29:675–683). A study of 963 patients with NMIBC (181 never smokers, 490 former smokers, and 292 current smokers) found no significant difference in the risk for recurrence and smoking status at the time of diagnosis (Urol Oncol. 2015:33:e9-17). In a study of 390 patients with recurrent NMIBC who underwent transurethral resection (91 never smokers, 192 former smokers, and 107 current smokers), investigators found no difference in recurrence risk among the 3 groups (J Urol. 2012;188:2121-2127).
Other studies, however, arrived at different conclusions. For example, a study of 718 patients with NMIBC who underwent transurethral resection found that ex-smokers and current smokers had a significantly shorter recurrence-free survival compared with nonsmokers (Eur Urol. 2011;60:713-720).
The study was supported by Photocure, Inc. ■
The study included 723 adults managed with photodynamic enhanced cystoscopy.
Obesity May Lower mCRPC Death Risk
OBESITY IN MEN with metastatic castration-resistant prostate cancer (mCRPC) is associated with better survival outcomes, investigators reported at the European Association of Urology 36th congress.
The finding emerged from a study of 1577 men with mCRPC who enrolled in the control arm of 3 randomized controlled phase 3 trials (ASCENT2, MAINSAL, and VENICE). Patients had a median age of 69 years and median body mass index (BMI) of 28 kg/m2. Of the study population, 655 had died by the end of the studies. The median follow-up for survivors was 12 months. The investigators defined obesity as a BMI higher than 30 kg/ m2 and normal weight and overweight as a BMI of 20-25 and 25-30 kg/m2 , respectively.
Obesity was significantly associated with a 29% decreased risk for death from any cause and a 35% decreased risk for prostate cancer-specific mortality (PCSM) compared with overweight and normal weight patients, investigator Giuseppe Ottone Cirulli, MD, of Vita-Salute San Raffaele University in Milan, Italy, reported. Each 1 kg/m2 increase in BMI was significantly associated with a 4% decreased risk of all-cause mortality and 6% decreased risk of CSM.
Dr Cirulli and colleagues examined interactions between BMI and chemotherapy (docetaxel) dose to exclude any possible effect attributable to higher dose of chemotherapy and found no association.
The latest study adds to previous findings by other investigators suggesting a protective effect of obesity in men with prostate cancer. In a previous study of 1129 men with nonmetastatic CRPC identified using the Shared Equal Access Regional Cancer Hospital (SEARCH) database, Adriana C. Vidal, PhD, and colleagues found that obesity (BMI of 30 kg/m2 or higher) was significantly associated with a 21% decreased risk for death from any cause compared with normal weight (BMI 21-24.9 kg/m2) patients, but was not associated with PCSM (BJU Int. 2018;122:76-82). A study of 1226 men with metastatic CRPC by Susan Halabi, PhD, and colleagues showed that compared with normal weight men (BMI 18.5-24.9 kg/m2), both overweight (BMI 25-29.9 kg/m2) and obese (30 kg/m2 or higher) men had a significant 20% decreased risk for death (Cancer. 2007;100:1478-1484). ■
SEMAGLUTIDE MARKEDLY improves albuminuria and other important renal and metabolic parameters in patients with diabetic kidney disease (DKD) at high risk for progression, according to real-world data presented at the 58th European Renal Association−European Dialysis and Transplant Association congress.
Beatriz Avilé, MD, PhD, of Hospital Costa del Sol in Málaga, Spain, and colleagues studied 122 patients with an estimated glomerular filtration rate (eGFR) higher than 15 but less than 60 mL/min/1.73 m2 or urinary albumin to creatinine ratio (UACR) exceeding 30 mg/g treated with semaglutide, a glucagon-like peptide-1 (GLP-1) receptor agonist. Over 12 months, semaglutide significantly decreased mean UACR from 349.5 to 187.3 mg/g, Dr Avilés and colleagues reported. Mean eGFR remained relatively stable with a slight increase of 2.2 mL/min/1.73 m2 .
Mean hemoglobin A1c significantly decreased from 7.6% to 6.8%, which is within target range. Mild hypoglycemia occurred in only 5% of patients taking insulin, and rapid insulin requirement declined by 25%. Mean weight also significantly declined from 98.5 to 91.5 kg, representing a more than 5% weight loss for 69% of patients.
Systolic blood pressure significantly declined from 129.95 to 120.09 mm Hg and diastolic blood pressure from 77.05 to 71.12 mm Hg. LDL cholesterol and triglyceridemia significantly decreased by 10.79 mg/dL and 29.15 mg/dL, respectively.
Semaglutide was discontinued in 5% of patients, commonly due to gastrointestinal intolerance.
“Our real-world study shows a significant reduction in albuminuria and weight with semaglutide treatment in patients with type 2 diabetes at high risk for kidney disease progression,” Dr Avilé told Renal & Urology News. “Hyperglycemia improved with only 5% of patients experiencing mild hypoglycemia with lower need of insulin. Semaglutide is safe and well tolerated and can ameliorate renal prognosis.” ■
