Renal & Urology News - May-June 2021 Issue

M AY/J U N E 2 0 21

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VOLUME 20, ISSUE NUMBER 3

Study: ADT Does Not Raise CV Death Risk Finding is based on men in the PLCO trial

BY JODY A. CHARNOW ANDROGEN deprivation therapy (ADT) plus radiation therapy for unfavorable-risk prostate cancer is not associated with an increased risk for cardiovascular (CV) mortality compared with RT alone, according to investigators.

The finding is from a secondary analysis of prospectively obtained data from 1463 men with unfavorable-risk clinically localized prostate cancer (PCa) who participated in the Prostate, Lung, Colorectal, and Ovarian (PLCO) randomized controlled trial. The analysis revealed no significant difference in

5-year CV mortality rates between ADT plus radiotherapy (RT) and RT alone overall (2.3% vs 3.3%, respectively) or in subgroups of men with a history of 1 or more preexisting comorbidities (3.2% vs 5.3%), a history of 2 or more preexisting comorbidities (6.9% vs 8.3%), or preexisting CV disease (CVD, 3.6% vs 4.3%), a team led by Vinayak Muralidhar, MD, MSc, of Brigham and Women’s Hospital in Boston, Massachusetts, reported in Cancer.

“These findings suggest that ADT may be a safe management option for men who have unfavorable-risk

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ADT AND CARDIOVASCULAR MORTALITY A study of men in the PLCO trial found no significant difference in 5-year cardiovascular (CV) mortality rates among men who underwent radiotherapy alone or combined with androgen deprivation therapy for unfavorable-risk prostate cancer, regardless of preexisting comorbidities.

6

5.3%

5 4 3

3.3%

Obese men are at particularly high risk of testosterone deficiency.

anti-inflammatory) to +5.48 (most pro-inflammatory).

An inflammatory diet is characterized by a higher content of refined carbohydrates, added sugars, saturated fat, and cholesterol, and a lower content of unsaturated fat, fiber, and polyphenols.

The mean total testosterone level was significantly lower in men with the most pro-inflammatory diet (highest tertile of DII) compared with men with the most anti-inflammatory diet (lowest tertile of DII): 410.42 vs 422.71 ng/dL, Shi Qiu, MD, and colleagues from West continued on page 9

4.3%

3.6%

3.2%

2.3%

2 1 0

Overall

1 or more preexisting comorbidities

Preexisting CV disease

Source: Butler SS, et al. Risk of cardiovascular mortality with androgen deprivation therapy in prostate cancer: A secondary analysis of the Prostate, Lung, Colorectal, and Ovarian (PLCO) randomized trial. Cancer. Published online April 27, 2021.

prostate cancer regardless of comorbidity status,” Dr Muralidhar and colleagues concluded. “However, the possible side effects of ADT and the high risk of other-cause mortality still should be weighed against the possible cancer-specific mortality benefit when

Low T Linked to Inflammatory Diet Men Rarely Die

BY NATASHA PERSAUD defined as total testosterone levels from Early-Stage CONSUMING pro-inflammatory foods less than 300 ng/dL. Their calculated may increase the risk of testosterone scores from the Dietary Inflammatory Prostate Cancer deficiency in men, a new study finds.

Index (DII) ranged from −5.05 (most During the National Health and Nutrition Examination Surveys (NHANES) 2013 to 2016, a total of 4151 men completed a 24-hour dietary history including 27 foods. Overall, 25.7% of the men had testosterone deficiency,

■ RT plus ADT ■ RT alone

MEN WITH EARLY-stage prostate cancer (PCa) are far more likely to die from other causes, especially noncancer ailments such as cardiac disease, according to a new study. The majority of men with advanced PCa, however, die from their cancer.

Investigators said the study “provides the most contemporary and comprehensive evaluation of causes of death for men with PCa.” The findings are based on an analysis of data from 18 registries in the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) program.

The study examined the causes of death among 200,302 men with PCa. Of the 172,767 men with local or regional PCa, 29,048 (16.8%) died from PCa, whereas 33,176 (19.2%) died from other cancers and 110,543 (64%) died from noncancer causes, Adam B. Weiner, MD, of Northwestern University Feinberg School of Medicine in Chicago, and colleagues reported in Cancer. Cardiac-related illness continued on page 9

making individual patient-level treatment decisions.”

Of the 1463 men, 565 received RT alone and 898 received RT plus ADT. The investigators defined unfavorable-risk PCa according to National continued on page 9

IN THIS ISSUE 6

Patients with advanced RCC can harbor occult brain metastasis

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Urologists are performing more PCNL renal access procedures

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Prostate radiotherapy found to increase survival in mHSPC

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Prostate cancer ADT is linked to dementia in younger men

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Ureteral stenting during bladder CA surgery may raise UTUC risk

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Renal hypothermia during PN shown to have no benefit

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Screening rates for prostate cancer fell early in the pandemic Treating psoriasis in patients with ESKD lowers their risk for some infections.

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4 Renal & Urology News

MAY/JUNE 2021 www.renalandurologynews.com

FROM THE EDITORIAL ADVISORY BOARD EDITORIAL ADVISORY BOARD

Pandemic’s Effects May Provide ESKD Insights

T

he COVID-19 supplement of the 2020 US Renal Data System 2020 Annual Data Report provides important insights into dialysis and chronic kidney disease (CKD) during the COVID-19 pandemic. Key findings include 11,200 COVID-19 hospitalizations among Medicare beneficiaries during the first half of 2020, with the rate of COVID19 hospitalizations being 3-4 times higher in hemodialysis compared with peritoneal dialysis patients. All-cause mortality was 37% higher during weeks 14-17 of 2020. A particularly important finding was a 20% decline in incident end-stage kidney disease (ESKD) cases, defined as dialysis initiations and preemptive kidney transplantations, during weeks 12-19 of 2020 compared with the corresponding period during 2017-2019.

What could explain a decline in new dialysis starts? Did more patients die at home without receiving dialysis, or perhaps opt for conservative therapy with the possibility of choosing dialysis at a later time point? Or did a decreased frequency of clinic visits result in delayed estimated glomerular filtration rate (eGFR) determinations and a later start of dialysis?

As we attempt to explain the drop in dialysis initiation early in the pandemic, we might consider the possibility that the decline occurred in mildly symptomatic or asymptomatic patients who were not started on dialysis due to lack of eGFR determinations early in the pandemic. Examination of the age groups in which the decline occurred may help to zero in on the cause. It also is important to determine if patients started dialysis at a lower eGFR during this period and how this affected patient survival.

Although early dialysis initiation was not found to be beneficial in the IDEAL study1 published in 2010, nephrologists have likely been slow to adapt these findings to clinical practice, with results from the USRDS in 2018 showing a median eGFR of 9.2 mL/min/1.73 m2 at the start of dialysis, being only marginally lower than in 2013 at 9.4 mL/ min/1.73 m2. A recent propensity score weighted analysis2 of USRDS data revealed a higher mortality risk for patients starting dialysis at higher eGFR values. These investigations suggest that some patients with late-stage CKD may be starting dialysis too soon.

The COVID-19 pandemic has touched each of us in our personal and professional lives. We have sadly seen many of our patients die from this terrible illness. We have also adapted with telehealth visits, decreased office visits, and decreased laboratory determinations. The effects of these practices could affect our patients and our practices for months and years to come.

Anthony J. Bleyer, MD Professor of Internal Medicine/Nephrology Wake Forest University School of Medicine Winston-Salem, North Carolina 1. Cooper BA, Branley P, Bulfone L, et al. A randomized controlled trial of early versus late initiation of dialysis. N Engl J Med. 2010; 363:609-619.

2. Bozorgmehri S, Aboud H, Chamarthi G, et al. Association of early initiation of dialysis with all-cause and cardiovascular mortality: A propensity score weighted analysis of the United States Renal Data System. Hemodial Int. 2021;25:188-197.

Medical Director, Urology

Medical Director, Nephrology

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

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

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

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

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

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

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

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

Renal & Urology News (ISSN 1550-9478) Volume 20, Number 3. Published bimonthly by Haymarket Media, Inc., 275 7th Avenue, 10th Floor, New York, NY 10001. For Advertising Sales & Editorial, call (646) 638-6000 (M–F, 9am–5pm, ET). For reprint/licensing requests, contact Customer Service at custserv@haymarketmedia.com. Postmaster: Send address changes to Renal & Urology News, c/o Direct Medical Data, 10255 W. Higgins Rd., Suite 280, Rosemont, IL 60018. 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 © 2021.

Contents

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ONLINE

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this month at renalandurologynews.com 12

Clinical Quiz Test your knowledge by taking our latest quiz at renalandurologynews.com/ run-quiz

HIPAA Compliance Read timely articles on various issues related to keeping protected health information secure.

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Drug Information Search a comprehensive drug database for prescribing and other information on more than 4000 drugs.

ADT, Dementia Linked in Younger Men Androgen deprivation therapy in men aged 40 to 64 years with nonmetastatic prostate cancer ups the risk for new-onset dementia and depression.

Inducing Hypothermia During PN Not Beneficial The strategy does not preserve remaining kidney function, according to researchers.

Editor’s note: Given the pandemic-related uncertainty whether live in-person medical conferences will take place, Renal & Urology News has omitted the cities in which they had been scheduled.

Canadian Urological Association Annual Meeting June 26–29 European Association of Urology Annual Congress July 9–13 American Urological Association Annual Meeting September 10–13 International Continence Society Annual Meeting October 12–15 American Society of Nephrology Kidney Week November 2-7

NSAIDs Linked to Reduced Kidney Function Any exposure to nonsteroidal anti-inflammatory drugs was associated with a 71% increased risk of incident eGFR less than 60 mL/min/1.73 m2, a study found.

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SMI Predicts KT Outcomes in Older Men A low skeletal muscle index in male kidney transplant recipients aged 60 years or older increases the risks for a combined endpoint of graft failure and death.

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CALENDAR

Society of Urologic Oncology Annual Meeting December 1-3

Lupus Nephritis in SLE Increases Risk for Preeclampsia, Study Shows In a study of pregnant women with systemic lupus erythematosus, 25.7% of those with LN had preeclampsia versus 2.9% of those without renal involvement.

News Coverage Visit our website for daily reports on the latest developments in clinical research.

Prostate RT May Up Survival in mHSPC Investigators demonstrated a benefit from radiation therapy directed at the primary prostate tumor.

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

Urologists Are Performing More Renal Access Procedures for PCNL The proportion of urologists obtaining renal access for percutaneous nephrolithotomy rose from 12.8% in 2007 to 32.3% in 2017.

Nephrology 11

Renal & Urology News 5

VOLUME 20, ISSUE NUMBER 3

Urology 8

MAY/JUNE 2021

Psoriasis Therapy Beneficial in ESKD The condition increases risk for certain infections, but treating it decreases risk for some of these infections and improves survival, investigators reported.

Structural inequities in our society leave a number of ethnic and minority groups at a distinct disadvantage when it comes to things like the ability to donate a kidney.

See our story on page 20

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Departments 4

From the Editorial Advisory Board ESKD insights from the COVID-19 pandemic

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News in Brief Pregnancy increases the risk for symptomatic kidney stones

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Ethical Issues in Medicine Managing uncertainty in patient care

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Practice Management Telehealth proves popular among patients

6 Renal & Urology News MAY/JUNE 2021 www.renalandurologynews.com

News in Brief

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

Short Takes Risk Factors for Urgent-Start Dialysis Identified

­dying from PCa, Per-Olof Lundgren,

Investigators have identified factors

Karolinska University Hospital in

that put patients with chronic kidney

Stockholm, Sweden, and colleagues

disease (CKD) at increased risk for

reported in BJU International. A free-

urgent-start dialysis, according to a

to-total PSA ratio of 0.25 or higher

recent report in Nephrology Dialysis

extended the low-risk range to a PSA

Transplantation.

level less than 2.0 ng/mL (1.5% risk).

In the CKD-REIN prospective cohort study that included 3033 patients

MD, of the Karolinska Institutet and

PCa mortality risk increased by 4% for each 1 unit increase in baseline PSA.

seen in 40 French nephrology clinics, Paris-Saclay, and colleagues found

Graft Loss Tied to Pre-KT Unintentional Weight Loss

that low health literacy, living alone,

Unintentional weight loss prior to

heart failure, and polypharmacy were

kidney transplantation (KT) results

significantly associated with 2.2-, 2.1-,

in worse post-transplant outcomes,

2.6-, and 2.1-fold increased odds of

investigators reported in Nephrology

urgent-start dialysis.

Dialysis Transplantation.

Single PSA Test Can Predict PCa Death Risk

team led by Mara McAdams-DeMarco,

A low baseline level of PSA and a large

School of Medicine in Baltimore,

fraction of free PSA predict a low risk

Maryland, and colleagues found that

of dying from prostate cancer (PCa)

unintentional weight loss of 5% or

according to investigators.

greater was independently associated

Victor Fages, MD, of the Université

In a study of 919 KT recipients, a MD, of Johns Hopkins University

The finding is from a prospective

with an 80% and 91% increased risk

cohort study of 1782 men aged 55

for death-uncensored and death-cen-

to 70 years screened for PCa in 1988

sored graft loss, respectively, and a

and 1989. After 30 years of follow-

72% increased all-cause mortality risk

up, men with PSA levels less than 1.0

compared with stable pre-KT weight

ng/mL at baseline had a 1.2% risk of

(weight change of 5% or less).

Hypertension in Pediatric Diabetes Approximately one-quarter of pediatric patients aged 7 to 20 years with type 2 diabetes have hypertension, according to a recent meta-analysis. The prevalence varies by racial group, as shown below.

26.7%

26.5% 21.0%

19.0%

18.4% 15.1%

Pacific Islander

Indigenous

White

Black

Asian

Hispanic

Source: Cioana M, Deng J, Hou M, et al. Prevalence of hypertension and albuminuria in pediatric type 2 diabetes: a systematic review and meta-analysis.

JAMA Netw Open.

Preemptive Therapy May Cut FSGS Recurrence Risk in KTRs P

reemptive therapeutic plasma exchange and rituximab treatment may lower the risk of recurrence of focal segmental glomerulosclerosis (FSGS) in kidney transplant recipients (KTRs), according to study findings presented at the virtual National Kidney Foundation 2021 Spring Clinical Meetings.

Venkata Kishore Mukku, MD, of The University of Texas Medical Branch in Galveston, and colleagues studied 18 KTRs in whom FSGS was the primary cause of end-stage kidney disease. Of these, 8 underwent preemptive TPE/rituximab treatment (group 1) and 10 did not (group 2). The median follow-up duration was 2 years for group 1 and 3 years for group 2. Three patients in group 2 had FSGS recurrence, including a patient who experienced allograft loss, compared with none in group 1, the investigators reported in a poster presentation.

Occult Brain Metastases Found in Advanced RCC R

ecent study findings suggest a rationale for brain screening of patients with advanced renal cell carcinoma (RCC), investigators concluded in a paper published in the Journal of the National Comprehensive Cancer Network (2021;19:432-438).

A retrospective study of 1689 patients with metastatic RCC screened for 68 clinical trials identified occult brain metastases in 72 (4.3%), Ritesh R. Kotecha, MD, of Memorial Sloan-Kettering Cancer Center in New York City, and colleagues reported. Of these, 26%, 61%, and 13% had favorable-, intermediate-, and poorrisk disease, respectively, according to International Metastatic RCC Database Consortium criteria. The patients had a median overall survival (OS) time of 10.3 months and a 1-year OS probability of 48%.

“Screening should be considered for patients with high metastatic burden or those who have experienced disease progression after first-line therapy,” the authors concluded.

Pregnancy Tied to Higher Risk of Symptomatic Kidney Stones P

regnancy is associated with an elevated risk for a first-time symptomatic kidney stone, according to the findings of a case-control study. The risk begins to increase in the second trimester and peaks just after delivery.

Compared with nonpregnant women, women in the second and third trimester of pregnancy have significant 2.0- and 2.7-fold increased odds of forming their first kidney stone, a team led by Andrew D. Rule, MD, of Mayo Clinic in Rochester, Minnesota, reported the American Journal of Kidney Diseases. From 0 to 3 months after delivery, women had a 3.5-fold increased risk of kidney stone formation.

Kidney stone risk returned to baseline by 1 year after delivery.

The authors concluded that prenatal counseling of kidney stone risk with pregnancy may be warranted, particularly for women with other risk for kidney stones, such as obesity, diabetes, or family history of kidney stones.

The study included 945 women aged 15 to 45 years who had a first-time symptomatic kidney stone and an age-matched control group of 1890 women.

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Renal & Urology News 7

Race, Ethnicity Affect ADPKD Outcomes Studies reveal differences in mortality rates and age at onset of end-stage kidney disease RACE AND ETHNICITY affect the course and outcomes of autosomal dominant polycystic kidney disease (ADPKD), findings from separate studies suggest.

In one study, Greg Mader, PhD, of RTI Health Solutions in Research Triangle Park, North Carolina, and colleagues identified racial differences in mortality rates among older patients with ADPKD. Using 2014-2016 data from the US Renal Data System, Dr Mader’s team calculated mortality rates for patients aged 65 years and older with ADPKD, including 1551 without end-stage kidney disease (ESKD) who had a mean age of 76.5 and 14,756 with ESKD who had a mean age of 70.8 years. In the cohort without ESKD, age-adjusted mortality was 61.9 per 1000 patientyears overall. Black patients had the highest age-adjusted mortality rate at 82.7 per 1000 patient-years, whereas White, Hispanic, Asian, and patients of other races all had rates below the mean at 59.5, 41.4, 51.2, and 54.2 per 1000 patient-years, respectively.

In the cohort with ESKD, the overall age-adjusted mortality rate was high at 129.6 per 1000 patient-years. This time, White patients had the highest death

Mortality By Race and Ethnicity Among patients with autosomal dominant polycystic kidney disease but not end-stage kidney disease, Black patients had the highest age-adjusted mortality rate (per 1000 patient years), a study found.

80

82.7%

60

59.5%

51.2%

40

41.4%

20 0

Black

White

Asian

Hispanic

Source: Mader G, Mladsi D, Zhou X, et al. Racial differences in mortality rates among elderly non-ESRD CKD and ESRD patients with autosomal dominant polycystic kidney disease (ADPKD): study findings using data from the USRDS. Presented at the virtual National Kidney Foundation 2021 Spring Clinical Meetings, April 6-10, 2021. Poster 312.

rate — 136.1 per 1000 patient-years — whereas Black, Hispanic, Asian, and patients of other races had rates below the mean at 123.3, 100.3, 102.9, and 94.2 per 1000 patient-years, respectively.

Only among Black men was mortality higher before kidney failure than after, indicating a possible survivorship effect.

“This would occur if black patients with ADPKD were less likely to receive dialysis or transplant and, therefore, were more likely to die prior to

i­nitiation of renal replacement therapy, with those black patients surviving to dialysis or transplant being relatively healthier than their white counterparts,” Dr Mader’s team wrote.

In another study, Teresa N. Harrison, SM, of Kaiser Permanente Research & Evaluation in Pasadena, California, and colleagues demonstrated that onset of ESKD in patients with ADPKD occurs earlier in Hispanic patients than in those of other races. The study, which included 3868 patients, found that the

mean age of ESKD onset was 50 years among Hispanic patients compared with 53, 56, and 57 years among Asian, Black, and White patients, respectively.

“To our knowledge, this study is one of the first to include Hispanic and Asian ADPKD patients and to report race/ethnic differences in the onset of ESKD,” the authors concluded.

The investigators defined ESKD onset as the initiation of dialysis or receipt of a kidney transplant.

The racial or ethnic distribution of patients in the cohort was 42% White, 32% Hispanic, 12% Black, and 10% Asian. Patients had a mean baseline estimated glomerular filtration rate of 67.4 mL/min/1.73 m2. The most common comorbidity was hypertension (53.5%), followed by abdominal pain (37.3%) and hyperlipidemia (32.7%). ESKD developed in 27% of the cohort.

The investigators pointed out that the study was limited by its retrospective design and its findings depended on the availability and accuracy of existing records. In addition, the study analyzed data from patients within a single, integrated healthcare system and therefore may not be generalizable to other settings, Harrison’s team noted. ■

Renal Denervation Has Positive Effects in HTN Cases Patients with higher plasma renin activity had significant reductions in systolic blood pressure RENAL DENERVATION (RDN) is associated with decreased plasma renin activity (PRA) and aldosterone levels in patients with hypertension, according to a recent study.

RDN is thought to interrupt the sympathetic-mediated neurohormonal pathway as part of its mechanism of action to reduce blood pressure (BP), noted study authors Felix Mahfoud, MD, of Saarland University Hospital in Homburg/Saar, Germany, and colleagues.

In a study of patients with hypertension who were not taking antihypertensive medications, RDN was significantly associated with decreased PRA and aldosterone levels at 3 months compared with a control group of patients who received a sham procedure.

The study included 331 patients who participated in the SPYRAL HTN-OFF

MED Pivotal trial: 166 in the RDN group and 165 in the control arm. At baseline, the intervention and control groups had similar PRA values

Significant declines observed in plasma renin activity and aldosterone levels.

(1.0 and 1.1 ng/mL/h, respectively).

At 3 months, the change in PRA from baseline was significantly greater for the RDN than control group (–2.0 vs 0.1 ng/mL/h), Dr Mahfoud’s team reported in the Journal of the American College of Cardiology. The RDN-treated patients also experienced a significantly

greater reduction in aldosterone level at 3 months compared with the control arm (–1.2 vs 0.4 ng/mL).

The investigators compared the effect of RDN in patients with a baseline PRA of 0.65 ng/mL/h or higher and those with a PRA less than 0.65 ng/mL/h.

Office and ambulatory BP measurements were similar for patients in both groups at baseline. The effect of RDN was stronger in the group with a baseline PRA of 0.65 ng/mL/h or higher.

In this group, the 24-hour systolic BP (SBP) at 3 months had decreased by 7.1 mm Hg in the RDN-treated patients compared with a decrease of 1.1 mm Hg in the control arm, a significant difference between the groups.

Among patients with PRA less than 0.65 ng/mL/h, both study arms had smaller decreases in PRA (–1.5 and

–0.7 mm Hg in the RDN and control groups, respectively), and the betweengroup difference was not significant.

The effect of RDN on office SBP also was more pronounced in the patients with a baseline PRA of 0.65 ng/mL/h or higher. At 3 months, RDN-treated patients had a 12.8 mm Hg reduction in office SBP, whereas those in the control arm had a 2.9 mm Hg reduction, a significant difference between the groups. In the patients with lower PRA, the reductions were 7.1 and 3.7 mm Hg, respectively, a nonsignificant difference.

Dr Mahfoud and colleagues pointed out that they observed reductions in office SBP according to baseline PRA at 2 weeks post-procedure, indicating that RDN impacts renal physiology as early as 2 weeks after treatment. ■

MAY/JUNE 2021 www.renalandurologynews.com

Urologists Are Performing More Renal Access Procedures for PCNL UROLOGISTS ARE increasingly performing their own initial renal access procedures for percutaneous nephrolithotomy (PCNL), with a corresponding decrease in the proportion of those procedures performed in interventional radiology (IR) departments, according to a recent study.

The proportion of urologists performing their own de novo renal access for PCNL rather than having patients undergo the procedure in an IR department rose from 12.8% in 2007 to 32.3% in 2017, Ian S. Metzler, MD, of the University of Washington School of Medicine in Seattle, and colleagues in the Journal of Endourology.

De novo renal access “is the most technically challenging aspect of the PCNL procedure and therefore remains a considerable barrier for wider adoption of PCNL,” Dr Metzler’s team wrote.

Although IR departments performed a shrinking proportion of renal access procedures during the study period, they still performed a greater proportion (40%) of the procedures in 2017 compared with urologists. In 27.7% of PCNL cases in 2017, no provider-assigned renal access CPT code for renal access was available, the investigators noted.

Use of PCNL, a common approach for staghorn stones, has remained stable.

Use of PCNL remained stable during the 10-year study period at around 3% to 4%, whereas use of ureteroscopy (URS) use increased from 46.3% to 60.0% of procedures and extracorporeal shockwave lithotripsy (SWL) use decreased from 50% to 36.7% of procedures.

Compared with urologist-gained access, radiologist-gained access was associated with a significantly greater percentage of patients requiring a

­ ospital stay of more than 2 days h (30.8% vs 18.6%) and a significantly higher 90-day rate of hospital readmission (16.7% vs 12.8%), and 90-day blood transfusion rate (0.8% vs 0.3%), according to the investigators.

“We were encouraged to see that the uptake of urologists obtaining their own access has increased over the last decade and that their outcomes on selected patients were comparable to our IR colleagues,” Dr Metzler told Renal & Urology News. “PCNL remains a lower-volume, but critically important procedure for urologists and continued support for education and training of percutaneous access should be emphasized.”

The study also revealed trends in the use of PCNL, URS, and SWL during 2007 to 2017. Using the MarketScan insurance claims database, the investigators used CPT codes to identify PCNL, URS, and SWL cases. During the 10-year study period, the annual proportion of PCNL procedures peaked at 4.5%, with a recent decline in 2016 and 2017 to 3.2%, Dr Metzler’s team reported. While URS use increased steadily from 46.3% to 60.0% of procedures, SWL use decreased from 50.0% to 36.7% of procedures. ■

In-Person CKD Visits Plummeted Early in Pandemic

BY NATASHA PERSAUD IN-PERSON VISITS among patients last known to have stage 3 to 4 chronic kidney disease (CKD) declined dramatically early in the COVID-19 pandemic compared with usual levels, and telehealth did not fully compensate for the loss in medical care, investigators revealed during the virtual National Kidney Foundation 2021 Spring Clinical Meetings.

According to data from United Health Medicare Advantage program, 2.74 million in-person visits were predicted for the early pandemic period March 1 to June 30, 2020, but only 1.56 million inperson visits occurred — a 44% loss of in-person services, Clarissa Diamantidis, MD, of Duke University in Durham, North Carolina, and colleagues reported.

Telehealth visits ramped up in April and May 2020, briefly approaching the number of in-person visits that would be expected, then declined in late May

as in-person visits resumed, the investigators observed. Telehealth visits supplemented in-person care by 12.5% early in the early pandemic, the investigators reported. The overall deficit in CKD care was 30%, they said. Total visits peaked in mid-June 2020 at 86% of predicted visits. Currently, CKD care appears to be at 5% below prepandemic utilization rates according to other sources, Dr Diamantidis told Renal & Urology News.

In addition, the team observed a reduction in medication coverage early in the pandemic, such as the number of days patients were covered by antihypertensives and diabetes medications, and a reduction in procedures, particularly lab tests used to monitor CKD (such as metabolic panel, urinary albumin quantification, and assays of urinary creatinine).

“The downstream impact of CKD care reduction on health outcomes, such as hospitalizations or dialysis p ­ reparedness,

requires further study, as does ­evaluation of which care delivery models are most effective for CKD populations,” Dr Diamantidis said. She said she hopes further research will distinguish areas of low value care from high value care.

Dr Diamantidis added that it is clear that nephrologists need to partner more with primary care physicians.

“The pandemic has taught us that digital care is possible and acceptable,” Dr Diamantidis said. “Prior to COVID19, there was a great deal of hesitation about using telehealth due to reimbursement issues — which have been mitigated due to new policies — technology issues, and the desire to interact with patients. Data are showing that telehealth visits are patient-centric, cost-effective, and efficient. Telehealth does not substitute for in-person visits, but it can supplement them. Notwithstanding, the digital divide in internet access, digital readiness, and trust remain an issue.” ■

Graft Failure Tied to Low Bicarbonate LOW SERUM bicarbonate in kidney transplant recipients is associated with an increased risk for graft failure, according to data presented at the virtual National Kidney Foundation 2021 Spring Clinical Meetings.

A study of a real-world population of 1722 renal transplant recipients who had a functioning graft at 1 year showed that each 1 mEq/L increase in serum bicarbonate over time was associated with a 10% reduction in graft failure risk in adjusted analyses, Vandana Mathur, MD, a nephrologist and president of MathurConsulting in Woodside, California, and colleagues reported in a poster presentation.

In addition, each 1 mEq/L increase in serum bicarbonate was associated with a 4% increased risk for a composite of major cardiovascular (CV) events (MACE+) that included the first occurrence of myocardial infarction, stroke, new-onset heart failure (HF), a HF inpatient admission in patients with comorbid HF, or CV death.

“Since metabolic acidosis is a risk factor for [chronic kidney disease] progression, we examined its role in predicting long-term graft loss in kidney transplant recipients in a large US community-based cohort,” Dr Mathur’s team explained.

They concluded, “The role of metabolic acidosis as a modifiable risk factor for chronic allograft nephropathy and MACE+ deserves further examination.”

The investigators analyzed data from the Optum EHR+Integrated dataset of US patients (2007-2019) with a kidney transplant preceded by 1 year or more of data and no graft loss during the first year.

The study cohort, which had a mean age of 51.1 years, consisted of 1034 male (60%) and 688 (40%) female patients. At baseline, patients had a mean estimated glomerular filtration rate of 63.4 mL/min/1.73 m2 and mean baseline serum bicarbonate level of 24.6 mEq/L. ■

© DU CANE MEDICAL IMAGING LTD / SCIENCE SOURCE

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No ADT-CV mortality link continued from page 1

Comprehensive Cancer Network criteria (clinical T2b-T4, Gleason score 7-10, or PSA level greater than 10 ng/mL).

They defined CV mortality as death from cardiac causes, stroke, or other vascular causes.

In an acknowledgment of study limitations, Dr Mualidhar’s team said it is possible that a difference in CV mortality by ADT use exists and that the study was underpowered to detect it. In addition, the PLCO trial lacked important clinical data endpoints, including development of nonlethal myocardial infarction, CVD, and diabetes, all of which have been associated with ADT use in prior studies, they noted.

Commenting on the new study, Sanoj Punnen, MD, MAS, associate professor of urology at the University of Miami Miller School of Miami, said the new findings add to the literature showing

Early PCa rarely fatal continued from page 1

was the most common noncancer cause of death (23.3%).

During follow-up, the risk of death overall was 10% lower for men with local or regional PCa compared with the general population, and, in particular, in the first year after diagnosis (42% lower).

Among the 27,535 men with distant PCa who died, PCa was the cause of death in 20,451 cases (74.3%). Another 1709 (6.2%) died from other cancers and 5375 (19.5%) died from noncancer causes. Also, 90% of deaths among men with distant PCa occurred within 5 years of diagnosis. Compared with the general population, men with distant PCa were 1.5-fold more likely to die from noncancer causes, notably suicide and sepsis.

Inflammatory diet continued from page 1

China Hospital, Sichuan University in China, reported in The Journal of Urology.

The odds of testosterone deficiency increased 4.0% for every unit increase in DII. In a fully adjusted model, men in tertiles 2 and 3 had significant 19% and 30% increased odds of testosterone deficiency compared with men in tertile 1.

Obese men with more pro-inflammatory diets (tertiles 2 and 3) had 15.91 and 26.75 ng/mL lower total testosterone than men with an anti-inflammatory diet (tertile 1). Results showed that obese men in the higher DII tertiles had

similar CV mortality risk between RT alone and RT plus ADT. In his view, he said, the biggest study limitation was that the decision regarding who received RT alone or in combination with ADT was based on routine clinical practice and did not follow a scientific protocol, a possible source of selection bias. The study authors, however, did

acknowledge that “the trial did not specifically dictate medical practice, implement uniform diagnostic and treatment protocols, or record data on clinician reasoning behind management decisions— all of which may create the potential for selection bias in our study.” The authors

noted that men with more than 1 comorbidity were less likely to receive ADT. Dr Punnen, who is co-chair of the Genitourinary Site Disease Group at the University of Miami’s Sylvester Comprehensive Cancer Center, pointed out that the new findings “are pertinent to those who are undergoing current ADT as part of radiation and may not be generalizable to those placed on longer durations of continuous ADT for recurrence or metastatic disease.”

The study by Dr Muralidhar’s group adds to a growing body of research examining the CV safety of ADT. A recent study conducted in South Korea found that ADT might even decrease the risk for ischemic CVD and cerebrovascular disease. In a propensity-scorematched cohort that included 61,722 men with PCa, men who received ADT, compared with those who did not, had a significant 11.0% and 13.1% reduced risk for ischemic CVD and cerebrovascular disease, respectively. ■

“Overall, our work highlights new opportunities to optimize overall health care management for men with distant PCa,” the authors wrote.

With regard to study limitations, the authors noted the SEER dataset for active surveillance (AS) and watchful waiting (WW) only extends back to 2010 and does not distinguish between these management approaches. AS involves disease monitoring with intent to provide curative treatment if signs of disease progression emerge, whereas WW often describes potential future treatment to palliate symptoms, they pointed out. “Patients managed with active surveillance or watchful waiting would likely greatly differ in that men managed with watchful waiting often elect watchful waiting because other comorbid health concerns which may limit

life expectancy take priority over PCa,” Dr Weiner’s team wrote. “Thus, the heterogeneity of this subgroup within SEER would limit interpretability.”

In an accompanying editorial, Joseph E. Bauer, PhD, of the Levine Cancer Institute/Atrium Health in Charlotte, North Carolina, praised the new study

by Dr Weiner and his colleagues.

“Their detailed account presents an increased awareness/sensitivity for clinical practitioners, including oncologists, radiation oncologists, urologists, and primary care physicians, among others.”

Dr Bauer added, “Think of their research findings as placing a bit more focus on noncancer causes of death in PCa survivors; this gives clinical practitioners the chance to affect the current mortality patterns by prioritizing health care management decisions.” ■

s­ ignificant 31% and 59% increased odds of testosterone deficiency, respectively.

“Our results suggest men who eat a pro-inflammatory diet, particularly those who are obese, are more likely to have testosterone deficiency,” Dr Qiu stated in a press release from the journal’s publisher. “Since men with obesity likely already experience chronic inflammation, physicians should be aware of contributing factors, like diet, that could likely worsen this inflammation and contribute to the risk of other health conditions, such as diabetes and heart disease.”

The authors acknowledged study limitations, the main one being that the NHANES database provides only

c­ ross-sectional data, “which severely hinders our ability to a make a causal inference.” They had to rely on selfreported dietary intake, which is subject to recall bias and is estimated from a 24-hour history, which cannot reflect the day-to-day variability in intake. The investigators were unable to directly exclude patients diagnosed with hypogonadism because those data are not available in the NHANES database, they noted. In addition, serum testosterone was only assayed at a single time point, and American Urological Association guidelines recommend obtaining 2 measurements because of intra-individual and diurnal variations in serum testosterone, they pointed out. ■

In a study, adding ADT to radiotherapy did not significantly up CV death risk.

Renal & Urology News 9

GG5 Pattern Influences PCa Mortality Risk PROSTATE CANCER (PCa) mortality differs by specific Gleason grade group (GG) 5 pattern, according to a new study.

Men with Gleason pattern 5+4 and 5+5 had significantly increased risks for cancer-specific mortality (CSM) compared with those with Gleason pattern 4+5, Mike Wenzel, MD, of the University Hospital Frankfurt in Germany and colleagues reported in a paper published in European Urology Focus.

“Ideally, individual Gleason patterns should be considered in pretreatment risk stratification,” they wrote.

Using the 2004-2016 data from the Surveillance, Epidemiology and End Results (SEER) database, the researchers identified 17,263 men with GG 5 cancer at biopsy, including 12,705 with Gleason 4+5, 3302 with Gleason 5+4, and 1256 with Gleason 5+5 disease. All patients underwent radical prostatectomy (RP) or external beam radiation therapy (EBRT).

Findings could have implications for pretreatment risk stratification.

The 5- and 10-year CSM rates were 7.3% and 18.2% for Gleason 4+5, 11.7% and 28.0% for Gleason 5+4, and 19.8% and 39.1% for Gleason 5+5, respectively, Dr Wenzel and his colleagues reported.

In multivariable analyses, Gleason 5+4 and Gleason 5+5 were associated with 1.6- and 2.2-fold higher CSM risks, respectively, compared with Gleason 4+5. The risks varied by treatment subgroup. Compared with Gleason 4+5, Gleason 5+4 was significantly associated with approximately 1.6- and 2.5-fold increased CSM risks among patients who underwent RP and EBRT, respectively. Gleason 5+5 was significantly associated with approximately 1.5- and 2.1-fold increased risks, respectively.

“Prostate cancer characteristics were increasingly unfavorable with increasingly aggressive Gleason pattern from 4+5 to 5+4 to 5+5,” Dr Wenzel’s team observed. They noted that the death risk associated with Gleason pattern 5+5 cancer was even higher for patients undergoing RP than EBRT, perhaps partly due to use of androgen deprivation therapy. ■

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Prostate RT May Up Survival in mHSPC Radiation therapy directed at the primary prostate tumor reduced mortality risk by 31%, study shows RADIATION therapy (RT) directed at the primary prostate tumor in patients with newly diagnosed metastatic hormone-sensitive prostate cancer (mHSPC) is associated with a statistically and clinically significant improvement in overall survival (OS), according to a recent study.

Scott C. Morgan, MD, of The Ottawa Hospital Cancer Centre in Ottawa, Canada, and colleagues studied a cohort of 410 patients with newly diagnosed mHSPC referred to a comprehensive cancer center from 2005 to 2015. Of these, 128 received prostate RT in addition to androgen deprivation therapy (ADT) and 282 received ADT alone. The median age of the ADT-only group was significantly higher than that of the prostate RT plus ADT group (77.5 vs 70 years). The median followup duration was 61 months.

The median OS was 47.4 months for the prostate RT group compared with

26.3 months for patients who did not receive prostate RT. On multivariate analysis, prostate RT was significantly associated with a 31% decreased risk of death compared with no prostate RT, the investigators reported in Prostate Cancer and Prostatic Diseases.

Study compared prostate radiation therapy plus ADT with ADT alone.

In addition, among patients who received prostate RT, OS improved along with increases in the biologically effective radiation dose. Each 10 Gy increase was significantly associated with a 13% decreased risk of death, according to the investigators.

COVID-19 Vaccine Hesitancy Common in Dialysis Population ALTHOUGH PATIENTS on dialysis are

Vaccine acceptability was lower

at increased risk for severe COVID-19-

among women, younger age groups

related complications, a substantial

(18-44 years), and patients identify-

percentage are hesitant to obtain a

ing as Black, Native American, or

SARS-CoV-2 vaccination, according to

Pacific Islander, the investigators

new nationwide survey results pre-

found. Although older patients were

sented during the virtual 2021 National

more accepting, the team encouraged

Kidney Foundation Spring Clinical

vaccination efforts toward this group

Meetings.

because older patients are at higher

A total of 943 patients from 135 facilities within a large dialysis network

risk for serious illness.

COVID-19 vaccine hesitancy declined

responded to an anonymized survey

to 18% of all respondents and 26% of

administered in English or Spanish via

respondents aged 18-44 years if the

tablet or smartphone during January

vaccine were offered at dialysis facili-

8 to February 11, 2021. In all, 22% of

ties. On March 25, the Biden adminis-

respondents and 34% of those aged

tration announced that SARS-CoV-2 vac-

18-44 years reported that they would

cines would indeed be made available

likely not seek a COVID-19 vaccine

to dialysis facilities for administration.

even if the vaccine were proven safe

“We believe this action will facilitate

and effective for the general popula-

access to vaccines—which seems to

tion, Pablo Garcia, MD, of Stanford

be the primary barrier in our population,

University in Palo Alto, California, and

rather than hesitancy,” Dr Garcia told

colleagues reported.

Renal & Urology News. “However, out-

Half of vaccine-hesitant respondents

reach programs targeted to the groups

expressed concerns about side effects

with lower vaccine acceptability will be

and 19% indicated concern about vac-

crucial to achieving levels of vaccinations

cine efficacy.

high enough to reach ‘herd immunity.’ ” ■

“To our knowledge, this cohort represents the largest single-institution experience with primary tumor-directed RT in mHSPC reported to date,” Dr Morgan’s team wrote. “Receipt of prostate RT in this cohort was associated with a clinically significant improvement in OS.” The authors noted that their cohort predated the debut of docetaxel and potent androgen receptor pathway inhibitors for use in mHSPC. “Whether the benefit of prostate RT in mHSPC will persist when used in addition to these therapies—or indeed, be enhanced by co-administration with these therapies—awaits the results of trials in progress.”

The authors acknowledged that the study was limited by its retrospective and nonrandomized design. They noted that there were significant differences in the baseline characteristics

of men who received prostate RT and those receiving ADT alone.

“Some of these differences reflect the treatment policy at our center at the time, with locally advanced primary tumors being favored for receipt of RT,” Dr Morgan and his collaborators wrote. “Our analysis has adjusted for differences in these known baseline prognostic factors.”

In addition, they noted that certain patient and disease characteristics could not be captured reliably from a retrospective review of records.

“Specifically, this analysis could not account for performance status, volume of metastatic disease, comorbidities, receipt of systemic therapies at time of castration resistance, and other potential confounders,” they wrote. “These results should therefore be interpreted with some caution; residual confounding is possible.” ■

Outcome Predictors in Pediatric LN

Transplantation. Patients who attained complete response at 6 months after induction treatment had better renal survival than patients who did not respond to treatment. The risk for poor renal outcome, defined as GFR less than 60 mL/min/1.73 m2 or dialysis), was a significant 8.6- and 13.8-fold higher for patients who did not attain remission at 6 and 12 months, respectively.

In addition, male vs female gender was significantly associated with an 8.4fold increased risk for poor renal outcomes. Requiring dialysis at the time of LN diagnosis was significantly associated with a 6.5-fold increased risk.

The remission rate at 6 months was significantly higher among patients treated with mycophenolate mofetil (MMF) or cyclophosphamide (CYC) compared with other combination therapies.

They observed no significant difference between the CYC and MMF groups’ response rates, although 79% of class 4 patients received CYC as induction therapy. By 12 months, response rates were comparable across treatment groups.

Renal survival rates at 5 and 10 years were 92% and 85.7%, respectively.

In the proliferative LN group, renal survival rates were 90.5% and 75%, respectively.

According to Dr Topaloğlu’s team, “prompt recognition and aggressive management of pediatric LN is essential to achieve and maintain remission.” ■

THE BEST PREDICTORS of poor renal outcomes in pediatric patients with lupus nephritis (LN) include male gender, requiring dialysis at the time of diagnosis, and failure to achieve remission within 1 year after induction therapy, recently reported data suggest.

The data are from a study that included 53 patients with childhood-onset systemic lupus erythematosus: 32 who were concurrently diagnosed with LN (median age 12.1 years) and 21 patients in whom LN developed later (median age 13.8 years). Patients with a concurrent LN diagnosis were significantly more likely to have arthritis (62.5% vs 33.3%) and a lower estimated glomerular filtration rate (eGFR; 110 vs 147 mL/min/1.73 m2) compared with patients who later developed LN. Renal biopsy results showed that 54.7% of patients with LN had class 4 and 22.6% had class 3 disease.

Among treated patients, 77.3% and 73% achieved complete or partial remission at 6 and 12 months, respectively, Rezan Topaloğlu, MD, PhD, of Hacettepe University in Ankara, Turkey, reported in Nephrology Dialysis

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Renal & Urology News 11

NSAIDs Linked to Reduced Kidney Function Ibuprofen had the smallest negative effect on eGFR of 9 oral nonsteroidal anti-inflammatory drugs studied

VFA Superior at Predicting CV Outcomes VISCERAL FAT area (VFA) is a better predictor of cardiovascular outcomes and all-cause mortality in patients on hemodialysis compared with coronary artery calcification (CAC) score, a recent study suggests.

The study included 97 Chinese patients on hemodialysis (HD). They had a median VFA and CAC score at baseline of 64.5 cm2 and 0.9, respectively.

Cardiovascular events (CVEs) occurred in 20 patients (20.6%) during a median follow-up of 26.4 months. Cardiovascular death (CVD) and all-cause mortality rates were 8.2% and 11.3%, respectively.

A VFA of 71.3 m2 or higher was significantly associated with a 9.2-fold increased risk for CVEs compared with a VFA less than 71.3 m2, Yuqin Xiong, MD, of West China Hospital, Sichuan University, Chengdu, China, and colleagues reported in the Journal of Renal Nutrition.

Each 1 cm2 increase in VFA was significantly associated with an 11% increased risk for CVD and 8% increased risk for all-cause mortality. CAC score was

NSAIDs and the Kidney In a recent study, any use of NSAIDs was associated with higher incidence rates of an eGFR less than 60 mL/min/1.73 m2, an eGFR decline of 30% or more, and a composite of both. Shown here are the rates per 1000 person-years.

PER 1000 PERSON-YEARS

EXPOSURE TO nonsteroidal antiinflammatory drugs (NSAIDs) is associated with higher risks for an incident estimated glomerular filtration rate (eGFR, in mL/min/1.73 m 2) below 60 and an eGFR decline of 30% or greater, investigators reported in the Clinical Journal of the American Society of Nephrology.

The study examined the effect of 9 oral NSAIDs on kidney function in a retrospective cohort of 1,982,488 Chinese individuals in Hong Kong aged 18 years or older with an eGFR higher than 60. The NSAIDs were ibuprofen, celecoxib, diclofenac, indomethacin, mefenamic acid, naproxen, piroxicam, sulindac, and etoricoxib.

Overall, NSAID treatment — defined as a prescription for NSAIDs for a minimum of 28 days — was significantly associated with a 71% increased risk of incident eGFR less than 60, 93% increased risk of an eGFR decline of 30% or greater, and 88% increased

n Any NSAID use

80 60 40 20 0

68.0

62.1 33.0

33.4

22.8

eGFR <60

eGFR decline ≥30%

n No NSAID use

36.8

Composite

Source: Wan EYF, et al. Comparative risks of nonsteroidal anti-inflammatory drugs on CKD. Clin J Am Soc Nephrol.

Published online ahead of print.

risk of the composite of either outcome compared with no NSAID use, Eric Yuk Fai Wan, MD, of The University of Hong Kong, and colleagues reported.Ibuprofen was the safest NSAID, conferring a significant 12% increased risk of incident eGFR

not significantly associated with CVEs, CVD, or all-cause mortality.

In addition, VFA was significantly correlated with cardiac structure parameters and development of left ventricular hypertrophy (LVH), according to the investigators. Each 1 cm2 increase in VFA was associated with 2% increased odds of LVH development.

“Increased VFA can be used as an independent predictor for CVEs, CVD, and all-cause mortality,” the authors concluded. “The effect VFA exerts on cardiac reconstruction might be the underlying mechanism.”

The study patients ranged in age from 35 to 62 years. Of the 97 patients, 60 (61.9%) were male. The median dialysis vintage was 10 months. Investigators measured VFA using bioelectrical impedance analysis and determined CAC score using dual-source computed tomography scanning. They used echocardiography to ascertain left ventricular mass index.

Dr Xiong and colleagues acknowledged that their study had limitations.

The sample size was relatively small and they could not rule out patient selection bias. “For instance, patients who had relatively short dialysis vintage or low levels of serum hemoglobin or albumin were more likely to [give] consent [for] the study.” ■

less than 60, 32% increased risk of an eGFR decline of 30% or greater, and 34% increased risk of the composite outcome. Etoricoxib had the largest negative effect on k ­ idney function. Its use was significantly associated with a 3.1-fold increased risk of both incident

eGFR less than 60 and eGFR decline of 30% or greater as well as the composite of either outcome.

The incidence rates for an eGFR less than 60, an eGFR decline of 30% or greater, and the composite outcome were 33.0, 62.1, and 68.0 cases per 1000 person-years, respectively, for any NSAID use compared with 22.8, 33.4, and 36.8 per 1000 person-years for no NSAID use.

For the study, Dr Wan and colleagues used the clinical database maintained by the Hong Kong Hospital Authority, which manages the public health care sector in Hong Kong.

Individuals in the study had an average age of 55 years, and 47% were men. The investigators limited their analysis to 154,991 individuals who used NSAIDs and 1,734,701 who did not. During a median follow-up duration of 6.3 years, 271,848 cases of incident eGFR less than 60 and 388,386 events of an eGFR decline of 30% or greater occurred. ■

Lupus Nephritis in SLE Ups Risk for Preeclampsia, Study Shows THE RISK FOR preeclampsia and other

with renal flares, premature births, and

adverse outcomes in pregnant women

c-sections, the investigators reported.

with systemic lupus erythematosus

Women with and without LN had

(SLE) rises even higher with lupus

comparable duration of SLE (9 years)

nephritis (LN), a new study finds.

and age at motherhood (32 years).

Of 103 women with SLE who gave birth

Women with LN were significantly

at the Karolinska University Hospital in

more likely to have proteinuria early in

Stockholm, Sweden, from 2000 to 2017,

pregnancy (40.0% vs 0%). They also

35 women had previous or current LN.

had significantly higher creatinine (58

Among patients who had a renal biopsy,

vs 50 mmol/L) and lower estimated

5 had class 2 (16%), 7 class 3 (23%), 15

glomerular filtration rate (eGFR): 98.8

class 4 (48%), and 4 class 5 (13%) LN.

vs 111.5 mL/min/1.73 m2.

Preeclampsia was significantly more

Dr Chaireti’s team wrote that “despite

likely to develop in women with LN than

broader usage of medications such

in women with SLE and no renal involve-

as [hydroxychloroquine] and decrease

ment (25.7% vs 2.9%), Roza Chaireti,

in the rates of complications such

MD, of Karolinska Institutet in Solna,

as preeclampsia, pregnancies in

Sweden, and collaborators reported

women with SLE are still at high risk

online ahead of print in Lupus. Most

for obstetric complications. This was

of the women in whom preeclampsia

particularly obvious in patients with pre-

developed had class 3 or 4 LN. Having

vious or active LN, where the risk for

LN also was significantly associated with

preeclampsia was significantly higher

a higher proportion of premature births:

compared to both SLE patients without

25.6% vs 7.5%. In a separate analysis,

renal involvement and to the general

preeclampsia significantly correlated

population.” ■

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ADT, Dementia Linked in Younger Men Study of military men and their dependents also revealed an increased risk for depression ANDROGEN DEPRIVATION therapy (ADT) in men aged 40 to 64 years with nonmetastatic prostate cancer (PCa) is associated with an increased risk for new-onset dementia and depression, according to investigators.

In an observational study of 9117 men aged 40 to 64 years diagnosed with localized PCa, a team led by Quoc-Dien Trinh, MD, of Brigham and Women’s Hospital in Boston, found that patients who received ADT had a significantly higher incidence of new-onset dementia and depression compared with those who did not (17.9 vs 7.5 per 1000 person-years and 30.2 vs 15.8 per 1000 person-years, respectively).

The ADT group had a 1.7- and 2.0fold increased risk for new-onset dementia and depression, respectively, compared with no-ADT, Dr Trinh and colleagues reported in European Urology Oncology. In addition, longer duration of ADT is associated with a higher risk for either outcome.

“Our results add to the evidence that the receipt of ADT is associated with

Preeclampsia Ups Future Stroke Risk PREECLAMPSIA MAY increase a woman’s risk for a future stroke, according to new study findings.

A population-based cohort study that included 1435 women found that those with a history of preeclampsia had a nearly 3.8-fold higher risk for stroke later in life compared with women who never had preeclamp-

ADT vs No ADT Androgen deprivation therapy (ADT) is associated with an increased incidence of newonset dementia and depression among men aged 40 to 64 years, a study found. Shown here are the rates per 1000 person-years.

35

n ADT

30.2%

30

n No ADT

25 20

17.9%

15.8%

15 10

7.5%

5 0

Dementia

Depression

Source: Tully KH, et al. Risk of dementia and depression in young and middle-aged men presenting with nonmetastatic prostate cancer treated with androgen depression therapy. Eur Urol Oncol. 2021;4:66-72.

depression and dementia, and emphasize the importance of neurocognitive assessment in patients undergoing ADT, especially in younger patients,” the authors wrote.

They added, “In patients with advanced disease, who are likely to remain on ADT for the rest of their lives, it is crucial to screen them for these adverse outcomes, especially in

the era of promising novel agents.”

The investigators identified study patients using the TRICARE military database. TRICARE insurance covers all active and retired service members of the US armed services and their respective dependents. No patient had pre-existing diagnoses of dementia or depression. Of the 9117 men, 325 (3.6%) received ADT and 8792 (96.4%)

did not. The median follow-up duration for the ADT and no-ADT groups was 9.3 and 10.0 years, respectively.

The authors pointed out that the TRICARE database does not contain detailed tumor-specific information, such as Gleason score, PSA levels, or T stage, so their analyses could not be adjusted for these factors. Another limitation was reliance on administrative claims to identify neurocognitive outcomes, as use of such claims has been shown to underestimate the true incidence of these outcomes, according to the investigators. “However, our study population consists of military service members and their dependents, which may differ from the general population,” they wrote.

Dr Trinh’s team also noted that ADT requires regular interactions with health care providers. “These regular interactions may provide more opportunity for health care providers to diagnose neurocognitive changes in patients undergoing ADT,” they wrote. “Therefore, the impact of ADT on both outcomes may be overestimated due to differential detection.” ■

Women Have Less Access to KT Waitlist WOMEN HAVE LESS access to the kidney transplant waitlist, investigators revealed at the virtual National Kidney Foundation 2021 Spring Clinical Meetings.

According to the US Renal Data System, 19.4% of the 1,337,386 patients receiving dialysis during 2005 to 2016 were placed on the waitlist for a deceased donor kidney transplant. Across 16 of the 18 end-stage renal disease (ESRD) networks, women had less access to the waitlist compared with White men, Reem Hamoda, MPH, MD candidate, of the

University of Chicago, reported. Further, Black women were more disadvantaged in waitlist access than White women in ESRD Networks 3, 6, 7, 12, 14, and 18.

After the kidney allocation system was implemented in 2015, Black women and White women had a significant 26% and 18% lower likelihood of waitlisting, respectively, compared with White men. Hispanic women likewise experienced reduced access, but Asian women had increased access. The investigators estimated that 2.6% of the variation in disparities was explained

by ESRD ­network-level variation. The model adjusted for age, clinical factors such as comorbidities, and sociodemographic factors.

“More work is needed to explain geographic variation to improve racial/ ethnic and gender equity in renal transplant access,” Hamoda’s team noted.

Future work should focus on identifying best practices in equitable ESRD networks, evaluating racial and sex-specific barriers and facilitators to transplant access, and implementing interventions to increase access, they stated. ■

sia, Adam de Havenon, MD, of the University of Utah in Salt Lake City, and colleagues reported in JAMA Network Open.

A total of 169 women had a history of preeclampsia and 231 experienced strokes during 41,422 personyears of follow-up, the investigators reported. At baseline, the women in the preeclampsia group were more likely to be younger and to be current smokers compared with women who did not experience preeclampsia. ■

Ureteral Stenting Shown to Increase UTUC Risk ROUTINE URETERAL stenting during bladder cancer surgery to prevent or decompress obstruction should be avoided because it may give rise to upper tract urothelial carcinoma (UTUC), according to investigators.

Petros Sountoulides, MD, PhD, of Aristotle University of Thessaloniki in Greece, and colleagues performed a meta-analysis of 5 studies that included

278 ureteral stent and 131 nephrostomy placements among 3309 patients with bladder cancer treated with transurethral resection of tumor or radical cystectomy (RC). Metachronous UTUC developed in 20 (7.2%) stent cases and 3 (2.3%) nephrostomy cases.

Patients treated with ureteral stents had significant 3.5- and 3.4fold increased odds of metachronous

UTUC compared with patients who had no ureteral stents or no upper urinary tract drainage, respectively, the investigators reported in The Journal of Urology.

In cases where drainage was deemed necessary, UTUC risk did not differ significantly between double-J stent and nephrostomy, even among patients with hydronephrosis. ■

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Renal & Urology News 13

Cancer Screening Dipped Early in Pandemic Biggest declines in prostate, breast, and colorectal cancer screening occurred in the Northeast SCREENING RATES for prostate, breast, and colorectal cancer in the US dropped sharply during March through May 2020 — the early months of the COVID-19 pandemic — compared with the same period in 2019, with the biggest decline occurring in April, investigators reported in JAMA Oncology.

The declines were most pronounced in the Northeast US and among individuals of high socioeconomic status (SES).

During March, April, and May 2020, the screening rates per 100,000 enrollees in Medicare Advantage or commercial insurance plans decreased by 27.4%, 63.4%, and 35.0%, respectively, for prostate cancer; 41.8%, 90.8%, and 52.6% for breast cancer; and 33.3%, 79.3%, and 57.7% for colorectal cancer, compared with the same months, respectively, in 2019, according to Ronald C. Chen, MD, MPH, of the

Dapagliflozin Reduces Renal Risks in IgAN DAPAGLIFLOZIN EFFECTIVELY reduces the risk for kidney disease progression in patients with immunoglobulin A nephropathy (IgAN) regardless of diabetes status, according to results from a prespecified analysis of the Dapagliflozin And Prevention of Adverse outcomes in Chronic Kidney Disease (DAPA-CKD) trial.

The original trial included 270 participants with IgAN who had an estimated glomerular filtration rate (eGFR) of 25-75 mL/min/1.73 m2 and urinary albumin-to-creatinine ratio (UACR) of 200-5000 mg/g and were receiving a stable dose of angiotensin converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB). No one could be currently receiving immunotherapy.

Investigators randomly assigned 137 patients to dapagliflozin (10 mg/d), a sodium-glucose cotransporter-2 (SGLT2) inhibitor, and 133 to placebo.

Compared with placebo, dapagliflozin treatment was associated with a significant 71% lower risk of the primary composite endpoint, which included a sustained decline in eGFR

University of Kansas in Kansas, and colleagues. Monthly screening rates for prostate and breast cancers recovered completely by July 2020, they noted.

The prostate cancer screening rate was 63.4% lower in April 2020 vs April 2019.

The investigators estimated that the absolute deficit across the US population in screening associated with the COVID19 pandemic was 1.6 million, 3.9 million, and 3.8 million for prostate, breast, and colorectal cancer, respectively, for a total deficit of 9.4 million screenings.

The Northeast experienced the biggest decline in screening from March through

of 50% or more, end-stage kidney disease (ESKD), or death from a kidney disease-related or cardiovascular cause over a median 2.1 years. The absolute risk reduction with dapagliflozin was 10.7% overall, David C. Wheeler, MD, of the University College London in the UK, and colleagues reported in Kidney International.

Among high-risk patients — those with baseline eGFR less than 45 mL/ min/1.73 m2 or UACR exceeding 1000 mg/g — dapagliflozin was associated with an absolute risk reduction in the primary composite endpoint of −9.2% and −18.3%, respectively, they reported. Results were consistent when analyses were limited to patients with biopsy-proven IgAN. Mean eGFR declined less with dapagliflozin than placebo: −3.5 vs −4.7 mL/ min/1.73 m 2 per year, respectively.

UACR decreased by 26% with dapagliflozin vs placebo.

Dapagliflozin significantly decreased the risk of a composite renal endpoint (a sustained decline in eGFR of 50% or more, ESKD, or death from a kidney disease-related cause) by 76% and ESKD by 70%, Dr Wheeler’s team reported.

Serious adverse events occurred in a smaller proportion of the dapagliflozin than placebo group (16.1% vs 25.6%), according to the researchers. No patients experienced ketoacidosis or severe hypoglycemia with dapagliflozin. ■

May 2020 compared with the same period in 2019, whereas the South and West regions had lower magnitudes of decline, the investigators reported. “This corresponds to the differential timing of COVID-19 rates across different regions of the country, with New York and other Northeastern states reporting early and higher surges of COVID-19 cases.”

Declines in cancer screening rates varied by SES, with the biggest declines among those in the highest quartile of SES. For example, the decline in the prostate cancer screening rate in April 2020 compared with April 2019 was 69.1% for those in the fourth quartile compared with 56.5%, 59.8%, and 61.9% for those in the first, second, and third quartiles, respectively.

Multivariate analysis that adjusted for SES showed that telemedicine use was associated with receipt of c­ ancer

s­creening. In March, April and May 2020, telehealth use compared with nonuse was significantly associated with a 1.13-, 2.46-, and 1.40-fold increased likelihood of cancer screening, respectively.

“This suggests a potential benefit of telehealth: while the COVID-19 pandemic led to broad cancellations of nonemergency in-person health care appointments, telehealth appointments might have enabled individuals to still receive medical consultation and advice, as well as a plan for rescheduling screening tests,” the authors wrote.

Study limitations included the enrollment of only insured individuals, “which may skew our population-level estimation of cancer screening deficit associated with the COVID-19 pandemic,” Dr Chen and colleagues noted.

Another limitation was lack of race and ethnicity information for analysis. ■

Inducing Renal Hypothermia During PN Not Beneficial INDUCING RENAL hypothermia during

in Ontario, Canada, and colleagues

partial nephrectomy (PN) for kidney can-

reported in The Journal of Urology. In

cer does not preserve remaining kidney

the operated kidney, mGFR was –5.8 vs

function, according to a new study.

-6.3 mL/min/1.73 m2, respectively, for a

In a trial, investigators randomly

mean difference of 0.5 mL/min/1.73 m2.

assigned 184 patients undergoing

Renal hypothermia did not affect the

open PN for renal tumors (the majority

rate of surgical complications or quality

renal cell carcinoma) to a hypothermia

of life, according to the investigators.

group or a control group. Preoperative

In the hypothermia group, 1 patient

mean measured glomerular filtration

received temporary hemodialysis (HD)

rate (mGFR) was 87.1 vs 81.0 mL/

postoperatively and 1 patient required

min/1.73 m in the hypothermia and

permanent HD at 10 months. No patient

control group, respectively.

in the control group required dialysis.

2

In the renal hypothermia group, sur-

“Given broad eligibility criteria,

geons surrounded the kidney with 2 cm

our study results are generalizable

or more of saline ice slush after clamp-

and should have immediate impact

ing the renal hilum and allowed 10

for patients undergoing open partial

minutes for cooling. Median clamp time

nephrectomy,” Dr Breau’s team wrote.

was 30 vs 21 minutes in the hypother-

“Equally important, the absence of ben-

mia and control group, respectively.

efit observed from renal hypothermia has

The mean change in mGFR at 1 year

implications for patients undergoing lapa-

was –6.6 vs –7.8 mL/min/1.73 m in the

roscopic/robotic partial nephrectomy.

hypothermia group and control group,

Our findings suggest that the inability to

respectively, for a mean difference

induce renal hypothermia during lapa-

of 1.2 mL/min/1.73 m that was not

roscopic/robotic partial nephrectomy

clinically significant, Rodney H. Breau,

should not be considered a limitation of

MD, MSc, of The University of Ottawa

these less invasive procedures.” ■

2

2

18 Renal & Urology News

MAY/JUNE 2021 www.renalandurologynews.com

Survey Finds Racial Disparities in Path to Dialysis Treatment

SMI Predicts KT Outcomes In Older Men

White patients and Black patients differ in how they choose dialysis modalities

A LOW SKELETAL muscle index (SMI) as assessed by computed tomography (CT) independently predicts increased risks for morbidity and mortality after kidney transplantation among men aged 60 years or older, according to a recent study.

“SMI, which can be easily calculated by routine CT scan, is a reliable tool to measure muscle mass in kidney transplantation candidates and could help nephrologists recommend appropriate rehabilitation and nutritional management for candidates with presarcopenia on the kidney transplant wait-list in order to improve post-transplant outcomes,” the authors concluded,” Pierre-Guillaume Deliège, MD, of Hôpital Maison Blanch in Reims, France, and colleagues reported in the Journal of Renal Nutrition.

The study included 122 patients (71 men and 51 women) aged 60 years or older at time of kidney transplantation (mean age of 66 years). On multivariate

BY NATASHA PERSAUD RESULTS OF AN online survey of patients who had reached end-stage kidney disease (ESKD) illustrate racial disparities in the transition to dialysis and highlight areas for improvement, such as in dialysis education.

The survey, conducted in February 2021 by Outset Medical and distributed by the National Kidney Foundation (NKF) via email, partner sites, and social media, included 173 (38%) Black respondents, 234 (52%) White respondents, and 43 (10%) respondents of

(54%), but only 37% were willing to pay more. Few Black and White patients worked full-time (12% vs 11%) or part-time (8% vs 5%), whereas a third of each group (34% vs 32%) were unable to work.

Choosing a Dialysis Option A greater proportion of Black than White patients were encouraged by their care team to adopt in-center HD: 62% vs 49%. Fewer Black respondents thought in-center HD was accessible (58% vs 84%) and perceived access to

Deciding Factors A survey of patients with end-stage kidney disease found racial differences in some factors White and Black patients consider when choosing a dialysis modality. n White patients 100

91%

79%

80

n Black patients

89% 76%

60 40 20 0

Efficacy

Quality of life

Source: Racial disparities in dialysis path to treatment. Outset Medical; March 2021.

other races. Findings with a 10% or more difference were reported.

“Our survey found socioeconomic factors played a major role in early knowledge of kidney disease status prior to the onset of kidney failure,” Tonya Saffer, head of government affairs at Outset Medical, told Renal & Urology News.

The 5 most important attributes to patients when selecting a dialysis modality included its effectiveness (87%), quality of life (84%), insurance coverage (82%), life expectancy (79%), and accessibility (77%). White respondents were more likely than Black respondents to focus on efficacy (91% vs 79%) and quality of life (89% vs 76%). Black respondents, however, were less likely to report that insurance covered all or most of their dialysis treatments (66% vs 80%).

More than half of respondents overall were willing to give up convenience for better dialysis treatment outcomes

trained clinical staff as an asset (62% vs 82%), however. More Black patients felt anxious about going to the dialysis clinic (46% vs 33%). Only 27% of respondents overall were worried about COVID-19 infection with 10% missing some or most of their sessions due to the pandemic. Although in-center HD was generally perceived as effective, fewer Black than White respondents thought so (65% vs 81%).

PD (62%) and home HD (59%) were also viewed as effective option by respondents. Fewer Black than White patients, however, felt knowledgeable about all of the available dialysis modalities: 71% vs 88%. Black respondents were far more likely to report that their care team failed to provide sufficient education on the treatment options: 25% vs 3%. A greater proportion of Black respondents researched home dialysis options on their own: 24% vs 14%. More Black than White respondents further reported that

they were never given the option to start at-home dialysis: 14% vs 4%.

“Strengthening patient education about treatment options early on in the kidney disease journey can enable access to higher-quality, affordable forms of treatment,” Saffer said. “We found, for example, that there were minimal differences in home therapy adoption between White and Black patients who had received comprehensive education about their options.”

Only 9% overall reported that the COVID-19 pandemic was very influential in the decision to start home dialysis. The main draws of PD were at-home comfort (49%) and no needle requirement (48%), which were balanced by concern over catheter infection (52%).

Home HD offered comfort (51%) and flexibility (47%) but with the drawbacks of no trained staff (46%) and a self-cannulation requirement (44%).

“More public policy is needed that encourages greater access to home dialysis, such as realigning reimbursement and modernizing outdated regulations that make it more challenging for patients to access home dialysis training and support,” according to Saffer.

“Breaking these barriers on a national level can significantly impact the overall availability of home dialysis including among underserved populations.”

Urgent Dialysis Starts Although there was an almost 50/50 split between respondents with a planned or unplanned start to dialysis, a greater proportion of Black than White patients had an emergent start to dialysis: 57% vs 44%. Patients younger than 50 years and those with incomes less than $75K also were more likely to have an emergent start compared with older and wealthier respondents.

“To help reduce emergent starts for Black individuals, health systems need to expand educational programs in underserved patient populations and communities of color to prepare them for kidney disease management early on,” Saffer said. “These programs empower them with the knowledge to proactively select their preferred dialysis modality sooner and to get on the kidney transplant list preemptively.” ■

A low skeletal muscle index ups risk for morbidity and mortality. analysis, a low SMI, defined as less than 42 cm2/m2, was significantly associated with 12.1-fold and 3.4-fold increased odds of wound complications and a combined endpoint of graft loss or death, respectively, in men compared with an SMI of 42 cm2/m2 or higher. In addition, a low SMI was significantly associated with longer immediate post-transplant hospitalization and longer total hospitalization during the first-year posttransplant. SMI was not associated with length of hospitalization or adverse outcomes after transplantation in women.

The average length of hospitalization was 20.5 days. Overall patient survival at 1 year was 89.7%, with cardiac etiologies and severe infections the most common causes of death.

Compared with women, men had a significantly higher serum creatinine level (836 vs 693 µmol/L), skeletal muscle mass (151.0 vs 96.5 cm2), and SMI (50.9 vs 37.8 cm2/m2). They were also significantly more likely to have hypertension as a cause of end-stage kidney disease (25.4% vs 7.8%), the investigators reported. ■

www.renalandurologynews.com MAY/JUNE 2021

Renal & Urology News 19

Psoriasis Therapy Beneficial in ESKD Treating the condition in patients with kidney failure shown to reduce infection and mortality risk PSORIASIS TREATMENT is associated with a reduced risk of some infections and improved survival in patients with end-stage kidney disease (ESKD), according to recent study findings.

Patients with ESKD and psoriasis may be at greater risk for infection due to chronic vascular access and epidermal dysfunction, in addition to other factors, Wendy B. Bollag, PhD, of the Medical College of Georgia at Augusta University, and colleagues explained.

Of 866,828 patients on hemodialysis or peritoneal dialysis in the 2004-2011 US Renal Data System (USRDS), 8911 (1.0%) had psoriasis. In adjusted analyses, a psoriasis diagnosis, compared with no psoriasis diagnosis, was significantly associated with an increased risk for 9 common infections in the ESKD population, including cellulitis (55% increased risk), conjunctivitis (47%), onychomycosis (36%), herpes zoster (32%), pericarditis (27%), ­bacteremia

Treating psoriasis in ESKD patients may lower the risk of common infections

(17%), fungemia (15%), septicemia (9%), and systemic inflammatory response syndrome (SIRS; 5%).

Psoriasis treatment significantly reduced the risk of some of these infections and was associated with improved survival, Dr Bollag and her colleagues reported in The American Journal of the

High Pain Burden Found in Chronic Kidney Disease PAIN IS COMMON among patients

proportions of patients with diabetes,

disease (CKD), those receiving dialysis,

hypertension, or a high body mass index.

and kidney transplant recipients, a new

Diabetes may lead to diabetic neuropa-

study finds.

thy, hypertension may impair nerve

In a systematic review and meta-

conduction, and obesity may causes

analysis involving 116 studies and

systemic inflammation leading to nerve

40,678 individuals, 60% had pain, 48%

damage, the investigators noted.

had chronic pain lasting more than 3

Musculoskeletal pain was the most

months, and 10% had neuropathic pain,

common pain symptom among patients

Samira Bell, MB ChB, of the University

with CKD managed conservatively

of Dundee in Scotland and colleagues

(42%) or receiving dialysis (45%), but

reported in Kidney International.

was less prevalent among kidney

Overall pain prevalence was lower

© KALINOVSKIY / GETTY IMAGES

Neuropathic pain affected higher

with stage 3 or higher chronic kidney

transplant recipients (18%). According

among kidney transplant recipients

to the researchers, musculoskeletal

(46%) compared with patients under-

pain, which includes bone and joint pain,

going dialysis (63%) and patients with

may relate to CKD-Mineral and Bone

nondialysis CKD (63%). Individuals on

Disorder (CKD-MBD), such as secondary

hemodialysis and peritoneal dialysis had

hyperparathyroidism. Fibromyalgia was

similar pain prevalence. Among patients

significantly associated with older age.

with nondialysis CKD, those with stage

Abdominal pain was most prevalent

3 or 4 disease reported pain as often

in kidney transplant recipients (41%),

as those with stage 5 disease, probably

whereas it was a lesser concern for

because these patients received pallia-

patients with nondialysis CKD (15%) and

tive care, according to the investigators.

on dialysis (16%).

■

Medical Sciences. Compared with no psoriasis treatment, systemic, local, and light therapies for psoriasis significantly decreased SIRS risk by 31%, 31%, and 25%, respectively. Septicemia risk decreased significantly by 25%, 29%, and 28%, respectively. Bacteremia risk decreased significantly by 38% and 25% with systemic and local therapy, respectively. Mortality risk declined significantly by 45%, 40%, and 25% with systemic, local, and light therapies, respectively.

Conversely, the risk for herpes zoster increased significantly by 91% with local therapy and the risk for cellulitis increased significantly by 56% with light therapies.

In the psoriasis cohort, 1071 patients (12.0% of cohort) received systemic (2.7%), local (3.6%), or light therapy (5.8%). Local treatment was defined as intralesional corticosteroid injections.

Light-based treatment included ultraviolet light and laser therapy.

SHPT Therapy Shown to Vary

by Specialty PHYSICIANS IN DIFFERENT specialties vary widely in how they would treat secondary hyperparathyroidism (SHPT), according to the results of a new Dutch survey.

The survey consisted of 8 case vignettes of patients with SHPT on hemodialysis and suitable candidates for kidney transplantation. Each case varied by 1 important variable: age (40 vs 65 years), parathyroid hormone (PTH; 40 vs 90 pmol/L), and serum calcium level (2.25 vs 2.8 mmol/L).

Respondents chose among active vitamin D, calcimimetics, or subtotal parathyroidectomy (PTx) for treatment.

A total of 115 specialists responded to the survey, including nephrologists, endocrinologists, and surgeons. In 6 out of 8 cases, more than a third of respondents disagreed on the best course of treatment. Elevated serum calcium level was the top reason for respondents to abandon conservative treatment in favor of subtotal PTx, Jaimie Zhang, MD-PhD student at Leiden University Medical

“We speculate that all forms of treatment included in this analysis improve the epidermal barrier disruption associated with untreated psoriasis, and thus may decrease the likelihood of microbial invasion via psoriatic skin portals,” Dr Bollag’s team wrote.

In addition, they advised, “Physicians caring for psoriasis patients on dialysis should be attentive to proper referrals for disease therapy, be cognizant of the increased risk of infection, and be vigilant about vaccination, especially for herpes zoster.”

Why psoriasis increases herpes zoster risk is unclear, the authors noted, but they speculate that the pathophysiology of a herpes zoster flare differs from other infections. A herpetic eruption, they explained, results from reactivation of latent virus from stress or immunosuppression, and thus is unrelated to microbial invasion via cutaneous psoriatic plaques with impaired barrier function. ■

Center in Leiden, The Netherlands, and colleagues reported in BMC Nephrology.

High serum calcium of 2.8 mmol/L was significantly associated with 93- and 31-fold increased odds of opting for subtotal PTx and calcimimetics, respectively, rather than vitamin D therapy. High PTH of 90 pmol/L was significantly associated with 22- and 8-fold increased odds of choosing subtotal PTx and calcimimetics, respectively.

By specialty, endocrinologists had significant 2.6-fold increased odds of choosing subtotal PTx compared with nephrologists. Both surgeons and endocrinologists had 45% decreased odds of choosing calcimimetics compared with nephrologists.

By volume of SHPT patients, clinicians with more experience had 55% decreased odds of opting for subtotal PTx and 29% increased odds of calcimimetics.

Other factors important in the decision-making process included response to vitamin D or calcimimetics, the identification of other causes of hypercalcemia, PTH stability, transplant eligibility, and the presence of hypercalcemia complications.

“Since consensus regarding the best treatment for [renal hyperparathyroidism] is lacking, shared decision making is of the utmost importance,” according to the investigators. ■

20 Renal & Urology News

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Race, Ethnicity, and Kidney Disease Care Racial and ethnic disparities permeate much of the healthcare system in the United States. To better understand why, Renal & Urology News interviewed Deidra C. Crews, MD, professor of medicine at Johns Hopkins University School of Medicine in Baltimore, Maryland, who has conducted research that focuses on racial and ethnic disparities in kidney disease. Dr Crews also is a member of the American Board of Internal Medicine Nephrology Board.

What do you see as the most concerning racial or ethnic disparities in the care of patients with kidney disease?

Dr Crews: Referral to nephrology in a timely way, and more broadly, access to specialty care and health insurance.

Even for those patients who have primary care clinicians, we still continue to see racial and ethnic disparities in timely referrals to nephrology.

Why do you think this is the case?

Dr Crews: It begins with the perception on the part of clinicians surrounding the level of severity of patients’ kidney disease and whether it warrants nephrology referral. That perception might vary depending upon the race or ethnicity of the patient. Physician bias may play a role such that more high-quality care isn’t always offered to ethnic and racial minority patients the way that it is to White patients. This is seen with home dialysis, for example. Racial and ethnic minorities, particularly Black and Hispanic individuals, are less likely to initiate dialysis on a home modality than are White patients.

They are too often, in my view, presumed to not have the social circumstances that would be able to support home dialysis, such as adequate social support and a suitable home environment.

What would explain the lower rates of live-donor kidney transplantation among people of color?

Dr Crews: In order for someone to receive a kidney from a living donor, they have to identify someone who is willing to come forward to get evaluated. That someone has to be clinically eligible to be a donor.

People tend to ask family members about

donating a kidney. For Black patients who seek out a family member to be a donor, there is a higher likelihood, for a host of reasons, that a family member may also have some of the same risk factors for kidney disease the patient has.

In addition, socioeconomic barriers are at play when it comes to racial and ethnic minority donors. Structural inequities in our society leave a number of ethnic and minority groups at a distinct disadvantage when it comes to things like the ability to donate a kidney. The interest in giving a kidney doesn’t vary so much when we look across race and ethnicity. What does vary, though, are the socioeconomic barriers to be able to donate, such as transportation and the ability to take time off from work. The gap between Black donors and White donors with respect to willingness or ability to donate appears at the lower levels of socioeconomic status. At higher levels of socioeconomic status, Black people are actually more likely to want to donate a kidney.

to thinking about engaging with the healthcare system. This really has to do with not just historical incidents, such as the “Tuskegee Study of Untreated Syphilis in the Negro Male,” but presentday experiences that they or a family member or friend have had where they were not treated fairly by systems in our society, including the healthcare system.

That is the reason many people do not trust these systems. These systems have not proven themselves trustworthy.

Have you observed racial differences in COVID-19 vaccine hesitancy?

Dr Crews: Early on, when the vaccines were being rolled out, it was documented that a smaller proportion of Black Americans were planning to get the vaccine than other groups. As information has come out, we have seen that hesitancy retreat among Black Americans in particular. Anecdotally, in my interactions with patients and community partners in the research work that I do, I’m mostly hearing challenges about access to the COVID-19 vaccines in the Black community. I hear way more about difficulty in navigating the process about getting the vaccines than I hear about hesitancy. I hear people saying they want the vaccine, but they haven’t been able to sort out how to get it.

Are Black people more distrustful of the healthcare system compared with White people?

Dr Crews: Many Black individuals do not have a high level of trust in the healthcare system. As citizens of the United States, we give up certain rights to have certain protections that are provided by our government and other systems that are in place. This is an important social contract. But there’s been a breach of that social contract in many cases with respect to communities of color. Given that, it would be understandable, I think, that there would be a certain level of hesitancy when it comes

Racial and ethnic disparities exist in timely referrals to nephrology. ­—Deidra C. Crews, MD

Do you think physicians have inherent or unconscious biases that contribute to disparities in care?

Dr Crews: Physicians are human beings.

In the United States, physicians, like other people, are all subject to images and messages that promote certain stereotypes and other biases. I see physicians as no different from any other people in American society. Given that, how could we not have biases that are present in everything we do? But awareness of biases is particularly important for physicians because the work we do has life and death consequences.

We should each be committed to continuously working to understand our own biases. Once we recognize that we have those biases, we should work to keep them in check. When we’re making treatment decisions for a patient that we know is from a group against which we have biases, we might ask, “Am I giving this person a timely referral to subspecialty care? Am I fully thinking through all of the reasons that this patient may be having some challenges with a particular therapy?”

Clinical trials often face a challenge in enrolling sufficient numbers of Black participants. What can be done to bolster black participation in clinical trials?

Dr Crews: For patients to be considered for enrollment in a clinical trial addressing kidney disease, they often have to be referred to a kidney specialist in a very timely way. What we see all too often is that racial and ethnic minorities are referred late, and so they don’t have access to high-quality advanced care that actually keeps their disease from progressing.

Then there’s the issue of whether trust has been earned with respect to research.

We all too often will plan the study we want to conduct, decide what treatment group A is going to be and what treatment group B is going to be, we apply for the grant, or we get funding from industry, and then we say, “Why can’t we enroll Black participants?” But what is missing is that we often don’t engage communities of color when we’re first thinking about conducting a study to make sure that the design of the trial would enable them to participate, and that the intervention being tested is responsive to their needs and priorities.

These communities should be engaged at the front end, giving them a part in the design, instead of after the whole protocol has been approved. ■

www.renalandurologynews.com MAY/JUNE 2021

Renal & Urology News 27

Ethical Issues in Medicine Physicians often experience uncertainty in the delivery of health care, but they have multiple ways to manage it BY DAVID J. ALFANDRE, MD, MSPH self-assessment of competency. In other words, those who lack a particular knowledge or expertise are most at risk for not recognizing they have such a deficit.2 This cognitive bias became painfully clear to me after watching a couple of YouTube videos in preparation for what was eventually my botched plumbing repair in my home. Knowing very little about plumbing made me vulnerable to not accurately appreciating how much I needed to know about plumbing to do the repair.

Gather Additional Information The most common and straightforward way of managing uncertainty is simply through gathering additional information. This may occur through further diagnostic evaluation, therapeutic trials, or consulting the literature or trusted colleagues. This is both logical and reasonable, but physicians often become aware that gathering more information may not solve the problem of uncertainty.

There may come a time in a diagnostic evaluation, for example, of chest pain, when concerning etiologies have been ruled out and no further testing will identify a likely diagnosis and indeed may be more likely to cause harm. There are likely to be some patients who will be unsatisfied with simply knowing that all the dangerous possibilities have been

For many health care professionals, managing uncertainty means recognizing that knowledge is iterative and provisional rather than definitive.

“Medicine is a science of uncertainty, and an art of probability.”

The ‘Dunning-Kruger Effect’ While all physicians must manage uncertainty, how they do so will vary. More importantly, as the “Dunning-Kruger effect” makes clear, there are risks to not adequately identifying uncertainty. The Dunning-Kruger effect is a cognitive bias in which a failure to recognize one’s own lack of knowledge leads to an overinflated

ruled out and want to know definitively what caused their chest pain symptoms.

It is not just patients who have varying tolerances for managing the sometimes adverse psychological effects of uncertainty: Physicians seek to manage these as well, often through a variety of methods.

Some physicians manage uncertainty not by trying to overcome it with more information but by identifying the cognitive state explicitly and either drawing more attention to it or disengaging from

© SAOVADEE / GETTY IMAGES

O

ne of the central themes of physicians’ professional lives this past year has been the lack of certainty when addressing COVID-19.

From a public health perspective, the knowledge base over the importance of face masking has changed and evolved while the risks and benefits of various formulations of COVID vaccines have shifted. From a patient care perspective, what constitutes an effective and safe therapeutic against SARS-CoV-2 has been less a certainty and more of an evolving science. Although these gaps in knowledge are expected in medicine, they feel more significant now and are probably likely to increase.

Uncertainty, which is the conscious awareness of not fully knowing, is central to the experience of caring for patients.1 Diagnostic, prognostic, and treatment processes in patient care are all predicated on the identification and management of uncertainty that results from imperfect and sometimes limited medical information. Physical examination, testing, and radiology reduces but does not eliminate uncertainty in diagnosis. Empiric trials of medication or reducing the risk of poor outcomes through evidence-based therapy also decreases uncertainty, but regrettably, nothing can entirely eliminate uncertainty. As William Osler said,

it. The former group may manage their uncertainty by devoting more cognitive resources to grappling with it, while the latter may choose to ignore the feelings associated with it so they can avoid getting stuck. These groups both accept that while uncertainty cannot be avoided, they can address and sometimes mitigate the unpleasant psychological effects.3 Finally, another method is to focus not on the uncertainty, but rather the relationships affected by it. Some physicians find consulting with other physicians incredibly helpful in palliating some of the unpleasant feelings associated with uncertainty. Other physicians share the specifics and degree of medical uncertainty directly with patients. This sharing of uncertainty with patients is a marked change from decades ago when physicians often chose not to reveal any of the actual uncertainty in medical decision-making. Now, of course, disclosing uncertainty is central to the process of shared decision-making and can help point the physician to alternative solutions in line with the patient’s preferences and interests.

Even if we as health care professionals arrive at solutions differently, what does successfully managing uncertainty look like? For many, it means reaching a point where one recognizes that complete knowledge is rarely fully known, that surety is complicated and illusory,

and that knowledge is iterative and provisional rather than definitive. Albert Einstein famously said, “The more I learn, the more I realize how much I don’t know.” Arriving at such a place is likely within the reach of all health care professionals, but may be more likely by cultivating virtues such as openness, flexibility and humility that can develop with experience.4 The challenge remains in finding a reasonable balance between accepting and resisting uncertainty and when to pursue more information and knowing when not to. At least that’s my sense. I can’t be sure about it. ■ David J. Alfandre MD, MSPH is a health care ethicist and an Associate Professor in the Department of Population Health at the NYU School of Medicine in New York. The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the VA National Center for Ethics in Health Care or the US Department of Veterans Affairs.

REFERENCES 1. Simpkin AL, Armstrong KA. Communicating uncertainty: a narrative review and framework for future research. J Gen Intern Med. 2019;34:2586-2591.

2. Dunning D. Chapter five - The Dunning–Kruger effect: On being ignorant of one’s own ignorance. Adv Exp Soc Psychol. 2011;44:247-296.

3. Han PKJ, Strout TD, Gutheil C, et al. How physicians manage medical uncertainty: A qualitative study and conceptual taxonomy. Med Decis Making.

2021;41:275-291.

4. Fox RC. The evolution of medical uncertainty. The Milbank Mem Fund Q Health Soc. 1980;58:1-49.

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Practice Management T

elehealth use has surged as a result of the COVID-19 pandemic. In a study of 36.5 million individuals in the United States, which was published recently in JAMA Network Open, investigators at Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland, found that in-person ambulatory medical contacts decreased by 18% during March to June 2020 compared with the same period in 2019. Telehealth use increased from 0.3% of all medical encounters in 2019 to 23.6% of all encounters in 2020. Individuals aged 18 to 49 years and those with more than 2 chronic conditions used telehealth the most. Overall total medical care costs, including hospitalizations, dropped 15%, from $358 to $306 per person per month, from 2019 to 2020.

The shift to telehealth occurred as many medical practices halted or curtailed in-person office hours and patients stayed away from physicians’ offices out of fear of transmission during the early months of the pandemic.

At the same time, insurance companies and the federal government relaxed policies around telehealth to meet demand for remote medical consults via internet video or telephone.

Recent survey findings presented at the Endocrine Society’s 2021 annual

Lead researcher Maryam Nemati, MD, of San Joaquin General Hospital in French Camp, California, who presented the study findings, said endocrinology clinics have significant numbers of patients who need long-term close follow-up for medication adjustments, symptom checks, and counseling.

“Recent progress in telemedicine and incorporating technologies such as Zoom make remote visits a lot easier,” Dr Nemati said. “In the past year, because of the pandemic many patients tended toward remote visits. This experience showed most patients felt that their concerns were addressed via telemedicine and quality of tele[medicine] visits both via video and phone were like in-person visits. Telemedicine is less expensive and timesaving.”

Dr Nemati and her collaborators conducted the survey from January to May 2020. They asked patients and providers about the benefits and limitations of telehealth visits compared with in-person visits. The investigators analyzed the patient no-show rate for 6 weeks before and after telehealth visits. Results showed that 65% said they would like to continue with telemedicine after the pandemic and 77% stated the quality of care with telehealth, both by video and phone, are almost the same as an in-person visit.

Telehealth use increased from 0.3% of all medical encounters in 2019 to 23.6% of all encounters in 2020, a recent study found. meeting showed that two-thirds of patients with chronic endocrine problems who need close monitoring say they would like to continue with telemedicine follow-up visits after the COVID-19 pandemic ends. The survey included 109 patients, with 65% of respondents saying they would like to continue with telemedicine after the pandemic. The survey also showed that 42% of patients prefer video visits and 37% prefer phone calls.

Among providers, 75% wanted to continue with telehealth after the pandemic, and 50% reported patient satisfaction as a benefit of telemedicine. The survey revealed that 60% of providers believed lack of physical examination is a limitation of phone visit, and 87% of the providers believe the quality of care is better with in-person visits than phone visits. The no-show rate decreased from 30% to 27% after the implementation of telehealth visits.

© MARKO GEBER / GETTY IMAGES

Telehealth use, which skyrocketed during the COVID-19 pandemic, proves popular with patients BY JOHN SCHIESZER

A big shift to telehealth occurred as many doctors’ offices halted or curtailed in-person visits.

“Popularity of telemedicine is growing fast. Telemedicine for chronic diseases may help with patients’ compliance by decreasing various burdens including taking time off from work, driving to appointments, and waiting to be seen. Telemedicine may help clinics reduce cost by seeing more patients with less staff,” Dr Nemati said.

Michelle Griffith, MD, associate professor of medicine and medical director of Telehealth Ambulatory Services at Vanderbilt University in Nashville, Tennessee, said many types of care can be provided by telehealth, and using telehealth does not have to be all or nothing.

“For many patients who are seen multiple times per year, a mix of in-person and telehealth visits may be most appropriate,” Dr Griffith told Renal & Urology News. “We have seen sustained uptake in specialties that care for chronic conditions and expect we will see continued growth there.”

Genitourinary oncologist Nancy B. Davis, MD, associate professor of medicine at Vanderbilt, said given the frequently immunocompromised status of cancer patients, it was vital to have telehealth as an option to continue their care without interruption.

“Telehealth was very well received by patients, older and younger,” Dr Davis

said. “Cancer patients and their cancer care teams develop strong bonds, as we are in the fight together. The pandemic decreased our ability to see our families, friends and, for our patients, their cancer teams. Telehealth was an excellent way for the patients to see their teams and know that we were still there, right alongside them.”

Telehealth has been available for years, but uptake until the pandemic was minimal primarily due to lack of reimbursement for these visits by Medicare and private insurance companies. Additionally, patients needed either a smartphone or a computer.

“I am optimistic telehealth is here to stay, as it was shown to be feasible and well received by both providers and patients,” Dr Davis said. “One of the biggest hurdles is that of interstate licensing. As by law, I would need to be licensed in the state in which my patient is residing or taking the telehealth visit.

The AMA and other medical societies are working on this, and currently there is the option for Interstate Compact Licensing, which facilitates the ability to become licensed in a state other than that of our primary practice site.” ■ John Schieszer is a freelance medical writer based in Seattle, Washington.