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. ■
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