www.renalandurologynews.com NOVEMBER/DECEMBER 2020
Renal & Urology News 1
FROM THE MEDICAL DIRECTOR EDITORIAL ADVISORY BOARD 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
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Renal & Urology News (ISSN 1550-9478) Volume 19, Number 6. 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 © 2020.
Dialysis Is Not Going Away Anytime Soon
A
s I was nearing graduation from medical school in Bonn, Germany, in May 1991 and preparing to start residency training in a large nephrology center in Nuremberg, Germany, one of my mentors said I should think twice before choosing nephrology as a career because dialysis would soon be obsolete and replaced by implantable or wearable artificial kidneys. Another mentor told me that with the rise of ACE inhibitors and new data showing that these agents can slow kidney disease, there would not be kidney failure in the future. I became a nephrologist anyway, first in Germany, then in the United States. Now, 30 years later, dialysis has expanded tremendously in the United States and Europe, and its use is expanding exponentially in such emerging economies as India, China, and Brazil. Some medical students and residents recently asked me whether there is any future in nephrology if dialysis would soon dissipate. My response is that dialysis is not likely to become obsolete — despite advances such as SGLT2 inhibitors that have been demonstrated to slow kidney disease progression — and nephrology goes way beyond renal replacement therapy. Recent trends to avoid or stop dialysis have been heightened by perverse financial incentives to reduce length of hospital stay and prevent 30-day readmissions of patients with kidney problems. Nephrologists may feel pressured to get their dialysis and kidney transplant patients out of needed intensive care unit (ICU) beds via discontinuation of immunosuppression medication or abrupt dialysis withdrawal to expedite hospice transition. Patients and family members may feel coerced by medical teams to choose the end-of-life route portrayed to them as the best option. Other options are available to ameliorate pressure to decrease hospital lengths of stay and prevent readmissions. These include conservative measures that can delay the need for dialysis among patients with chronic kidney disease, such as diet and lifestyle modifications.1 Under a presidential executive order issued in July 2019 (the Advancing American Kidney Health Initiative), the Department of Health and Human Services hopes to achieve a 25% decrease in the incidence of end-stage kidney disease by 2030. It would be against the choice and hope of many patients if this is to be achieved at least in part by steering patients toward palliative and supportive care rather than dialysis. Each time a patient under my care expresses thoughts to stop therapy to die, I spend extra time to discuss all options. I explain to patients and their families why it may still not be time to give up. I tell my patients that, as long as I am around, you will be, too, if you choose to be. Kam Kalantar-Zadeh, MD, PhD, MPH Professor & Chief, Division of Nephrology, Hypertension & Kidney Transplantation UC Irvine School of Medicine, Orange, CA Twitter/Facebook: @KamKalantar 1. Kalantar-Zadeh K, Wightman A, Liao S. Ensuring choice for people with kidney failure – Dialysis, supportive care, and hope. N Engl J Med. 2020;383:99-101.
