From the Medical Director

EDITORIAL ADVISORY BOARD

Medical Director, Urology

Robert G. Uzzo, MD, MBA, FACS

G. Willing “Wing” Pepper Chair in Cancer Research Professor and Chairman Department of Surgery Fox Chase Cancer Center Temple University School of Medicine Philadelphia Urologists

Christopher S. Cooper, MD

Director, Pediatric Urology Children’s Hospital of Iowa Iowa City

R. John Honey, MD

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

Stanton Honig, MD

Department of Urology Yale University School of Medicine New Haven, CT

J. Stephen Jones, MD

Chief Executive Officer Inova Health System Falls Church, VA Professor and Horvitz/Miller Distinguished Chair in Urologic Oncology (ret.) Cleveland Clinic Lerner College of Medicine Cleveland

Jaime Landman, MD

Professor of Urology and Radiology Chairman, Department of Urology UC Irvine School of Medicine Orange, CA

James M. McKiernan, MD

John K. Lattimer Professor of Urology Chair, Department of Urology Director, Urologic Oncology Columbia University College of Physicians and Surgeons New York

Kenneth Pace, MD, MSc

Assistant Professor, Division of Urology St. Michael’s Hospital University of Toronto Vancouver, Canada Medical Director, Nephrology

Kamyar Kalantar-Zadeh, MD, PhD, MPH

Professor & Chief, Division of Nephrology, Hypertension & Kidney Transplantation UC Irvine School of Medicine Orange, CA

Nephrologists

Anthony J. Bleyer, MD, MS

Professor of Internal Medicine/Nephrology Wake Forest University School of Medicine Winston-Salem, NC

David S. Goldfarb, MD

Professor, Department of Medicine Clinical Chief New York University Langone Medical Center Chief of Nephrology NY Harbor VA Medical Center

Csaba P. Kovesdy, MD

Chief of Nephrology Memphis VA Medical Center Fred Hatch Professor of Medicine University of Tennessee Health Science Center Memphis

Edgar V. Lerma, MD

Clinical Associate Professor of Medicine Section of Nephrology Department of Medicine University of Illinois at Chicago College of Medicine Chicago

Allen Nissenson, MD

Emeritus Professor of Medicine The David Geffen School of Medicine at UCLA Chief Medical Officer, DaVita Inc. Denver

Rulan Parekh, MD, MS

Associate Professor of Pediatrics and Medicine University of Toronto

Robert Provenzano, MD

Associate Professor of Medicine Wayne State University School of Medicine Detroit Vice President of Medical Affairs, DaVita Healthcare Denver

Robert S. Rigolosi, MD

Director, Regional Hemodialysis Center Holy Name Hospital Teaneck, NJ

Renal & Urology News Staff

Editor Web editor Production editor Group creative director Production manager Vice president, sales operations and production Director of audience insights National accounts manager Editorial director, Haymarket Oncology Vice president, content, medical communications General manager, medical communications President, medical communications Chairman & CEO, Haymarket Media Inc. Jody A. Charnow Natasha Persaud Kim Daigneau Jennifer Dvoretz Brian Wask Louise Morrin Boyle Paul Silver William Canning Lauren Burke Kathleen Walsh Tulley James Burke, RPh Michael Graziani Lee Maniscalco

FROM THE MEDICAL DIRECTOR

Dialysis Is Not Going Away Anytime Soon

As 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

2 Renal & Urology News NOVEMBER/DECEMBER 2020 www.renalandurologynews.com Contents NOVEMBER/DECEMBER 2020 ■ VOLUME 19, ISSUE NUMBER 6

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Nephrology

4 Novel IV Drug Eases Pruritus in HD Patients In a phase 3 trial, difelikefalin decreased moderate to severe itching.

4 Drug May Prevent CV Events in High-Risk Diabetic CKD Apabetalone decreased the likelihood of major cardiovascular events among patients with diabetic nephropathy who recently suffered from acute coronary syndrome.

5 Finerenone Slows CKD Advance in Diabetics Patients treated with the investigational mineralocorticoid receptor antagonist had an 18% decreased risk for deteriorating kidney function.

9 Fruits, Vegetables Ease Metabolic Acidosis A healthy diet may be a cost-effective way for patients with chronic kidney disease to manage a potentially serious abnormality.

Urology

6 Prostate Cancer Management Falls Short in Rural America The likelihood of undergoing certain procedures is diminished compared with urban centers, studies show.

11 NAC Offers Survival Edge in UTUC Neoadjuvant chemotherapy prior nephroureterectomy is associated with superior 5-year survival, a study found.

11 RT for Abdominal, Pelvic Cancers Ups Risk for Secondary Sarcomas Radiotherapy combined with chemotherapy is associated with the greatest risk.

13 Earlier Surrogate for Survival After RP Relapse Possibly ID’d Castration-resistant prostate cancer-free survival after post-RP biochemical recurrence could serve as an intermediate endpoint in clinical trials.

The understandable challenge is to get patients to change their diets, something that we all recognize is very dif cult to do. CALENDAR

Editor’s note: With the cancellation of in-person medical conferences thus far in 2020 in response to the COVID-19 pandemic and the status of meetings unclear, we are providing listings of conferences scheduled for 2021.

Genitourinary Cancer Symposium

San Francisco January 21 to 23, 2021

American Urological Association

Annual Meeting Las Vegas May 13–14, 2021

ERA-EDTA

Annual Congress Berlin, Germany June 5–8, 2021

Canadian Urological Association

Annual Meeting Niagara Falls, Ontario, Canada June 26–29, 2021

International Continence Society

Annual Meeting Melbourne, Australia October 12–15, 2021

16

Departments

1 From the Medical Director Will there always be a need for dialysis?

3 News in Brief Pulse pressure prior to hemodialysis may predict mortality risk

15 Ethical Issues in Medicine Physician virtues may help them navigate possible COVID-19 ethical dilemmas

16 Practice Management Experts suggest ways to deal with psychological stress during the pandemic