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2 years after treatment, occurred in 1 of men with clinical stage I disease.
Post-Kidney Transplant MACE Predicts Diminished Survival
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RECENTLY REPORTED study findings provide a detailed look at how a major adverse cardiovascular event (MACE) after kidney transplantation adversely affects survival and identify which patients are at elevated risk for MACE. Data also demonstrate that patients who receive a kidney transplant
are at lower MACE risk compared with those who remain on dialysis.
In a study of 30,325 KTRs in England published in Kidney International, a MACE occurred in 781 within the first year of transplantation surgery. KTRs who had a nonfatal MACE within that timeframe had significantly decreased patient survival compared with KTRs who did not experience a MACE at 1 year (80.5% vs 97.4%), 3 years (70.2% vs 94.4%), 5 years (59.5% vs 90.7%), and 10 years (38.6% vs 78.4%). A nonfatal MACE within the firstyear of transplant surgery was significantly associated with 2.6fold increased risk for longterm mortality, Adnan Sharif, MBChB, MD, of Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom and colleagues reported.
“Nonfatal MACE within the first year, regardless of the precise timing, was a powerful predictor of increased future mortality,” the investigators wrote. “Understanding MACE rates is important for service providers, healthcare professionals and kidney transplant recipients themselves.”
The investigators defined MACE broadly as any hospitalization for unstable angina, myocardial infarction (MI), stroke, heart failure, any coronary revascularization procedure and/or any cardiovascular death. A MACE occurred in 781 patients (2.6%) within the first 12 months of transplant surgery. Unstable angina occurred in 0.2%, heart failure in 0.3%, MI in 1.1%,
coronary revascularization in 0.4%, stroke in 0.8%, and immediate cardiac death in 0.1% within the first 12 months after transplant surgery. The investigators noted that these rates are lower than rates reported in North America.
Sex and Age Differences Results also showed that men had a 20% higher risk for a MACE within 12 months than women. Compared with KTRs younger than 40 years, those aged 4049, 5059, and 60 years or older had a 2.4, 4.3, and 7.1fold greater risk for an early MACE after kidney transplantation. Recipients of deceased donor vs living donor kidneys had a 37% higher 1year MACE risk. Previous myocardial infarction, stroke, or angina was significantly associated with a 6.9, 4.1, and 2.6fold increased risk of an early MACE, respectively. Diabetes at transplantation was significantly associated with a 2.2fold increased risk for a 1year MACE after kidney transplantation.
“Successful kidney transplantation reduces cardiovascular burden compared to remaining on dialysis, but risk remains elevated compared to the agematched general population,” Dr Sharif’s team wrote. “Adequate counselling aside, strategies to predict and/or mitigate cardiovascular risk in the setting of kidney transplantation are urgently required.”
ADPKD Tied to Lower MACE Risk In a study published in Kidney International Reports, investigators found that KTRs with autosomal dominant polycystic kidney disease (ADPKD) have a more favorable MACEfree survival rate than patients with diabetes and other forms of kidney disease. In an ageand sexmatched analysis, KTRs with ADPKD had a significant 29% reduced risk for MACE after kidney transplantation compared with those with diabetic nephropathy and those without diabetes or ADPKD, Fouad T. Chebib, MD, of Mayo Clinic in Jacksonville, Florida, and colleagues reported.
Transplantation vs Dialysis In a Korean study published in Nephrology Dialysis Transplantation, investigators examined de novo MACE in KTRs compared with patients receiving dialysis. Using the South Korean nationwide health insurance database, they matched 4156 patients without a preexisting MACE in each of 3 groups: KTRs, dialysis recipients, and the general population.
Over 4.7 years of followup, de novo MACE occurred in 3.7, 21.7, and 2.5 individuals per 1000 personyears in the KTR, dialysis, and general population groups, respectively. De novo MACE included myocardial infarction, revascularization, and ischemic stroke. The investigators noted that these rates are lower than those reported in Western populations. KTRs had a significant 84% lower risk for de novo MACE compared with patients on dialysis, but a similar risk compared with the general population after adjusting for underlying comorbidities such as diabetes and hypertension, Hajeong Lee, MD, of Seoul National University Hospital and colleagues reported. This finding suggests that kidney transplantation effectively reduces the risk of MACE compared with remaining on dialysis, according to Dr Lee’s team. ■
Survival After MACE
Kidney transplant recipients who had a nonfatal major adverse cardiovascular event (MACE) within the first year after transplant surgery, compared with those who did not, had significantly lower 1-, 3-, 5-, and 10-year survival rates, a study found.
80.5% 97.4% 94.4%
70.2%
■ MACE ■ No MACE
90.7%
59.5% 78.4%
38.6%
0 1 Year 3 Years 5 Years 10 Years
Source: Anderson B et al. A population cohort analysis of English transplant centers indicates major adverse cardiovascular events after kidney transplantation. Kidney Int. Published online June 15, 2022.
Aspirin May Lower MACE Risk in CKD
ASPIRIN MAY prevent major adverse cardiovascular events (MACE) in patients with chronic kidney disease (CKD), according to study findings presented at the European Renal Association’s 59th Congress held in Paris, France, and virtually.
The findings are from the International Polycap Study3 (TIPS3) study in which investigators randomly assigned 5713 individuals with and without CKD, but without previous cardiovascular (CV) disease, to receive aspirin, aspirin plus a polypill (containing atenolol, ramipril, hydrochlorothiazide, and simvastatin), a polypill alone, or respective placebo. Of the 5713 participants, 983 had CKD, defined as an estimated glomerular filtration rate (eGFR) less than 60 mL/ min/1.73 m2 . The primary outcome was MACE, which included nonfatal myocardial infarction, nonfatal stroke, or CVrelated death. Secondary outcomes included allcause mortality. The mean followup duration was 4.6 years.
A total of 250 primary MACE occurred: 116 among aspirin recipients and 134 among placebo recipients, Johannes F.E. Mann, MD, from the University of ErlangenNürnberg and Munich General Hospitals in Germany, reported. Among patients with CKD, there were 65 primary MACE outcomes: 26 in the 502 participants on aspirin and 39 in the 481 participants on placebo. Aspirin use in those with CKD was significantly associated with a 43% reduction in MACE risk.
Death from any cause occurred in 312 participants, with 82 occurring in the CKD group. Aspirin use was significantly associated with a 36% decreased risk for death compared with placebo.
For all participants, the aspirinpolypill combination was significantly associated with a 31% decreased risk for MACE. Among patients with CKD, the combination treatment was significantly associated with a 63% and 51% decreased risk for MACE and death, respectively. ■
Aspirin vs placebo was associated with a 43% reduced risk for MACE.
■ AUA 2022, New Orleans American Urological Association 2022 Annual Meeting
Baseline EF Influences Potency Recovery After Nerve-Sparing RC
Good erectile function before surgery is a positive sign, new findings suggest
BY JOHN SCHIESZER IN HIGHLY SELECTED cases, men who have good baseline erectile function (EF) can recover potency following nerve-sparing radical cystectomy (RC), according to the findings of a singlecenter, prospective nonrandomized trial presented at the 2022 American Urological Association annual meeting in New Orleans, Louisiana.
“Most men undergoing RC have poor erectile function at baseline and experience further decline after surgery without recovery. However, in a select group of men with good erectile function at baseline, the use of nerve-sparing surgery allowed many to recover erectile function after surgery, and this recovery continued out to 2 years,” said study investigator Benjamin Beech, MD, a urologic oncology fellow at Memorial Sloan Kettering Cancer Center in New York City.
RC can have significant adverse effects on quality of life (QoL). Both sexual impairment and sexual dysfunction are significant problems for men and women post-RC. Sexual dysfunction may be due to a combination of organic and surgery-related iatrogenic factors. There is a paucity of data on long-term outcomes and the impact of preoperative EF.
Dr Beech and colleagues examined the natural history of EF before and after RC and examined QoL in 210 men who were seen between 2008 and 2014. All the men completed the International Index of Erectile Function (IIEF) at their presurgical visit and at 3, 6, 12, 18, and 24 months post-RC.
Orthotopic neobladder was performed in 115 men (55%) and ileal conduit in 95 (45%). Bilateral or unilateral nerve-sparing surgery was performed in 50% of the men with neobladder and 11% of men with ileal conduit. In this cohort, ileal conduit patients were significantly older (73 vs 63 years) and had a significantly higher rate of severe ED (65% vs 44%) prior to RC. They also were significantly less likely to have no ED (17% vs 30%) prior to RC.
The researchers found that 84% of men reported having severe ED at 12 months and 79% at 24 months postRC. However, among 35 men with no preoperative ED and neobladder diversion, 16.7% reported no ED at 3 months (67% had bilateral nerve sparing and 22% underwent partial nerve sparing). The largest recovery occurred from 12-24 months, with rates of no ED improving from 14% to 35%.
Among men who were potent preoperatively and underwent nerve-sparing surgery, around one-third of those with orthotopic neobladder and one-fifth of those with ileal conduit reported no ED at 24 months.
“We believe these findings are clinically relevant and can help with preoperative counseling for men facing radical cystectomy and can also inform the decisions of surgeons around nervesparing surgery,” Dr Beech said.
The strengths of the current study include the prospective collection of patient-reported outcome measures conducted repeatedly over the short to medium-term post-operative period. Limitations included a focus on EF specifically, which does not account for other components of overall sexual function, such as desire, orgasmic function, and satisfaction.
Eric Klein, MD, chair of the Glickman Urological & Kidney Institute at Cleveland Clinic in Ohio, where he is professor of surgery in the Lerner College of Medicine, said it is important to have serial monitoring and long-term follow-up in this patient population. “There is older literature supporting this concept, both with respect to not compromising cancer control and return of erectile function,” Dr Klein said. “Nerve sparing is the right thing to do in appropriately selected patients.”
“Nerve sparing is a major aspect of radical prostatectomy, but within pelvic uro-oncology it has received less attention as a part of the technique for radical cystectomy,” said Zachary Dovey, MD, assistant professor, general urology, robotics and uro-oncology at Mount Sinai Queens and Icahn School of Medicine at Mount Sinai, New York, New York. “This study confirms the important finding that, when oncologically safe, nerve sparing is feasible and can maintain EF in the postoperative period.”
Neobladder for appropriately selected patients, especially using the robotic approach, is increasingly performed in high-volume pelvic uro-oncology centers as the chosen modality of urinary diversion for the surgical treatment of muscle-invasive bladder cancer, Dr Dovey said. The study by Dr Beech’s group is clinically relevant because of its prospective nature with repeated surveillance. ■
OAB Linked to Visceral Fat in Men
INCREASED VISCERAL fat area (VFA) is significantly associated with the presence and severity of overactive bladder (OAB) in men, data suggest.
Further, excessive abdominal visceral fat accumulation alone is an important OAB risk factor, concluded a team led by Tomohiro Matsuo, MD, PhD, of Nagasaki University Graduate School of Biomedical Sciences in Nagasaki, Japan.
Dr Matsuo and colleagues analyzed data from 519 participants who underwent abdominal computed tomography (CT) as part of health checks and had not been treated for lower urinary tract symptoms prior to study enrollment. Of these, 135 met criteria for OAB: 2 points or higher on question 3 (urinary urgency) of the Overactive Bladder Symptom Score questionnaire and a total score of 3 points or higher. Investigators calculated VFA, visceral fat volume (VFV), and total abdominal fat volume (TAV) from the abdominal CT scans. Patients had a mean age of 57.4 years.
Compared with the men without OAB, the men with OAB had significantly higher mean VFA (113.5 vs 72.1 cm2), VFV (3299.6 vs 1829.1 cm3), and VFV/TAV (0.50 vs 0.32). VFV/TAV at a cutoff value of 0.409 had a sensitivity and specificity for OAB of 74% and 73%, respectively. On multivariable analysis, a VFV/TAV of 0.409 was independently associated with 4.5-fold increased odds for OAB.
Recent research suggests that metabolic syndrome is an important factor in the development of lower urinary tract symptoms, Dr Matsuo and colleagues noted. A recent study of women demonstrated that excessive visceral fat accumulation, which can trigger metabolic syndrome, is associated with OAB presence and severity. No such research has been conducted with men, who are considered more susceptible to the effects of visceral fat than women, according to the investigators. ■
