Nephrology

The American Urological Association (AUA) published guidelines for asymptomatic microhematuria. The document includes 19 guidelines with recommendation levels ranging from A to C (high to low) and some expert opinion recommendations included. The full guidelines can be accessed at  http://www.auanet.org/common/pdf/education/clinical-guidance/Asymptomatic-Microhematuria.pdf.

Q: I am studying for my boards and am deep into the renal/urology section. I graduated so long ago that IVPs were the evaluation of choice. What is the “expert opinion” now on managing the patient with hematuria? Do we go straight to cystoscopy or use a different test?

First-line evaluation for asymptomatic microscopic hematuria now requires CT urography instead of IV pyelography (IVP) or cystoscopy (see AUA guideline 10).¹ The CT should be done with and without IV contrast and be multiphasic in nature. Specific high-resolution evaluation of the urothelium of the upper urinary tracts during the excretory phase must be included. This is the most sensitive and specific radiologic examination to adequately evaluate for a renal mass in the parenchyma as well as for abnormalities in the upper tracts simultaneously.¹

Using contrast dye in a patient with decreased renal function is always problematic. Precautions to be taken include withholding ACE inhibitors and angiotensin receptor blockers before and after the procedure and hydrating the patient before, during, and after administration of contrast dye.

Sarah Sparks, NP, St. Luke’s Clinic–Nephrology, St. Luke’s Health System, Boise, ID

References
1. Davis R, Jones JS, Barocas DA, et al; American Urological Association. Diagnosis, Evaluation, and Follow-up of Asymptomatic Microhematuria (AMH) in Adults: AUA Guideline. Linthicum, MD: American Urological Association Education and Research, Inc; 2012.  http://www.auanet.org/common/pdf/education/clinical-guidance/Asymptomatic-Microhematuria.pdf. Accessed January 24, 2013.
2. National Kidney and Urologic Diseases Information Clearinghouse. Hematuria: blood in the urine (2012). http://kidney.niddk.nih.gov/kudiseases/pubs/hematuria. Accessed January 17, 2013.
3. Geavlete B, Jecu M, Multescu R, et al. HAL blue-light cystoscopy in high-risk nonmuscle-invasive bladder cancer: re-TURBT recurrence rates in a prospective, randomized study. Urology. 2010;76(3):664-669.

Suggested Reading
Feldman AS, Hsu C-Y, Kurtz M, Cho KC. Etiology and evaluation of hematuria in adults (2012). www.uptodate.com/contents/etiology-and-evaluation-of-hematuria-in-adults. Accessed January 17, 2013.
Jayne D. Hematuria and proteinuria. In: Greenberg A, ed; National Kidney Foundation. Primer on Kidney Diseases. 5th ed. Saunders; 2009:33-42.

The American Urological Association (AUA) published guidelines for asymptomatic microhematuria. The document includes 19 guidelines with recommendation levels ranging from A to C (high to low) and some expert opinion recommendations included. The full guidelines can be accessed at  http://www.auanet.org/common/pdf/education/clinical-guidance/Asymptomatic-Microhematuria.pdf.

Q: I am studying for my boards and am deep into the renal/urology section. I graduated so long ago that IVPs were the evaluation of choice. What is the “expert opinion” now on managing the patient with hematuria? Do we go straight to cystoscopy or use a different test?

First-line evaluation for asymptomatic microscopic hematuria now requires CT urography instead of IV pyelography (IVP) or cystoscopy (see AUA guideline 10).¹ The CT should be done with and without IV contrast and be multiphasic in nature. Specific high-resolution evaluation of the urothelium of the upper urinary tracts during the excretory phase must be included. This is the most sensitive and specific radiologic examination to adequately evaluate for a renal mass in the parenchyma as well as for abnormalities in the upper tracts simultaneously.¹

Using contrast dye in a patient with decreased renal function is always problematic. Precautions to be taken include withholding ACE inhibitors and angiotensin receptor blockers before and after the procedure and hydrating the patient before, during, and after administration of contrast dye.

Sarah Sparks, NP, St. Luke’s Clinic–Nephrology, St. Luke’s Health System, Boise, ID

References
1. Davis R, Jones JS, Barocas DA, et al; American Urological Association. Diagnosis, Evaluation, and Follow-up of Asymptomatic Microhematuria (AMH) in Adults: AUA Guideline. Linthicum, MD: American Urological Association Education and Research, Inc; 2012.  http://www.auanet.org/common/pdf/education/clinical-guidance/Asymptomatic-Microhematuria.pdf. Accessed January 24, 2013.
2. National Kidney and Urologic Diseases Information Clearinghouse. Hematuria: blood in the urine (2012). http://kidney.niddk.nih.gov/kudiseases/pubs/hematuria. Accessed January 17, 2013.
3. Geavlete B, Jecu M, Multescu R, et al. HAL blue-light cystoscopy in high-risk nonmuscle-invasive bladder cancer: re-TURBT recurrence rates in a prospective, randomized study. Urology. 2010;76(3):664-669.

Suggested Reading
Feldman AS, Hsu C-Y, Kurtz M, Cho KC. Etiology and evaluation of hematuria in adults (2012). www.uptodate.com/contents/etiology-and-evaluation-of-hematuria-in-adults. Accessed January 17, 2013.
Jayne D. Hematuria and proteinuria. In: Greenberg A, ed; National Kidney Foundation. Primer on Kidney Diseases. 5th ed. Saunders; 2009:33-42.

The American Urological Association (AUA) published guidelines for asymptomatic microhematuria. The document includes 19 guidelines with recommendation levels ranging from A to C (high to low) and some expert opinion recommendations included. The full guidelines can be accessed at  http://www.auanet.org/common/pdf/education/clinical-guidance/Asymptomatic-Microhematuria.pdf.

Q: I am studying for my boards and am deep into the renal/urology section. I graduated so long ago that IVPs were the evaluation of choice. What is the “expert opinion” now on managing the patient with hematuria? Do we go straight to cystoscopy or use a different test?

First-line evaluation for asymptomatic microscopic hematuria now requires CT urography instead of IV pyelography (IVP) or cystoscopy (see AUA guideline 10).¹ The CT should be done with and without IV contrast and be multiphasic in nature. Specific high-resolution evaluation of the urothelium of the upper urinary tracts during the excretory phase must be included. This is the most sensitive and specific radiologic examination to adequately evaluate for a renal mass in the parenchyma as well as for abnormalities in the upper tracts simultaneously.¹

Using contrast dye in a patient with decreased renal function is always problematic. Precautions to be taken include withholding ACE inhibitors and angiotensin receptor blockers before and after the procedure and hydrating the patient before, during, and after administration of contrast dye.

Sarah Sparks, NP, St. Luke’s Clinic–Nephrology, St. Luke’s Health System, Boise, ID

References
1. Davis R, Jones JS, Barocas DA, et al; American Urological Association. Diagnosis, Evaluation, and Follow-up of Asymptomatic Microhematuria (AMH) in Adults: AUA Guideline. Linthicum, MD: American Urological Association Education and Research, Inc; 2012.  http://www.auanet.org/common/pdf/education/clinical-guidance/Asymptomatic-Microhematuria.pdf. Accessed January 24, 2013.
2. National Kidney and Urologic Diseases Information Clearinghouse. Hematuria: blood in the urine (2012). http://kidney.niddk.nih.gov/kudiseases/pubs/hematuria. Accessed January 17, 2013.
3. Geavlete B, Jecu M, Multescu R, et al. HAL blue-light cystoscopy in high-risk nonmuscle-invasive bladder cancer: re-TURBT recurrence rates in a prospective, randomized study. Urology. 2010;76(3):664-669.

Suggested Reading
Feldman AS, Hsu C-Y, Kurtz M, Cho KC. Etiology and evaluation of hematuria in adults (2012). www.uptodate.com/contents/etiology-and-evaluation-of-hematuria-in-adults. Accessed January 17, 2013.
Jayne D. Hematuria and proteinuria. In: Greenberg A, ed; National Kidney Foundation. Primer on Kidney Diseases. 5th ed. Saunders; 2009:33-42.

The American Urological Association (AUA) published guidelines for asymptomatic microhematuria. The document includes 19 guidelines with recommendation levels ranging from A to C (high to low) and some expert opinion recommendations included. The full guidelines can be accessed at  http://www.auanet.org/common/pdf/education/clinical-guidance/Asymptomatic-Microhematuria.pdf.

Q: A 39-year-old woman came to my office for an annual physical, and there was blood in the urine when I sent her urine out for microscopy. She is having abnormal menses, so she could not be sure this was not contamination (and neither could I). I repeated the urine and it was positive for blood on micro. What do I do now? Where do I refer her?

There are numerous causes of microhematuria, and the answer can often be found by considering the possible differential diagnoses. The causes of hematuria include urinary tract infection (UTI), bladder or kidney stones, kidney disease, use of certain medications, strenuous exercise, and trauma.² Health care professionals should follow a process to make logical assessments and decisions in the care of this 39-year-old woman with microhematuria.

What to do first? The first step is to obtain a complete history, including any associated symptoms, medication history, last menstrual period, family history, previous medical history, recent trauma, strenuous exercise, and easy bruising or bleeding. In this case, since the urinalysis was repeated and remained positive for hematuria, the next step is to consider a renal function panel and complete blood count (CBC).

A renal function panel (sodium, potassium, chloride, carbon dioxide, anion gap, glucose, urea reduction ratio, creatinine, albumin, calcium, and phosphorous) will help to rule out existing renal function dysfunction.

The CBC will help to rule out any blood loss or presence of systemic involvement. Also, look at other results noted on the urinalysis, such as protein, nitrates, and leukocytes. Looking for protein will help the clinician determine whether fever, diabetes, chronic kidney disease, or hypertension may be the cause. Nitrates will appear as a result of UTI, and leukocytes may suggest a UTI or possible contamination. Dysmorphic red blood cells (RBCs with irregular shapes) found on the microscopic exam of the urine indicate a glomerular etiology, in which case the patient should be referred to nephrology for possible renal biopsy. If the red blood cells are nonglomerular (ie, the glomerulus is not the source of the bleeding) and there is no other obvious cause, then the patient should be referred to urology.

When is it time to refer? If microhematuria is persistent, the patient will need to be referred to a urologist for further evaluation. According to AUA guidelines 7, 8, and 16 through 19,¹ cystoscopy should be considered for patients 35 or older with asymptomatic hematuria. For younger patients, a cystoscopy may be considered at the discretion of the provider. Although blue light cystoscopy has FDA approval, in the opinion of the AUA, the risks of the technique outweigh its benefits. Blue light cystoscopy is reported to improve identification of bladder tumors.³

For patients with a history of persistent asymptomatic hematuria, no further urinalyses are needed after two consecutive yearly tests with negative results. Those with a negative urologic workup should have urinalyses performed annually. If a patient has persistent or recurrent asymptomatic microhematuria with an initially negative urologic workup, then patients should be considered for reevaluation by urology every 3 to 5 years.¹

In conclusion, the best approach to microhematuria is to obtain a thorough history, check the necessary labs, and if microhematuria persists, make the necessary referral to the appropriate specialist, ensuring that the patient receives the best possible care.

Tia Austin Hayes, FNP-C, JMM Renal Clinic/Outpatient Dialysis, University of Mississippi Department of Nephrology; Donna Anderson, PA-C, CAQ, Nephrology Specialists of Oklahoma, Tulsa

References
1. Davis R, Jones JS, Barocas DA, et al; American Urological Association. Diagnosis, Evaluation, and Follow-up of Asymptomatic Microhematuria (AMH) in Adults: AUA Guideline. Linthicum, MD: American Urological Association Education and Research, Inc; 2012.  http://www.auanet.org/common/pdf/education/clinical-guidance/Asymptomatic-Microhematuria.pdf. Accessed January 24, 2013.
2. National Kidney and Urologic Diseases Information Clearinghouse. Hematuria: blood in the urine (2012). http://kidney.niddk.nih.gov/kudiseases/pubs/hematuria. Accessed January 17, 2013.
3. Geavlete B, Jecu M, Multescu R, et al. HAL blue-light cystoscopy in high-risk nonmuscle-invasive bladder cancer: re-TURBT recurrence rates in a prospective, randomized study. Urology. 2010;76(3):664-669.

Suggested Reading
Feldman AS, Hsu C-Y, Kurtz M, Cho KC. Etiology and evaluation of hematuria in adults (2012). www.uptodate.com/contents/etiology-and-evaluation-of-hematuria-in-adults. Accessed January 17, 2013.
Jayne D. Hematuria and proteinuria. In: Greenberg A, ed; National Kidney Foundation. Primer on Kidney Diseases. 5th ed. Saunders; 2009:33-42.

The American Urological Association (AUA) published guidelines for asymptomatic microhematuria. The document includes 19 guidelines with recommendation levels ranging from A to C (high to low) and some expert opinion recommendations included. The full guidelines can be accessed at  http://www.auanet.org/common/pdf/education/clinical-guidance/Asymptomatic-Microhematuria.pdf.

Q: A 39-year-old woman came to my office for an annual physical, and there was blood in the urine when I sent her urine out for microscopy. She is having abnormal menses, so she could not be sure this was not contamination (and neither could I). I repeated the urine and it was positive for blood on micro. What do I do now? Where do I refer her?

There are numerous causes of microhematuria, and the answer can often be found by considering the possible differential diagnoses. The causes of hematuria include urinary tract infection (UTI), bladder or kidney stones, kidney disease, use of certain medications, strenuous exercise, and trauma.² Health care professionals should follow a process to make logical assessments and decisions in the care of this 39-year-old woman with microhematuria.

What to do first? The first step is to obtain a complete history, including any associated symptoms, medication history, last menstrual period, family history, previous medical history, recent trauma, strenuous exercise, and easy bruising or bleeding. In this case, since the urinalysis was repeated and remained positive for hematuria, the next step is to consider a renal function panel and complete blood count (CBC).

A renal function panel (sodium, potassium, chloride, carbon dioxide, anion gap, glucose, urea reduction ratio, creatinine, albumin, calcium, and phosphorous) will help to rule out existing renal function dysfunction.

The CBC will help to rule out any blood loss or presence of systemic involvement. Also, look at other results noted on the urinalysis, such as protein, nitrates, and leukocytes. Looking for protein will help the clinician determine whether fever, diabetes, chronic kidney disease, or hypertension may be the cause. Nitrates will appear as a result of UTI, and leukocytes may suggest a UTI or possible contamination. Dysmorphic red blood cells (RBCs with irregular shapes) found on the microscopic exam of the urine indicate a glomerular etiology, in which case the patient should be referred to nephrology for possible renal biopsy. If the red blood cells are nonglomerular (ie, the glomerulus is not the source of the bleeding) and there is no other obvious cause, then the patient should be referred to urology.

When is it time to refer? If microhematuria is persistent, the patient will need to be referred to a urologist for further evaluation. According to AUA guidelines 7, 8, and 16 through 19,¹ cystoscopy should be considered for patients 35 or older with asymptomatic hematuria. For younger patients, a cystoscopy may be considered at the discretion of the provider. Although blue light cystoscopy has FDA approval, in the opinion of the AUA, the risks of the technique outweigh its benefits. Blue light cystoscopy is reported to improve identification of bladder tumors.³

For patients with a history of persistent asymptomatic hematuria, no further urinalyses are needed after two consecutive yearly tests with negative results. Those with a negative urologic workup should have urinalyses performed annually. If a patient has persistent or recurrent asymptomatic microhematuria with an initially negative urologic workup, then patients should be considered for reevaluation by urology every 3 to 5 years.¹

In conclusion, the best approach to microhematuria is to obtain a thorough history, check the necessary labs, and if microhematuria persists, make the necessary referral to the appropriate specialist, ensuring that the patient receives the best possible care.

Tia Austin Hayes, FNP-C, JMM Renal Clinic/Outpatient Dialysis, University of Mississippi Department of Nephrology; Donna Anderson, PA-C, CAQ, Nephrology Specialists of Oklahoma, Tulsa

References
1. Davis R, Jones JS, Barocas DA, et al; American Urological Association. Diagnosis, Evaluation, and Follow-up of Asymptomatic Microhematuria (AMH) in Adults: AUA Guideline. Linthicum, MD: American Urological Association Education and Research, Inc; 2012.  http://www.auanet.org/common/pdf/education/clinical-guidance/Asymptomatic-Microhematuria.pdf. Accessed January 24, 2013.
2. National Kidney and Urologic Diseases Information Clearinghouse. Hematuria: blood in the urine (2012). http://kidney.niddk.nih.gov/kudiseases/pubs/hematuria. Accessed January 17, 2013.
3. Geavlete B, Jecu M, Multescu R, et al. HAL blue-light cystoscopy in high-risk nonmuscle-invasive bladder cancer: re-TURBT recurrence rates in a prospective, randomized study. Urology. 2010;76(3):664-669.

Suggested Reading
Feldman AS, Hsu C-Y, Kurtz M, Cho KC. Etiology and evaluation of hematuria in adults (2012). www.uptodate.com/contents/etiology-and-evaluation-of-hematuria-in-adults. Accessed January 17, 2013.
Jayne D. Hematuria and proteinuria. In: Greenberg A, ed; National Kidney Foundation. Primer on Kidney Diseases. 5th ed. Saunders; 2009:33-42.

The American Urological Association (AUA) published guidelines for asymptomatic microhematuria. The document includes 19 guidelines with recommendation levels ranging from A to C (high to low) and some expert opinion recommendations included. The full guidelines can be accessed at  http://www.auanet.org/common/pdf/education/clinical-guidance/Asymptomatic-Microhematuria.pdf.

Q: A 39-year-old woman came to my office for an annual physical, and there was blood in the urine when I sent her urine out for microscopy. She is having abnormal menses, so she could not be sure this was not contamination (and neither could I). I repeated the urine and it was positive for blood on micro. What do I do now? Where do I refer her?

There are numerous causes of microhematuria, and the answer can often be found by considering the possible differential diagnoses. The causes of hematuria include urinary tract infection (UTI), bladder or kidney stones, kidney disease, use of certain medications, strenuous exercise, and trauma.² Health care professionals should follow a process to make logical assessments and decisions in the care of this 39-year-old woman with microhematuria.

What to do first? The first step is to obtain a complete history, including any associated symptoms, medication history, last menstrual period, family history, previous medical history, recent trauma, strenuous exercise, and easy bruising or bleeding. In this case, since the urinalysis was repeated and remained positive for hematuria, the next step is to consider a renal function panel and complete blood count (CBC).

A renal function panel (sodium, potassium, chloride, carbon dioxide, anion gap, glucose, urea reduction ratio, creatinine, albumin, calcium, and phosphorous) will help to rule out existing renal function dysfunction.

The CBC will help to rule out any blood loss or presence of systemic involvement. Also, look at other results noted on the urinalysis, such as protein, nitrates, and leukocytes. Looking for protein will help the clinician determine whether fever, diabetes, chronic kidney disease, or hypertension may be the cause. Nitrates will appear as a result of UTI, and leukocytes may suggest a UTI or possible contamination. Dysmorphic red blood cells (RBCs with irregular shapes) found on the microscopic exam of the urine indicate a glomerular etiology, in which case the patient should be referred to nephrology for possible renal biopsy. If the red blood cells are nonglomerular (ie, the glomerulus is not the source of the bleeding) and there is no other obvious cause, then the patient should be referred to urology.

When is it time to refer? If microhematuria is persistent, the patient will need to be referred to a urologist for further evaluation. According to AUA guidelines 7, 8, and 16 through 19,¹ cystoscopy should be considered for patients 35 or older with asymptomatic hematuria. For younger patients, a cystoscopy may be considered at the discretion of the provider. Although blue light cystoscopy has FDA approval, in the opinion of the AUA, the risks of the technique outweigh its benefits. Blue light cystoscopy is reported to improve identification of bladder tumors.³

For patients with a history of persistent asymptomatic hematuria, no further urinalyses are needed after two consecutive yearly tests with negative results. Those with a negative urologic workup should have urinalyses performed annually. If a patient has persistent or recurrent asymptomatic microhematuria with an initially negative urologic workup, then patients should be considered for reevaluation by urology every 3 to 5 years.¹

In conclusion, the best approach to microhematuria is to obtain a thorough history, check the necessary labs, and if microhematuria persists, make the necessary referral to the appropriate specialist, ensuring that the patient receives the best possible care.

Tia Austin Hayes, FNP-C, JMM Renal Clinic/Outpatient Dialysis, University of Mississippi Department of Nephrology; Donna Anderson, PA-C, CAQ, Nephrology Specialists of Oklahoma, Tulsa

References
1. Davis R, Jones JS, Barocas DA, et al; American Urological Association. Diagnosis, Evaluation, and Follow-up of Asymptomatic Microhematuria (AMH) in Adults: AUA Guideline. Linthicum, MD: American Urological Association Education and Research, Inc; 2012.  http://www.auanet.org/common/pdf/education/clinical-guidance/Asymptomatic-Microhematuria.pdf. Accessed January 24, 2013.
2. National Kidney and Urologic Diseases Information Clearinghouse. Hematuria: blood in the urine (2012). http://kidney.niddk.nih.gov/kudiseases/pubs/hematuria. Accessed January 17, 2013.
3. Geavlete B, Jecu M, Multescu R, et al. HAL blue-light cystoscopy in high-risk nonmuscle-invasive bladder cancer: re-TURBT recurrence rates in a prospective, randomized study. Urology. 2010;76(3):664-669.

Suggested Reading
Feldman AS, Hsu C-Y, Kurtz M, Cho KC. Etiology and evaluation of hematuria in adults (2012). www.uptodate.com/contents/etiology-and-evaluation-of-hematuria-in-adults. Accessed January 17, 2013.
Jayne D. Hematuria and proteinuria. In: Greenberg A, ed; National Kidney Foundation. Primer on Kidney Diseases. 5th ed. Saunders; 2009:33-42.

Fifteen years after treatment for localized prostate cancer, men who underwent radical prostatectomy reported no differences in urinary, bowel, or sexual function compared with men who underwent external-beam radiation, according to a report published online Jan. 30 in the New England Journal of Medicine.

Using data from the Prostate Cancer Outcomes Study (PCOS), a population-based cohort of men across the United States diagnosed as having prostate cancer in the mid-1990s, researchers tracked the long-term disease-specific outcomes of 1,655 men who underwent radical prostatectomy (70.3% of patients) or radiotherapy (29.7%), with or without androgen-deprivation therapy.

Source: American Gastroenterological Association (www.youtube.com/AmerGastroAssn)

"Since the median life expectancy after treatment for prostate cancer is 13.8 years, a careful evaluation of long-term functional outcomes is critical to an understanding of the comprehensive experience of men living with a diagnosis of prostate cancer," said Dr. Matthew J. Resnick of the department of urologic surgery and the Center for Surgical Quality and Outcomes Research, Vanderbilt University, Nashville, Tenn., and his associates.

Even though men who had radical prostatectomy were more likely to be bothered by such difficulties as urinary incontinence, bowel urgency, and erectile dysfunction at 2 years and 5 years after treatment, those differences disappeared by the 15-year mark. At that time, the prevalence of ED was "nearly universal," affecting 87% of men in the prostatectomy group and 94% of those in the radiotherapy group; yet only 43% and 38%, respectively, reported that this bothered them.

"Long-term follow-up reveals consistent functional declines after 5 years. It remains unknown whether this continued decline is due to prostate cancer and its treatment, the normal aging process, or a combination of factors," the investigators said (N. Engl. J. Med. 2013 [doi10.1056/NEJMoa1209978]).

This study was funded by the National Cancer Institute. Dr. Resnick was supported by the VA National Quality Scholars Program and the T. J. Martell Foundation. Dr. Resnick reported ties to Dendreon and Bayer Healthcare, and his associates reported ties to Ferring and Johnson & Johnson.

Fifteen years after treatment for localized prostate cancer, men who underwent radical prostatectomy reported no differences in urinary, bowel, or sexual function compared with men who underwent external-beam radiation, according to a report published online Jan. 30 in the New England Journal of Medicine.

Using data from the Prostate Cancer Outcomes Study (PCOS), a population-based cohort of men across the United States diagnosed as having prostate cancer in the mid-1990s, researchers tracked the long-term disease-specific outcomes of 1,655 men who underwent radical prostatectomy (70.3% of patients) or radiotherapy (29.7%), with or without androgen-deprivation therapy.

Source: American Gastroenterological Association (www.youtube.com/AmerGastroAssn)

"Since the median life expectancy after treatment for prostate cancer is 13.8 years, a careful evaluation of long-term functional outcomes is critical to an understanding of the comprehensive experience of men living with a diagnosis of prostate cancer," said Dr. Matthew J. Resnick of the department of urologic surgery and the Center for Surgical Quality and Outcomes Research, Vanderbilt University, Nashville, Tenn., and his associates.

Even though men who had radical prostatectomy were more likely to be bothered by such difficulties as urinary incontinence, bowel urgency, and erectile dysfunction at 2 years and 5 years after treatment, those differences disappeared by the 15-year mark. At that time, the prevalence of ED was "nearly universal," affecting 87% of men in the prostatectomy group and 94% of those in the radiotherapy group; yet only 43% and 38%, respectively, reported that this bothered them.

"Long-term follow-up reveals consistent functional declines after 5 years. It remains unknown whether this continued decline is due to prostate cancer and its treatment, the normal aging process, or a combination of factors," the investigators said (N. Engl. J. Med. 2013 [doi10.1056/NEJMoa1209978]).

This study was funded by the National Cancer Institute. Dr. Resnick was supported by the VA National Quality Scholars Program and the T. J. Martell Foundation. Dr. Resnick reported ties to Dendreon and Bayer Healthcare, and his associates reported ties to Ferring and Johnson & Johnson.

Fifteen years after treatment for localized prostate cancer, men who underwent radical prostatectomy reported no differences in urinary, bowel, or sexual function compared with men who underwent external-beam radiation, according to a report published online Jan. 30 in the New England Journal of Medicine.

Using data from the Prostate Cancer Outcomes Study (PCOS), a population-based cohort of men across the United States diagnosed as having prostate cancer in the mid-1990s, researchers tracked the long-term disease-specific outcomes of 1,655 men who underwent radical prostatectomy (70.3% of patients) or radiotherapy (29.7%), with or without androgen-deprivation therapy.

Source: American Gastroenterological Association (www.youtube.com/AmerGastroAssn)

"Since the median life expectancy after treatment for prostate cancer is 13.8 years, a careful evaluation of long-term functional outcomes is critical to an understanding of the comprehensive experience of men living with a diagnosis of prostate cancer," said Dr. Matthew J. Resnick of the department of urologic surgery and the Center for Surgical Quality and Outcomes Research, Vanderbilt University, Nashville, Tenn., and his associates.

Even though men who had radical prostatectomy were more likely to be bothered by such difficulties as urinary incontinence, bowel urgency, and erectile dysfunction at 2 years and 5 years after treatment, those differences disappeared by the 15-year mark. At that time, the prevalence of ED was "nearly universal," affecting 87% of men in the prostatectomy group and 94% of those in the radiotherapy group; yet only 43% and 38%, respectively, reported that this bothered them.

"Long-term follow-up reveals consistent functional declines after 5 years. It remains unknown whether this continued decline is due to prostate cancer and its treatment, the normal aging process, or a combination of factors," the investigators said (N. Engl. J. Med. 2013 [doi10.1056/NEJMoa1209978]).

This study was funded by the National Cancer Institute. Dr. Resnick was supported by the VA National Quality Scholars Program and the T. J. Martell Foundation. Dr. Resnick reported ties to Dendreon and Bayer Healthcare, and his associates reported ties to Ferring and Johnson & Johnson.

Women with overactive bladder have access to an over-the-counter treatment for the first time, thanks to the Food and Drug Administration’s approval of Merck’s Oxytrol for Women Jan. 25.

This is a partial switch for the drug from prescription to over-the-counter, as men with overactive bladder still need a prescription for Oxytrol.

Although overactive bladder affects an estimated 33 million women, some studies suggest that many don’t seek treatment for it, and those who do seek treatment continue to have daily leakage (J. Urol. 2007;177:680-4).

"This effective, over-the-counter treatment offers women an option to independently manage their condition and achieve a newfound sense of control," Dr. Eman Elkadry of Harvard Medical School in Boston said in a statement issued by Merck. "The approval also provides recognition that this is a real medical disorder that can be addressed."

Each Oxytrol for Women patch is applied to the skin for 4 continuous days and nights, and delivers 3.9 mg of oxybutynin daily. Oxybutynin is an antispasmodic agent and is available in the United States under other prescription brand names, including Ditropan XL, Gelnique 3%, and Gelnique.

The safety and efficacy of the Oxytrol for Women patch were established in nine studies that included 5,000 participants, according to the FDA. "Overall, results from these studies showed that consumers can understand the information on the label, properly select whether the product is right for them, and use the drug appropriately," the agency noted.

The drug is not without side effects, although the ones reported in the studies were mild, including skin irritation at the site of the patch, dry mouth, and constipation, according to the FDA statement.

The announcement comes a week after the FDA approved Botox (onabotulinumtoxinA) for treatment of adults who don’t respond to a class of medications known as anticholinergics, which includes Oxytrol.

[email protected]

On Twitter @NaseemSMiller

Women with overactive bladder have access to an over-the-counter treatment for the first time, thanks to the Food and Drug Administration’s approval of Merck’s Oxytrol for Women Jan. 25.

This is a partial switch for the drug from prescription to over-the-counter, as men with overactive bladder still need a prescription for Oxytrol.

Although overactive bladder affects an estimated 33 million women, some studies suggest that many don’t seek treatment for it, and those who do seek treatment continue to have daily leakage (J. Urol. 2007;177:680-4).

"This effective, over-the-counter treatment offers women an option to independently manage their condition and achieve a newfound sense of control," Dr. Eman Elkadry of Harvard Medical School in Boston said in a statement issued by Merck. "The approval also provides recognition that this is a real medical disorder that can be addressed."

Each Oxytrol for Women patch is applied to the skin for 4 continuous days and nights, and delivers 3.9 mg of oxybutynin daily. Oxybutynin is an antispasmodic agent and is available in the United States under other prescription brand names, including Ditropan XL, Gelnique 3%, and Gelnique.

The safety and efficacy of the Oxytrol for Women patch were established in nine studies that included 5,000 participants, according to the FDA. "Overall, results from these studies showed that consumers can understand the information on the label, properly select whether the product is right for them, and use the drug appropriately," the agency noted.

The drug is not without side effects, although the ones reported in the studies were mild, including skin irritation at the site of the patch, dry mouth, and constipation, according to the FDA statement.

The announcement comes a week after the FDA approved Botox (onabotulinumtoxinA) for treatment of adults who don’t respond to a class of medications known as anticholinergics, which includes Oxytrol.

[email protected]

On Twitter @NaseemSMiller

Women with overactive bladder have access to an over-the-counter treatment for the first time, thanks to the Food and Drug Administration’s approval of Merck’s Oxytrol for Women Jan. 25.

This is a partial switch for the drug from prescription to over-the-counter, as men with overactive bladder still need a prescription for Oxytrol.

Although overactive bladder affects an estimated 33 million women, some studies suggest that many don’t seek treatment for it, and those who do seek treatment continue to have daily leakage (J. Urol. 2007;177:680-4).

"This effective, over-the-counter treatment offers women an option to independently manage their condition and achieve a newfound sense of control," Dr. Eman Elkadry of Harvard Medical School in Boston said in a statement issued by Merck. "The approval also provides recognition that this is a real medical disorder that can be addressed."

Each Oxytrol for Women patch is applied to the skin for 4 continuous days and nights, and delivers 3.9 mg of oxybutynin daily. Oxybutynin is an antispasmodic agent and is available in the United States under other prescription brand names, including Ditropan XL, Gelnique 3%, and Gelnique.

The safety and efficacy of the Oxytrol for Women patch were established in nine studies that included 5,000 participants, according to the FDA. "Overall, results from these studies showed that consumers can understand the information on the label, properly select whether the product is right for them, and use the drug appropriately," the agency noted.

The drug is not without side effects, although the ones reported in the studies were mild, including skin irritation at the site of the patch, dry mouth, and constipation, according to the FDA statement.

The announcement comes a week after the FDA approved Botox (onabotulinumtoxinA) for treatment of adults who don’t respond to a class of medications known as anticholinergics, which includes Oxytrol.

[email protected]

On Twitter @NaseemSMiller

The Food and Drug Administration on Jan. 18 approved Botox for patients with overactive bladder who have contraindications to or don’t respond to anticholinergics.

"Clinical studies have demonstrated Botox’s ability to significantly reduce the frequency of urinary incontinence," Dr. Hylton V. Joffe, director of the Division of Reproductive and Urologic Products in the Food and Drug Administration’s Center for Drug Evaluation and Research, said in a statement.

"With the approval of Botox [onabotulinumtoxinA], we have a new treatment option to offer these patients that has demonstrated efficacy in reducing urinary leakage and other symptoms of OAB with the effect lasting up to 6 months," Dr. Victor Nitti, vice chairman in the department of urology at NYU Langone Medical Center, said in a statement released by Botox maker Allergan.

Overactive bladder (OAB) results in an uncontrolled urge to urinate, frequent urination, and uncontrollable leakage of urine, according to the Allergan statement. About 14.7 million American adults have overactive bladder, and 3.3 million use anticholinergics; however, at least half of them stop taking the drugs within a year because of intolerance.

Botox injected into the bladder muscle relaxes the organ and increases its storage capacity, thus reducing incontinence, according to the FDA. The Botox is injected via cystoscopy.

The FDA evaluated the drug’s safety and efficacy for overactive bladder through two studies in which 1,105 patients were randomly assigned to receive injections of 100 units of Botox (20 injections of 5 units each) or placebo. At 12 weeks, patients who received Botox had 1.6 to 1.9 fewer incidents of incontinence per day, and also needed to urinate less frequently.

The treatment needs to be repeated to maintain effectiveness; the FDA recommends at least 12 weeks between injections. Side effects during trials included urinary tract infections, painful urination, and urinary retention.

Patients must take antibiotics before, during, and a few days after Botox treatment to reduce infection risk.

[email protected]

On Twitter @aliciaault

The Food and Drug Administration on Jan. 18 approved Botox for patients with overactive bladder who have contraindications to or don’t respond to anticholinergics.

"Clinical studies have demonstrated Botox’s ability to significantly reduce the frequency of urinary incontinence," Dr. Hylton V. Joffe, director of the Division of Reproductive and Urologic Products in the Food and Drug Administration’s Center for Drug Evaluation and Research, said in a statement.

"With the approval of Botox [onabotulinumtoxinA], we have a new treatment option to offer these patients that has demonstrated efficacy in reducing urinary leakage and other symptoms of OAB with the effect lasting up to 6 months," Dr. Victor Nitti, vice chairman in the department of urology at NYU Langone Medical Center, said in a statement released by Botox maker Allergan.

Overactive bladder (OAB) results in an uncontrolled urge to urinate, frequent urination, and uncontrollable leakage of urine, according to the Allergan statement. About 14.7 million American adults have overactive bladder, and 3.3 million use anticholinergics; however, at least half of them stop taking the drugs within a year because of intolerance.

Botox injected into the bladder muscle relaxes the organ and increases its storage capacity, thus reducing incontinence, according to the FDA. The Botox is injected via cystoscopy.

The FDA evaluated the drug’s safety and efficacy for overactive bladder through two studies in which 1,105 patients were randomly assigned to receive injections of 100 units of Botox (20 injections of 5 units each) or placebo. At 12 weeks, patients who received Botox had 1.6 to 1.9 fewer incidents of incontinence per day, and also needed to urinate less frequently.

The treatment needs to be repeated to maintain effectiveness; the FDA recommends at least 12 weeks between injections. Side effects during trials included urinary tract infections, painful urination, and urinary retention.

Patients must take antibiotics before, during, and a few days after Botox treatment to reduce infection risk.

[email protected]

On Twitter @aliciaault

The Food and Drug Administration on Jan. 18 approved Botox for patients with overactive bladder who have contraindications to or don’t respond to anticholinergics.

"Clinical studies have demonstrated Botox’s ability to significantly reduce the frequency of urinary incontinence," Dr. Hylton V. Joffe, director of the Division of Reproductive and Urologic Products in the Food and Drug Administration’s Center for Drug Evaluation and Research, said in a statement.

"With the approval of Botox [onabotulinumtoxinA], we have a new treatment option to offer these patients that has demonstrated efficacy in reducing urinary leakage and other symptoms of OAB with the effect lasting up to 6 months," Dr. Victor Nitti, vice chairman in the department of urology at NYU Langone Medical Center, said in a statement released by Botox maker Allergan.

Overactive bladder (OAB) results in an uncontrolled urge to urinate, frequent urination, and uncontrollable leakage of urine, according to the Allergan statement. About 14.7 million American adults have overactive bladder, and 3.3 million use anticholinergics; however, at least half of them stop taking the drugs within a year because of intolerance.

Botox injected into the bladder muscle relaxes the organ and increases its storage capacity, thus reducing incontinence, according to the FDA. The Botox is injected via cystoscopy.

The FDA evaluated the drug’s safety and efficacy for overactive bladder through two studies in which 1,105 patients were randomly assigned to receive injections of 100 units of Botox (20 injections of 5 units each) or placebo. At 12 weeks, patients who received Botox had 1.6 to 1.9 fewer incidents of incontinence per day, and also needed to urinate less frequently.

The treatment needs to be repeated to maintain effectiveness; the FDA recommends at least 12 weeks between injections. Side effects during trials included urinary tract infections, painful urination, and urinary retention.

Patients must take antibiotics before, during, and a few days after Botox treatment to reduce infection risk.

[email protected]

On Twitter @aliciaault

A scoring system based on demographics and comorbidities predicted which hospitalized patients were at risk for nosocomial gastrointestinal bleeding.

Used as a guideline for administering acid suppressors, the system found that treating fewer than 100 high-risk patients would prevent one case of bleeding, Dr. Shoshana Herzig and her colleagues wrote in the January online issue of General Internal Medicine (2013 [doi:10.1007/s11606-012-2296-x]).

"This scoring system allows identification of subsets of patients in whom the risk of nosocomial gastrointestinal bleeding may be higher enough to warrant the use of prophylactic acid-suppressive medication, in the absence of other indicators for use," said Dr. Herzig of Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, and her coauthors.

The model "allows for risk stratification of patients using readily available information, and can be used to guide more selective use of acid-suppressive medication in patients outside of the ICU," the investigators wrote. The investigators reviewed about 76,000 records of noncritically ill patients hospitalized for more than 3 days, from 2004 through 2007. Nosocomial gastrointestinal bleeding occurred in about 3% of the group.

The authors constructed the risk score by identifying several factors that could potentially affect bleeding, including age, sex, comorbid conditions, admission service, and the receipt of certain medications during hospitalization.

A multivariate analysis identified those factors that significantly correlated with gastrointestinal bleeding. These included:

• Age more than 60 years (odds ratio, 2.2).

• Male sex (OR, 1.6).

• Liver disease (OR, 2.1).

• Acute renal failure (OR, 1.9).

• Admission to a medical service (OR, 2.7).

• Prophylactic anticoagulation (OR, 1.7).

• Coagulotherapy without antiplatelet medication (OR, 2.6).

• Coagulotherapy with one antiplatelet agent (OR, 3.2).

• Coagulotherapy with dual antiplatelet agents (OR, 3.3).

Based on these factors, they constructed a points-based risk scoring system that significantly correlated with the incidence of gastrointestinal bleeding. Patients in the lowest-score quartile were at the least risk of bleeding (less than 0.3%), while those in the highest quartile had the highest risk (1.5%).

The number needed to treat (NNT) to prevent one bleed increased as the risk score increased. The NNT was 500 in patients whose score was at least 6, 179 in those whose score was at least 8, 95 in those whose score was at least 10 (moderate risk), and 48 in those whose score was at least 12 (high risk).

The patients’ mean age was 56 years, although the range was very wide (18-107 years); 40% were male. Most patients received an acid-suppressing medication (58%). Proton pump inhibitors were most commonly used (81%); 29% received a histamine-2 receptor antagonist.

"With further validation at other medical centers, this scoring system may help clinicians individualize the decision to prescribe acid-suppressive medication as prophylaxis," the authors said.

The study was funded by grants from the National Institute on Aging and the National Center for Research Resources. None of the authors reported any financial conflicts.

A scoring system based on demographics and comorbidities predicted which hospitalized patients were at risk for nosocomial gastrointestinal bleeding.

Used as a guideline for administering acid suppressors, the system found that treating fewer than 100 high-risk patients would prevent one case of bleeding, Dr. Shoshana Herzig and her colleagues wrote in the January online issue of General Internal Medicine (2013 [doi:10.1007/s11606-012-2296-x]).

"This scoring system allows identification of subsets of patients in whom the risk of nosocomial gastrointestinal bleeding may be higher enough to warrant the use of prophylactic acid-suppressive medication, in the absence of other indicators for use," said Dr. Herzig of Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, and her coauthors.

The model "allows for risk stratification of patients using readily available information, and can be used to guide more selective use of acid-suppressive medication in patients outside of the ICU," the investigators wrote. The investigators reviewed about 76,000 records of noncritically ill patients hospitalized for more than 3 days, from 2004 through 2007. Nosocomial gastrointestinal bleeding occurred in about 3% of the group.

The authors constructed the risk score by identifying several factors that could potentially affect bleeding, including age, sex, comorbid conditions, admission service, and the receipt of certain medications during hospitalization.

A multivariate analysis identified those factors that significantly correlated with gastrointestinal bleeding. These included:

• Age more than 60 years (odds ratio, 2.2).

• Male sex (OR, 1.6).

• Liver disease (OR, 2.1).

• Acute renal failure (OR, 1.9).

• Admission to a medical service (OR, 2.7).

• Prophylactic anticoagulation (OR, 1.7).

• Coagulotherapy without antiplatelet medication (OR, 2.6).

• Coagulotherapy with one antiplatelet agent (OR, 3.2).

• Coagulotherapy with dual antiplatelet agents (OR, 3.3).

Based on these factors, they constructed a points-based risk scoring system that significantly correlated with the incidence of gastrointestinal bleeding. Patients in the lowest-score quartile were at the least risk of bleeding (less than 0.3%), while those in the highest quartile had the highest risk (1.5%).

The number needed to treat (NNT) to prevent one bleed increased as the risk score increased. The NNT was 500 in patients whose score was at least 6, 179 in those whose score was at least 8, 95 in those whose score was at least 10 (moderate risk), and 48 in those whose score was at least 12 (high risk).

The patients’ mean age was 56 years, although the range was very wide (18-107 years); 40% were male. Most patients received an acid-suppressing medication (58%). Proton pump inhibitors were most commonly used (81%); 29% received a histamine-2 receptor antagonist.

"With further validation at other medical centers, this scoring system may help clinicians individualize the decision to prescribe acid-suppressive medication as prophylaxis," the authors said.

The study was funded by grants from the National Institute on Aging and the National Center for Research Resources. None of the authors reported any financial conflicts.

A scoring system based on demographics and comorbidities predicted which hospitalized patients were at risk for nosocomial gastrointestinal bleeding.

Used as a guideline for administering acid suppressors, the system found that treating fewer than 100 high-risk patients would prevent one case of bleeding, Dr. Shoshana Herzig and her colleagues wrote in the January online issue of General Internal Medicine (2013 [doi:10.1007/s11606-012-2296-x]).

"This scoring system allows identification of subsets of patients in whom the risk of nosocomial gastrointestinal bleeding may be higher enough to warrant the use of prophylactic acid-suppressive medication, in the absence of other indicators for use," said Dr. Herzig of Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, and her coauthors.

The model "allows for risk stratification of patients using readily available information, and can be used to guide more selective use of acid-suppressive medication in patients outside of the ICU," the investigators wrote. The investigators reviewed about 76,000 records of noncritically ill patients hospitalized for more than 3 days, from 2004 through 2007. Nosocomial gastrointestinal bleeding occurred in about 3% of the group.

The authors constructed the risk score by identifying several factors that could potentially affect bleeding, including age, sex, comorbid conditions, admission service, and the receipt of certain medications during hospitalization.

A multivariate analysis identified those factors that significantly correlated with gastrointestinal bleeding. These included:

• Age more than 60 years (odds ratio, 2.2).

• Male sex (OR, 1.6).

• Liver disease (OR, 2.1).

• Acute renal failure (OR, 1.9).

• Admission to a medical service (OR, 2.7).

• Prophylactic anticoagulation (OR, 1.7).

• Coagulotherapy without antiplatelet medication (OR, 2.6).

• Coagulotherapy with one antiplatelet agent (OR, 3.2).

• Coagulotherapy with dual antiplatelet agents (OR, 3.3).

Based on these factors, they constructed a points-based risk scoring system that significantly correlated with the incidence of gastrointestinal bleeding. Patients in the lowest-score quartile were at the least risk of bleeding (less than 0.3%), while those in the highest quartile had the highest risk (1.5%).

The number needed to treat (NNT) to prevent one bleed increased as the risk score increased. The NNT was 500 in patients whose score was at least 6, 179 in those whose score was at least 8, 95 in those whose score was at least 10 (moderate risk), and 48 in those whose score was at least 12 (high risk).

The patients’ mean age was 56 years, although the range was very wide (18-107 years); 40% were male. Most patients received an acid-suppressing medication (58%). Proton pump inhibitors were most commonly used (81%); 29% received a histamine-2 receptor antagonist.

"With further validation at other medical centers, this scoring system may help clinicians individualize the decision to prescribe acid-suppressive medication as prophylaxis," the authors said.

The study was funded by grants from the National Institute on Aging and the National Center for Research Resources. None of the authors reported any financial conflicts.

SAN DIEGO – Beta-blocker use by patients with advanced chronic kidney disease was not associated with a lower risk of all-cause mortality or initiation of chronic dialysis, results from a large study demonstrated.

"The sympathetic nervous system is increased in chronic kidney disease and end-stage renal disease," Dr. Anna Jovanovich said in an interview during a poster session at Kidney Week 2012. "That can be associated with mortality – you can have more arrhythmias when your sympathetic drive is higher. You would think that beta-blockers might help decrease the sympathetic drive and then decrease mortality, but from this observational study we don’t see that association."

Dr. Jovanovich, a second-year renal fellow at the University of Colorado, Denver, and her associates evaluated 1,099 advanced kidney disease patients not yet on dialysis who participated in the Homocysteine in Kidney and End-Stage Renal Disease (HOST) study, conducted between 2001 and 2006.

The mean age of patients was 69 years, 98% were male, 26% were African American, and the mean estimated glomerular filtration rate was 18 mL/min per 1.73 m². During a mean follow-up of 3 years, 453 patients (41%) died from any cause and 615 (56%) started chronic dialysis.

After adjustment for age, gender, race, smoking status, diabetes, hypertension, cardiovascular disease, body mass index, systolic blood pressure, albumin, and eGFR, baseline beta-blocker use was not associated with lower risk of all-cause mortality (adjusted HR of 1.14; P = .07), nor was it associated with a lower risk of initiation of chronic dialysis (adjusted HR of 0.90).

"This is only an observational study so we can’t draw conclusions, but in a kidney disease patient who has heart failure, I think beta-blockers are an important medication in their armamentarium," she said. "However, in a kidney disease patient without heart failure there may be other blood pressure–lowering medications to try first before you try a beta-blocker."

Dr. Jovanovich said that the findings support those of the Hemodialysis Study (Am. J. Kidney Dis. 2011;58:939-45).

Dr. Jovanovich said that she had no relevant financial conflicts to disclose.

The meeting was sponsored by the American Society of Nephrology.

SAN DIEGO – Beta-blocker use by patients with advanced chronic kidney disease was not associated with a lower risk of all-cause mortality or initiation of chronic dialysis, results from a large study demonstrated.

"The sympathetic nervous system is increased in chronic kidney disease and end-stage renal disease," Dr. Anna Jovanovich said in an interview during a poster session at Kidney Week 2012. "That can be associated with mortality – you can have more arrhythmias when your sympathetic drive is higher. You would think that beta-blockers might help decrease the sympathetic drive and then decrease mortality, but from this observational study we don’t see that association."

Dr. Jovanovich, a second-year renal fellow at the University of Colorado, Denver, and her associates evaluated 1,099 advanced kidney disease patients not yet on dialysis who participated in the Homocysteine in Kidney and End-Stage Renal Disease (HOST) study, conducted between 2001 and 2006.

The mean age of patients was 69 years, 98% were male, 26% were African American, and the mean estimated glomerular filtration rate was 18 mL/min per 1.73 m². During a mean follow-up of 3 years, 453 patients (41%) died from any cause and 615 (56%) started chronic dialysis.

After adjustment for age, gender, race, smoking status, diabetes, hypertension, cardiovascular disease, body mass index, systolic blood pressure, albumin, and eGFR, baseline beta-blocker use was not associated with lower risk of all-cause mortality (adjusted HR of 1.14; P = .07), nor was it associated with a lower risk of initiation of chronic dialysis (adjusted HR of 0.90).

"This is only an observational study so we can’t draw conclusions, but in a kidney disease patient who has heart failure, I think beta-blockers are an important medication in their armamentarium," she said. "However, in a kidney disease patient without heart failure there may be other blood pressure–lowering medications to try first before you try a beta-blocker."

Dr. Jovanovich said that the findings support those of the Hemodialysis Study (Am. J. Kidney Dis. 2011;58:939-45).

Dr. Jovanovich said that she had no relevant financial conflicts to disclose.

The meeting was sponsored by the American Society of Nephrology.

SAN DIEGO – Beta-blocker use by patients with advanced chronic kidney disease was not associated with a lower risk of all-cause mortality or initiation of chronic dialysis, results from a large study demonstrated.

"The sympathetic nervous system is increased in chronic kidney disease and end-stage renal disease," Dr. Anna Jovanovich said in an interview during a poster session at Kidney Week 2012. "That can be associated with mortality – you can have more arrhythmias when your sympathetic drive is higher. You would think that beta-blockers might help decrease the sympathetic drive and then decrease mortality, but from this observational study we don’t see that association."

Dr. Jovanovich, a second-year renal fellow at the University of Colorado, Denver, and her associates evaluated 1,099 advanced kidney disease patients not yet on dialysis who participated in the Homocysteine in Kidney and End-Stage Renal Disease (HOST) study, conducted between 2001 and 2006.

The mean age of patients was 69 years, 98% were male, 26% were African American, and the mean estimated glomerular filtration rate was 18 mL/min per 1.73 m². During a mean follow-up of 3 years, 453 patients (41%) died from any cause and 615 (56%) started chronic dialysis.

After adjustment for age, gender, race, smoking status, diabetes, hypertension, cardiovascular disease, body mass index, systolic blood pressure, albumin, and eGFR, baseline beta-blocker use was not associated with lower risk of all-cause mortality (adjusted HR of 1.14; P = .07), nor was it associated with a lower risk of initiation of chronic dialysis (adjusted HR of 0.90).

"This is only an observational study so we can’t draw conclusions, but in a kidney disease patient who has heart failure, I think beta-blockers are an important medication in their armamentarium," she said. "However, in a kidney disease patient without heart failure there may be other blood pressure–lowering medications to try first before you try a beta-blocker."

Dr. Jovanovich said that the findings support those of the Hemodialysis Study (Am. J. Kidney Dis. 2011;58:939-45).

Dr. Jovanovich said that she had no relevant financial conflicts to disclose.

The meeting was sponsored by the American Society of Nephrology.

SAN DIEGO – A 12-week exercise program improved the physical capacity of patients with stage 3 and 4 chronic kidney disease, results from a single-center demonstrated.

The intervention also improved patient perceptions of general health, vitality, and physical functioning. "We believe that renal rehabilitation exercise programs can be integrated into standard chronic kidney disease treatment," Dr. Ana Paula Rossi, a nephrology fellow at Maine Medical Center, Portland, said at Kidney Week 2012.

"We need longer follow-up and larger studies to determine if this will translate into decreased mortality rates and slow the progression of CKD," she said.

In a 12-week study conducted in 2011, Dr. Rossi and her associates randomized 48 patients with stage 3 and 4 CKD to usual care and 59 patients to an exercise intervention, which consisted of guided exercise at a cardiac rehabilitation facility two times per week for 3 months. Patients were encouraged to exercise an additional day per week on their own.

Exercise consisted of treadmill walking and/or stationary cycling. The duration was increased by 2-3 minutes per session, with the ultimate goal of 60 minutes of continuous exercise. Patients also did weight training with upper and lower extremity extensions and flexions with free weights. They started with one set of 10 repetitions per exercise, which was increased to a goal of three sets of 15 repetitions before the weight was increased. They also did stretching exercises.

Outcomes included the results of the 6-minute walk test (the number of feet walked per 6 minutes), the sit-to-stand test in which the patient is asked to sit and stand up 10 times (time reported is the percentage of age-predicted time), and the gait-speed test, a measurement of centimeters per second walked over a distance of 20 feet. To assess quality of life, the researchers administered the RAND 36-item Short Form Health Survey.

Patients with ongoing angina or transient ischemic attacks were excluded from the study, as were those with chronic lung disease resulting in significant shortness of breath or oxygen desaturation at rest, and those with lower-extremity amputation with no prosthesis or with an orthopedic disorder severely exacerbated by activity.

Patients in both groups were around 69 years old and had similar baseline reported levels of activity.

After the 12-week study period, the usual care group had no significant improvements in the three main outcomes. Patients in the exercise intervention group had significant improvements in the 6-minute walk test (19%, from 1,117 to 1,327 feet per 6 minutes; P = less than .0001) and in the sit-to-stand test (29%, from 68% to 97% of age predicted; P = .0004), but not in the gait-speed test (183 vs. 171 cm; P = .06).

Compared with their counterparts in the usual care group, patients in the intervention group reported significant improvements in energy (P = .01), physical functioning (P less than .01), and in general health (P = .03). Neither group experienced significant improvements in pain, emotional well-being, or in social functioning.

The study was funded by the Maine Medical Center Research Institute. Dr. Rossi said that she had no relevant financial conflicts to disclose.

The meeting was sponsored by the American Society of Nephrology.

SAN DIEGO – A 12-week exercise program improved the physical capacity of patients with stage 3 and 4 chronic kidney disease, results from a single-center demonstrated.

The intervention also improved patient perceptions of general health, vitality, and physical functioning. "We believe that renal rehabilitation exercise programs can be integrated into standard chronic kidney disease treatment," Dr. Ana Paula Rossi, a nephrology fellow at Maine Medical Center, Portland, said at Kidney Week 2012.

"We need longer follow-up and larger studies to determine if this will translate into decreased mortality rates and slow the progression of CKD," she said.

In a 12-week study conducted in 2011, Dr. Rossi and her associates randomized 48 patients with stage 3 and 4 CKD to usual care and 59 patients to an exercise intervention, which consisted of guided exercise at a cardiac rehabilitation facility two times per week for 3 months. Patients were encouraged to exercise an additional day per week on their own.

Exercise consisted of treadmill walking and/or stationary cycling. The duration was increased by 2-3 minutes per session, with the ultimate goal of 60 minutes of continuous exercise. Patients also did weight training with upper and lower extremity extensions and flexions with free weights. They started with one set of 10 repetitions per exercise, which was increased to a goal of three sets of 15 repetitions before the weight was increased. They also did stretching exercises.

Outcomes included the results of the 6-minute walk test (the number of feet walked per 6 minutes), the sit-to-stand test in which the patient is asked to sit and stand up 10 times (time reported is the percentage of age-predicted time), and the gait-speed test, a measurement of centimeters per second walked over a distance of 20 feet. To assess quality of life, the researchers administered the RAND 36-item Short Form Health Survey.

Patients with ongoing angina or transient ischemic attacks were excluded from the study, as were those with chronic lung disease resulting in significant shortness of breath or oxygen desaturation at rest, and those with lower-extremity amputation with no prosthesis or with an orthopedic disorder severely exacerbated by activity.

Patients in both groups were around 69 years old and had similar baseline reported levels of activity.

After the 12-week study period, the usual care group had no significant improvements in the three main outcomes. Patients in the exercise intervention group had significant improvements in the 6-minute walk test (19%, from 1,117 to 1,327 feet per 6 minutes; P = less than .0001) and in the sit-to-stand test (29%, from 68% to 97% of age predicted; P = .0004), but not in the gait-speed test (183 vs. 171 cm; P = .06).

Compared with their counterparts in the usual care group, patients in the intervention group reported significant improvements in energy (P = .01), physical functioning (P less than .01), and in general health (P = .03). Neither group experienced significant improvements in pain, emotional well-being, or in social functioning.

The study was funded by the Maine Medical Center Research Institute. Dr. Rossi said that she had no relevant financial conflicts to disclose.

The meeting was sponsored by the American Society of Nephrology.

SAN DIEGO – A 12-week exercise program improved the physical capacity of patients with stage 3 and 4 chronic kidney disease, results from a single-center demonstrated.

The intervention also improved patient perceptions of general health, vitality, and physical functioning. "We believe that renal rehabilitation exercise programs can be integrated into standard chronic kidney disease treatment," Dr. Ana Paula Rossi, a nephrology fellow at Maine Medical Center, Portland, said at Kidney Week 2012.

"We need longer follow-up and larger studies to determine if this will translate into decreased mortality rates and slow the progression of CKD," she said.

In a 12-week study conducted in 2011, Dr. Rossi and her associates randomized 48 patients with stage 3 and 4 CKD to usual care and 59 patients to an exercise intervention, which consisted of guided exercise at a cardiac rehabilitation facility two times per week for 3 months. Patients were encouraged to exercise an additional day per week on their own.

Exercise consisted of treadmill walking and/or stationary cycling. The duration was increased by 2-3 minutes per session, with the ultimate goal of 60 minutes of continuous exercise. Patients also did weight training with upper and lower extremity extensions and flexions with free weights. They started with one set of 10 repetitions per exercise, which was increased to a goal of three sets of 15 repetitions before the weight was increased. They also did stretching exercises.

Outcomes included the results of the 6-minute walk test (the number of feet walked per 6 minutes), the sit-to-stand test in which the patient is asked to sit and stand up 10 times (time reported is the percentage of age-predicted time), and the gait-speed test, a measurement of centimeters per second walked over a distance of 20 feet. To assess quality of life, the researchers administered the RAND 36-item Short Form Health Survey.

Patients with ongoing angina or transient ischemic attacks were excluded from the study, as were those with chronic lung disease resulting in significant shortness of breath or oxygen desaturation at rest, and those with lower-extremity amputation with no prosthesis or with an orthopedic disorder severely exacerbated by activity.

Patients in both groups were around 69 years old and had similar baseline reported levels of activity.

After the 12-week study period, the usual care group had no significant improvements in the three main outcomes. Patients in the exercise intervention group had significant improvements in the 6-minute walk test (19%, from 1,117 to 1,327 feet per 6 minutes; P = less than .0001) and in the sit-to-stand test (29%, from 68% to 97% of age predicted; P = .0004), but not in the gait-speed test (183 vs. 171 cm; P = .06).

Compared with their counterparts in the usual care group, patients in the intervention group reported significant improvements in energy (P = .01), physical functioning (P less than .01), and in general health (P = .03). Neither group experienced significant improvements in pain, emotional well-being, or in social functioning.

The study was funded by the Maine Medical Center Research Institute. Dr. Rossi said that she had no relevant financial conflicts to disclose.

The meeting was sponsored by the American Society of Nephrology.

SAN DIEGO – Being catheter free and having a serum albumin level of at least 4 g/dL were among the quality indicators associated with the ability of dialysis patients to return to work, judging from the results of a large study.

"There has been limited attention to employment issues in this patient population," Nancy G. Kutner, Ph.D., said in an interview during a poster session at Kidney Week 2012. "There has been a general impression that most people aren’t going to even try to resume employment – even those who were employed immediately before starting dialysis."

Doug Brunk/IMNG Medical Media

Dr. Kutner, professor of rehabilitation medicine at Emory University, Atlanta, and her associates enrolled 509 patients who were on hemodialysis treatment for 3 months or longer during 2009-2011 for a U.S. Renal Data System study conducted in seven outpatient clinics in San Francisco and seven in Atlanta. The patients were between the ages of 18 and 64 years, and they responded to the question: "Are you now able to work for pay (full-time or part-time)?"

Using a logistic regression model adjusted for age, gender, race, educational level, diabetes, congestive heart failure, presence of symptoms of depression, length of time on dialysis, and facility clustering, the researchers investigated whether incremental achievement of certain hemodialysis quality indicator (HD QI) goals were correlated with patient-reported ability to work. The HD QI goals were standardized Kt/V of 1.2 or greater; being catheter free; and having a hemoglobin level of 10-12 g/dL, a serum albumin level of 4 g/dL or greater, and a serum phosphorus level of 3.5 mg/dL to 5.5 mg/dL.

The mean age of the patients was 50 years, and 61% were male. Of the 509 patients, 36% said that they were able to work and 13% were actually employed. The mean number of HD QI goals met was 3.31, and the patients’ likelihood of reporting being able to work increased with an increasing number of QI goals met (odds ratio 1.28; P = .02). "Achieving a quality indicator goal is likely a joint process between the provider and the patient," said Dr. Kutner, who directs the USRDS Rehabilitation/QoL Special Studies Center at Emory.

"The end result seems to be that as more of these goals are met, it furthers the potential for work and rehabilitation. This is very encouraging," she said at the meeting, which was sponsored by the American Society of Nephrology.

Compared with their counterparts who reported being unable to work, a higher proportion of those who reported being able to work met the QI goals of Kt/V of 1.2 or greater (92% vs. 90%, respectively), being catheter free (84% vs. 74%), having a hemoglobin level of 10-12 g/dL (62% vs. 60%), and having a serum albumin of 4.0 g/dL or greater (59% vs. 49%). The proportion of those reporting a serum phosphorus level of 3.5-5.5 mg/dL was similar between the two groups (48% vs. 50%).

Dr. Kutner said that she had no relevant financial conflicts to disclose.

SAN DIEGO – Being catheter free and having a serum albumin level of at least 4 g/dL were among the quality indicators associated with the ability of dialysis patients to return to work, judging from the results of a large study.

"There has been limited attention to employment issues in this patient population," Nancy G. Kutner, Ph.D., said in an interview during a poster session at Kidney Week 2012. "There has been a general impression that most people aren’t going to even try to resume employment – even those who were employed immediately before starting dialysis."

Doug Brunk/IMNG Medical Media

Dr. Kutner, professor of rehabilitation medicine at Emory University, Atlanta, and her associates enrolled 509 patients who were on hemodialysis treatment for 3 months or longer during 2009-2011 for a U.S. Renal Data System study conducted in seven outpatient clinics in San Francisco and seven in Atlanta. The patients were between the ages of 18 and 64 years, and they responded to the question: "Are you now able to work for pay (full-time or part-time)?"

Using a logistic regression model adjusted for age, gender, race, educational level, diabetes, congestive heart failure, presence of symptoms of depression, length of time on dialysis, and facility clustering, the researchers investigated whether incremental achievement of certain hemodialysis quality indicator (HD QI) goals were correlated with patient-reported ability to work. The HD QI goals were standardized Kt/V of 1.2 or greater; being catheter free; and having a hemoglobin level of 10-12 g/dL, a serum albumin level of 4 g/dL or greater, and a serum phosphorus level of 3.5 mg/dL to 5.5 mg/dL.

The mean age of the patients was 50 years, and 61% were male. Of the 509 patients, 36% said that they were able to work and 13% were actually employed. The mean number of HD QI goals met was 3.31, and the patients’ likelihood of reporting being able to work increased with an increasing number of QI goals met (odds ratio 1.28; P = .02). "Achieving a quality indicator goal is likely a joint process between the provider and the patient," said Dr. Kutner, who directs the USRDS Rehabilitation/QoL Special Studies Center at Emory.

"The end result seems to be that as more of these goals are met, it furthers the potential for work and rehabilitation. This is very encouraging," she said at the meeting, which was sponsored by the American Society of Nephrology.

Compared with their counterparts who reported being unable to work, a higher proportion of those who reported being able to work met the QI goals of Kt/V of 1.2 or greater (92% vs. 90%, respectively), being catheter free (84% vs. 74%), having a hemoglobin level of 10-12 g/dL (62% vs. 60%), and having a serum albumin of 4.0 g/dL or greater (59% vs. 49%). The proportion of those reporting a serum phosphorus level of 3.5-5.5 mg/dL was similar between the two groups (48% vs. 50%).

Dr. Kutner said that she had no relevant financial conflicts to disclose.

SAN DIEGO – Being catheter free and having a serum albumin level of at least 4 g/dL were among the quality indicators associated with the ability of dialysis patients to return to work, judging from the results of a large study.

"There has been limited attention to employment issues in this patient population," Nancy G. Kutner, Ph.D., said in an interview during a poster session at Kidney Week 2012. "There has been a general impression that most people aren’t going to even try to resume employment – even those who were employed immediately before starting dialysis."

Doug Brunk/IMNG Medical Media

Dr. Kutner, professor of rehabilitation medicine at Emory University, Atlanta, and her associates enrolled 509 patients who were on hemodialysis treatment for 3 months or longer during 2009-2011 for a U.S. Renal Data System study conducted in seven outpatient clinics in San Francisco and seven in Atlanta. The patients were between the ages of 18 and 64 years, and they responded to the question: "Are you now able to work for pay (full-time or part-time)?"

Using a logistic regression model adjusted for age, gender, race, educational level, diabetes, congestive heart failure, presence of symptoms of depression, length of time on dialysis, and facility clustering, the researchers investigated whether incremental achievement of certain hemodialysis quality indicator (HD QI) goals were correlated with patient-reported ability to work. The HD QI goals were standardized Kt/V of 1.2 or greater; being catheter free; and having a hemoglobin level of 10-12 g/dL, a serum albumin level of 4 g/dL or greater, and a serum phosphorus level of 3.5 mg/dL to 5.5 mg/dL.

The mean age of the patients was 50 years, and 61% were male. Of the 509 patients, 36% said that they were able to work and 13% were actually employed. The mean number of HD QI goals met was 3.31, and the patients’ likelihood of reporting being able to work increased with an increasing number of QI goals met (odds ratio 1.28; P = .02). "Achieving a quality indicator goal is likely a joint process between the provider and the patient," said Dr. Kutner, who directs the USRDS Rehabilitation/QoL Special Studies Center at Emory.

"The end result seems to be that as more of these goals are met, it furthers the potential for work and rehabilitation. This is very encouraging," she said at the meeting, which was sponsored by the American Society of Nephrology.

Compared with their counterparts who reported being unable to work, a higher proportion of those who reported being able to work met the QI goals of Kt/V of 1.2 or greater (92% vs. 90%, respectively), being catheter free (84% vs. 74%), having a hemoglobin level of 10-12 g/dL (62% vs. 60%), and having a serum albumin of 4.0 g/dL or greater (59% vs. 49%). The proportion of those reporting a serum phosphorus level of 3.5-5.5 mg/dL was similar between the two groups (48% vs. 50%).

Dr. Kutner said that she had no relevant financial conflicts to disclose.

SAN DIEGO – Levels of calcium, phosphorus, and parathyroid hormone are poorer in patients with heart failure at each stage of chronic kidney disease, results from a large study showed.

The finding "raises more questions than it answers," Dr. Claudine T. Jurkovitz said in an interview during a poster session at Kidney Week 2012. "The question is, are these patients less well managed for their metabolic bone disease than the patients without HF? If so, why? Is it because their HF is so severe, or is it because the nephrologists count on cardiologists or primary care physicians to treat the patients’ metabolic bone disease also? And do cardiologists identify metabolic bone disease in patients with HF?"

Doug Brunk/IMNG Medical Media

Dr. Jurkovitz, a physician scientist with Christiana Care Health System in Newark, Del., and her associates compared the management of CKD-associated metabolic bone disease between patients with and without HF who were treated at a local nephrology practice between 2000 and 2010. They evaluated the medical records of 11,883 patients with CKD stage 3 and above, and excluded dialysis and transplant patients. The researchers calculated average calcium, phosphorus, and intact parathyroid hormone (iPTH) by radioimmunoassay for each patient, and used multilinear regressions to determine the effects of CKD and HF on calcium, phosphorus, and iPTH after controlling for age, race, and gender.

The mean follow-up of the 11,883 patients was 4 years. Of these, nearly one-quarter (24%) had HF at baseline, while 76% had stage 3 CKD, 22% had stage 4 CKD, and 2% had stage 5 CKD. Patients with HF were slightly older, with a mean of 69 years, than were their counterparts without HF, who had a mean 66 years.

Dr. Jurkovitz and her associates found that the adjusted mean for calcium was significantly lower in patients with HF at each CKD stage. The interaction between CKD and HF was statistically significant. The adjusted means for phosphorus and iPTH were significantly higher in patients with HF at each CKD stage, while the interactions between CKD and HF were not significant.

"Physicians need to be concerned about the management of chronic kidney disease in their patients with HF, and the management of metabolic bone disease addressed on a case by case basis in a dialogue between the cardiologists, nephrologists, and primary care physicians," she concluded.

The meeting was sponsored by the American Society of Nephrology. Dr. Jurkovitz said that she had no relevant financial conflicts to disclose.

SAN DIEGO – Levels of calcium, phosphorus, and parathyroid hormone are poorer in patients with heart failure at each stage of chronic kidney disease, results from a large study showed.

The finding "raises more questions than it answers," Dr. Claudine T. Jurkovitz said in an interview during a poster session at Kidney Week 2012. "The question is, are these patients less well managed for their metabolic bone disease than the patients without HF? If so, why? Is it because their HF is so severe, or is it because the nephrologists count on cardiologists or primary care physicians to treat the patients’ metabolic bone disease also? And do cardiologists identify metabolic bone disease in patients with HF?"

Doug Brunk/IMNG Medical Media

Dr. Jurkovitz, a physician scientist with Christiana Care Health System in Newark, Del., and her associates compared the management of CKD-associated metabolic bone disease between patients with and without HF who were treated at a local nephrology practice between 2000 and 2010. They evaluated the medical records of 11,883 patients with CKD stage 3 and above, and excluded dialysis and transplant patients. The researchers calculated average calcium, phosphorus, and intact parathyroid hormone (iPTH) by radioimmunoassay for each patient, and used multilinear regressions to determine the effects of CKD and HF on calcium, phosphorus, and iPTH after controlling for age, race, and gender.

The mean follow-up of the 11,883 patients was 4 years. Of these, nearly one-quarter (24%) had HF at baseline, while 76% had stage 3 CKD, 22% had stage 4 CKD, and 2% had stage 5 CKD. Patients with HF were slightly older, with a mean of 69 years, than were their counterparts without HF, who had a mean 66 years.

Dr. Jurkovitz and her associates found that the adjusted mean for calcium was significantly lower in patients with HF at each CKD stage. The interaction between CKD and HF was statistically significant. The adjusted means for phosphorus and iPTH were significantly higher in patients with HF at each CKD stage, while the interactions between CKD and HF were not significant.

"Physicians need to be concerned about the management of chronic kidney disease in their patients with HF, and the management of metabolic bone disease addressed on a case by case basis in a dialogue between the cardiologists, nephrologists, and primary care physicians," she concluded.

The meeting was sponsored by the American Society of Nephrology. Dr. Jurkovitz said that she had no relevant financial conflicts to disclose.

SAN DIEGO – Levels of calcium, phosphorus, and parathyroid hormone are poorer in patients with heart failure at each stage of chronic kidney disease, results from a large study showed.

The finding "raises more questions than it answers," Dr. Claudine T. Jurkovitz said in an interview during a poster session at Kidney Week 2012. "The question is, are these patients less well managed for their metabolic bone disease than the patients without HF? If so, why? Is it because their HF is so severe, or is it because the nephrologists count on cardiologists or primary care physicians to treat the patients’ metabolic bone disease also? And do cardiologists identify metabolic bone disease in patients with HF?"

Doug Brunk/IMNG Medical Media

Dr. Jurkovitz, a physician scientist with Christiana Care Health System in Newark, Del., and her associates compared the management of CKD-associated metabolic bone disease between patients with and without HF who were treated at a local nephrology practice between 2000 and 2010. They evaluated the medical records of 11,883 patients with CKD stage 3 and above, and excluded dialysis and transplant patients. The researchers calculated average calcium, phosphorus, and intact parathyroid hormone (iPTH) by radioimmunoassay for each patient, and used multilinear regressions to determine the effects of CKD and HF on calcium, phosphorus, and iPTH after controlling for age, race, and gender.

The mean follow-up of the 11,883 patients was 4 years. Of these, nearly one-quarter (24%) had HF at baseline, while 76% had stage 3 CKD, 22% had stage 4 CKD, and 2% had stage 5 CKD. Patients with HF were slightly older, with a mean of 69 years, than were their counterparts without HF, who had a mean 66 years.

Dr. Jurkovitz and her associates found that the adjusted mean for calcium was significantly lower in patients with HF at each CKD stage. The interaction between CKD and HF was statistically significant. The adjusted means for phosphorus and iPTH were significantly higher in patients with HF at each CKD stage, while the interactions between CKD and HF were not significant.

"Physicians need to be concerned about the management of chronic kidney disease in their patients with HF, and the management of metabolic bone disease addressed on a case by case basis in a dialogue between the cardiologists, nephrologists, and primary care physicians," she concluded.

The meeting was sponsored by the American Society of Nephrology. Dr. Jurkovitz said that she had no relevant financial conflicts to disclose.