Updates in ID and Nephrology: Lona Mody, Rasheeda Hall, Devika Nair, Sonali Advani

Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, we got a full house with us today.

Alex: We have a very full house today. Our first guest is a repeat guest. It’s Lona Mody who is a translational infectious disease researcher at the University of Michigan and VA Ann Arbor Healthcare System. Welcome back Lona.

Lona: Thank you so much.

Alex: Wonderful. Geriatrician researcher.

We also have Sonali Advani, who is a physician scientist in the division of Infectious Disease at Duke University School of Medicine. She’s a K12 scholar, Pepper scholar and is focused on UTIs in older adults.

Welcome to the GeriPal Podcast, Sonali.

Sonali: Thank you for having me.

Alex: And we are delighted to welcome Rasheeda Hall, who is a physician scientist in the division of nephrology at Duke University School of Medicine, and sees patients at the Durham VA. Rasheeda, welcome to GeriPal.

Rasheeda: Thank you for having me.

Alex: And we are also delighted to welcome Devika Nair, who is a nephrologist at Vanderbilt University Medical Center in Tennessee Valley VA Healthcare System. She’s supported by an NIDDK K23. Welcome to the GeriPal podcast, Devika.

Devika: Thank you so much Eric and Alex.

Eric: So we got a pretty exciting topic today. This all came out from JAGS just published their first Clin-STAR corner, which is, and we’ll talk about what that is, but it’s a series of articles bringing in specialists to talk about updates in the last couple years within their field. So today we’re going to be focusing on nephrology and infectious disease.

But before we jump into that topic, I think somebody has a song request. Who has a song request for us?

Sonali: I have one. I’m going to suggest Miley Cyrus Wrecking ball.

Eric: All right, Sonali, why did you choose Miley Cyrus?

Alex: Other than torturing a vulnerable senior faculty member with a female diva singer/songwriter request? What is your other reason?

Sonali: So my other reason, which is much more scientific, is as an ID physician I see prescribing antibiotics for asymptomatic bacteruria like the wrecking ball. And there is a UTI parody song which I’ll share in the chat box, which is based on this.

Alex: Terrific, we’ll put that in the show notes affiliated with the podcast. All right, here’s a little Miley Cyrus. I think this is the first time we’ve had Miley Cyrus in over 230 podcasts on GeriPal. Here we go.

[singing]

“We called, we chained our hearts in vain. We jumped, never asking why.

We kissed, I fell under your spell. A love no one could deny. Don’t you ever say, I just walked away. I will always want you. I can’t live a lie running for my life. I will always want you.

I came in like a wrecking ball. I never hit so hard in love. All I wanted was to break your walls. All you ever did was wreck me.

I came in like a wrecking ball. I never hit so hard in love. All I wanted was to break your walls. All you ever did was wreck me.”

Lona: Wow.

Eric: Just like antibacterials for antibiotics, for UTIs, right? [laughter]

Devika: Amazing, Amazing.

Eric: So let’s start off with the topic.

Lona, can you give us a kind of 30,000 foot view? What the heck is Clin-STAR?

Lona: Yeah, no, I think, Thank you for the question. As you know, our population is aging at a rapid speed and older, adult older persons is no longer cared for only by a geriatrician or a primary care physician. There’s a team now with them behind them making sure that they stay safe and held in our communities. That includes many medical specialists, surgical specialists, many specialists and many other disciplines who are on our older adults team.

And so there was a report in 2009 by the Institute of Medicine saying that we need to equip all of these individuals in caring for older person in an evidence based manner. And they should be forced by doing research, followed by translating research into practice and continued education of a wide variety of individuals to then care for our aging population. That gave rise to the GEMSSTAR, which is grants for early medical and surgical specialists in aging research that’s supported by NIA.

Those are grants given to early career junior faculty to initiate the research into aging fields. So for example, a surgeon doing aging research or a nephrologist doing aging research or cardiologist doing aging research. And that led to many specialists doing work and advancing their fields within their professional societies, providing guidance and so on for older adults. There was a need then to then support these specialists even further using a national platform. So NIA and further funded this coordinating center that we call Clin-STAR. And this coordinating center brings together many resources and the platform for our specialists, junior, mid-career senior to drive and conduct and promote aging research.

Eric: And then what is Clin-STAR corner?

Lona: So Clin-STAR corner, with incredible support from JAGS, is a series of articles where our specialist will come to us and geriatricians and tell us what is on their minds, what is on the minds of their fields in terms of research, in terms of good, excellent papers published within their journals, their views that they’re talking about, that they’re conversing about that applies to us geriatricians as we care for our older population. So that’s what Clin-STAR Corner is. It’s going to be a series of articles published over time giving us updates from these specialist societies.

Eric: That’s exciting. And we’re going to be talking about that. We’re going to be talking about both infectious disease updates and also nephrology updates.

Let’s start off with infectious disease.

Sonali, how did you come up with these papers? Three papers, seems to have a theme, and I’m also impressed that something was published besides COVID in the last two years, two and a half years in infectious disease.

Sonali: So I’d like to start by saying thank you again for having me on this podcast and also for the opportunity to publish this work and mostly to Dr. Mody for the mentorship and for the opportunity to bring together these articles. How we came about to select these articles or to have interest in this topic is really older adults are unique population that are at risk for both over diagnosis of infections as well as under diagnosis of infections. There’s the complications associated with immune senescence, comorbidities, atypical clinical presentations. And so what we wanted to focus on is how do we help clinicians approach a population where infections pose a risk, but at the same time, overuse of antibiotics can also cause a risk. So it’s not easy to tell people withhold antibiotics in this population or don’t use antibiotics. And so we have to come up with deprescribing approaches that are more amenable to this higher risk population.

And this is where we started to look at the literature and saw that there were actually a lot of clinical trials that had been published that focused on shortening the duration of antibiotic use and especially these trials had a reasonable number of older adults enrolled in them. As we started to look at the data over the past year or so, we found that there were at least three different major infections, namely pneumonia, urinary tract infections, and gram negative bacteriemia that had been covered for deprescribing intervention as it relates to shortening the duration of therapy. Around this time the American College of Physicians also released new guidelines recommending shorter courses of antibiotics. So this point led us to select these articles.

Eric: Why is shorter courses important? More is better usually, right?

Sonali: Well not in this case and not in many cases. I think what we are starting to find with antibiotics, especially in older adults, is with increasing duration as well as increasing dose, older adults are especially susceptible to adverse events associated with the drugs as well as other risk factors like C. difficile infections. And so one thing that we can start to think about is not only can we avoid antibiotics where they’re not necessary, but at times when we are using antibiotics where they’re necessary, is there an avenue to shorten the duration and reduce the exposure of antibiotics because then we’re reducing the side effects associated with each antibiotic and the risk of C. difficile that patients are exposed to and antibiotic resistance.

Eric: Yeah, I love this paper because I remember in med school being taught maybe this talks about how maybe old I am now, UTI and men always complicated, always requires a two to four week course because it’s a complicated UTI.

One of your articles addresses that. We don’t have time to jump into all the methods, but tell me about the seven versus 14 day antibiotic for afebrile UTIs in men.

Sonali: So great question. Actually have been talking so much about UTIs today because of another article that I wrote. It’s been like the flavor of the month or my life rather.

Eric: Wait, you were on another podcast that wasn’t ours.

Sonali: No, no. It’s another article, another major article that has triggered the complicated UTI circuit. But what I did want to highlight is how we got to thinking about men that have UTIs have complicated UTIs. I always tell people take a step back and we got to that as when there’s a person with a structural or a functional abnormality of the urinary tract, then they have a complicated UTI. In many cases, men will have some kind of structural or functional abnormality which puts them at increased risk for a UTI.

Eric: Like BPH.

Sonali: Like BPH or any other prostate issue that they have or they’ve had recent neurologic surgery. And I think that’s not always the case because now we’re seeing sometimes patients have indwelling urinary catheters that can be removed quickly and sometimes we even see in rare cases that the patient may not have a complicated UTI. It’s very rare and they may be a male patient.

So you’re right. And I think that’s where we are now challenging that dogma. Do we really need two weeks or four weeks? And I think that’s where this clinical trial which looked at seven versus 14 days was really practice-changing for many of us. It doesn’t mean that every patient should get seven days. It means that there are some patients that can get seven and I think that that’s an avenue for deprescribing when you are faced with those patients.

Eric: So in this case afebrile men, it looks like seven days kind of was similar to 14 days as far as outcomes. Why the important part of afebrile?

Sonali: I think that some of that was trial recruitment as well as risk for pyelo and ascending UTI and that is my belief was the reasoning behind febrile men.

Eric: Lona, did this change your practice?

Lona: Absolutely. I think that it’ll change practice and it does in terms of shortening the duration of antibiotics in our VA population particularly and not to go for two weeks. If at day seven the patient is doing really well and afebrile it should work on my patient absolutely.

Sonali: This seven versus 14 days for male UTI combines really well with the gram negative bacteriemia paper because sometimes we are faced with patients in the hospital which are disposition issue. And this happened to me while I was in service a couple of weeks ago. And at times, you know don’t have any place, you don’t have any avenue for discharging a patient and you are faced with should I give someone a PICC line and 14 days of antibiotics for gram negative and you have a clinical trial that has shown gram negative bacteremia from a urinary tract infection that has completely resolved and the patient has defervesced can be treated for seven days.

So I think when you start combining these trials and you’re faced with an older adult that the option would be to now put in a PICC line and send them to a nursing home and then you can have a really sit down with the patient through shared decision making decide we stop at seven days. So I don’t know Dr. Mody, but I think some of these trials can really be combined and really help with reducing duration of treatment.

Eric: And this trial you’re particular talking about is using CRP to help you decide between seven days or 14 days and gram negative bacteremia?

Sonali: Well there’s three arms to that. That trial has CRP, seven day, and 14 days. So you don’t necessarily need the CRP. CRP arm, the seven day arm and the 14 day arm all did similarly. And there have been two other studies on gram negative bacteremia that have been published that have shown seven versus 14 days have had equivalent outcomes if your patient does not have any complicating factors, has had source control and has defervesced

Eric: Lana, what do you think about that?

Lona: Yeah, no I think that these are all important studies for us to look at low hanging fruit. What are the simpler interventions that we can do to reduce antibiotic duration? And Sonali mentioned the impact of longer duration at the patient level. There are studies that have impact of just overall reduced what I call burden of antibiotic use at the unit level. So there have been studies shown that if you reduce antibiotic use that can reduce C. Diff rates, for example at a unit level. So transmission of other drug resistant organisms and C difficile to other patients in the hospital reduces if you control.

Eric: So it doesn’t just help the patient but it helps everybody around the patient too importantly, like in nursing homes.

Lona: Absolutely.

Eric: Can I touch on the last study? I think this is…Treatment of community acquired pneumonia in just regular medicine awards, not in the ICU three versus seven days. Was there a difference Sonali?

Sonali: In this study there were a lot of caveats. If you look specifically, they looked at several different clinical criteria as well as laboratory criteria. And I think that there is room for shortening the duration if your patient is non-immunocompromised and not severely ill. So I think there are caveats and if you have a non immunocompromised, not severely ill patient that has again defervesced, then there is room for reducing the duration to three days for community acquired pneumonia.

Eric: That’s pretty impressive.

Sonali: I think that’s where the caveat comes to this. In a very healthy population where you could go to three.,I think that there’s room for shortening duration to a less, I’d say less stringent, criteria. And some of these trials are just kind of introducing the idea to us of shortening the duration. So if you had a patient that was clinically doing great at day three and was generally healthy, you could consider stopping it at day three.

Alex: That aligns with my own personal, this is terrible.

Okay, I’m going to admit it.

I have never finished a course of antibiotics in my life. When I start to feel better, I stop taking them.

Eric: Doctors are terrible patients.

Alex: I know, we’re terrible patients.

Lona: Terrible patients, I agree.

Alex: Agree. But really where do, yeah infectious disease folks come up with these durations like number of days?

Sonali: And that’s a whole website dedicated to this by Brad Spellberg where he challenges the notion of duration. And we talk about this a lot. A lot of these durations are just based on expert opinion. So really when your patient is doing clinically better, should we be continuing antibiotics? I think in some cases like staph bacteremia, yes, those are cases where I would not stop antibiotics when you just kind of feel better. I think there are some ID dogmas we will hold very strong to like staph bacteremia, endocarditis. There’s few things that are very, very scary and we will stick to, but if they’re mild infections like pneumonia, uncomplicated UTI, uncomplicated gram negative bacteremia, I think there is room for reducing the duration of treatment and challenging the previously held dogmas about 14 days that we were using for a long time.

Alex: That’s great.

Eric: It also feels like that there’s growing questioning over IV versus PO sometimes because…What are your thoughts on that? Where are we with a lot of these medications? Because a lot of these antibiotics have pretty good availability depending on which one, why is so much focus on IV antibiotics?

Sonali: Absolutely and I think if this podcast can influence our funding agencies to provide some funding for us to fund more clinical trials to show that PO is as good as IV, I think we would love that.

I think it is really largely driven by the fact that we do not have large scale randomized clinical trials to show that PO is as good as IV. We do have good retrospective studies and again are moving in many areas like osteomyelitis to move towards oral options and showing that oral therapies are good even in some cases of bacteremia.

Again, I always exclude staph bacteremia. In this case I would say never use orals for staff, but in other bacteremias we are definitely seeing a movement towards oral therapies and there is a shift, but if we had money for more studies, this shift would move faster.

Lona: And there are situations where IVs are needed if the person is not able to take in orals, is very ill clinical and unstable.

You don’t want to mess around with that situation.

Eric: Well I want to thank you for, it was a excellent article, loved reading it.

Anything else before we shift over to nephrology?

Devika: I had a question for Sonali actually.

Eric: Yeah.

Devika: Sonali, my husband’s an infectious disease physician and so I’ve learned a lot about what you’re talking about from him and he mentions Brad Spellberg a lot as well.

I would love to hear from you, for those of us listening in who are not infectious disease specialists, how can we interface more effectively with you all? I’ve learned that there’s so much nuance in infectious disease, the seven versus 10 versus 14 and sometimes those outside the field might not feel well equipped enough to be able to make that judgment call, okay, is the patient really getting well enough? Am I comfortable enough to stop the antibiotics at day 10 or should we really, when we have a doubt always involve you all in the patient’s care even if it is for cystitis or a pneumonia?

Sonali: Absolutely. And no thank you for bringing up that question.

I think some of that depends on the kind of health system or hospital that you are involved with. So we have a network of community hospitals and not every hospital has a strong ID consult service or some hospitals have one physician covering many, many patients, the whole hospital so may not have the bandwidth to cover everyone.

At least here at Duke, we would say that I would prefer that people call us and ask us before they make an assumption about a treatment duration and we usually almost see all our bacteremia patients and also have a very strong stewardship team. One untapped avenue is ID pharmacists and sometimes if you don’t have access to an ID physician or if the ID physician is too busy, if there is an avenue to talk to an ID pharmacist or even a pharmacist, they can be an untapped avenue for places that are resource poor or resource challenged.

But I would say that in most cases, if you can even talk to your ID physician, if there’s someone who’s on call or who’s around, I would say that they would be more than happy to engage you about duration and see the patient because we always say we would rather see the consult than it become a complication later.

Devika: Thank You.

Eric: Thank you. Let’s move over to nephrology. I think one of the things I think has been a lot in the press and a lot of journals is the removal of race based coefficients when we’re estimating kidney function.

That was one of the papers right in the Clin-STAR Corner. I’m going to turn you to Rasheeda.

Rasheeda. Why was this important? Why was this article chosen?

Rasheeda: Yeah, hands down when we started thinking about this, we both agreed that this had to be addressed in this Clin-STAR Corner. And I think the main reason was we are representing the nephrology community to JAGS and recognizing how over the prior two years there have been a lot of discussion within American Society of Nephrology, the National Kidney Foundation, addressing this question of what do we do about the race coefficient, recognizing that race is a social construct and that we should remove it from how we estimate kidney function. And so recognizing, oh this is a great opportunity, how else is going to get into JAGS Journal to be something that a geriatrician would pick up and read, I think we definitely felt like it needed to be mentioned.

Eric: Why was race even included? I remember med school again, we were taught about the Cockcroft-Gault. That was our main estimate, age and race important in that equation. Why was it?

Rasheeda: Devika, you help me, I think I can explain this but I might not get it just right. So obviously there’s been a lot of equations around estimating kidney function and generally they all have their flaws. So if I recall correctly, it’s the MDRD equation that was developed primarily to transition clinicians using creatine to using an estimated GFR, glomerular filtration rate. And so to develop that equation, they use the cohort of individuals and their data, their blood samples, creatine and other physical attributes.

It was in that development of the equation that it had appeared that the individuals in the cohort who were black race perhaps either had higher creatinine means, I believe that’s right, which led to some assumptions being made then that means that the equation needs to be modified for race.

We didn’t go into this in the article, but for those who are interested, a lot has been written about this because there has been an assumption there that in general that patients of black race than would have higher creatine the higher muscle mass. And that means that there needs to be a different equation. But honestly it never has been born out in additional studies. With that one study unfortunately it’s been something that was kind of put into place and then adopted. Because I know in the early 2000s, there was this whole thing about reporting estimation of GFR, let’s get the GFR in front of people so that we can diagnose CKD and that was the equation that was being used.

Devika: That’s right. Yeah. Because the cohort that the equation was originally based on, one of the cohorts that an earlier version of the equation was created from included participants who did self-identify as black and there were certain things that were found among those participants. And as Rasheeda said, there were frankly assumptions made as Rasheeda said, have not really born out in subsequent studies.

But kind of taking a step further back, race has unfortunately been included in a lot of clinical algorithms as we are now kind of understanding more and more whether in nephrology, whether in pulmonology, whether in so many different fields. And it’s kind of this newfound recognition that, oh my gosh, this social construct, which doesn’t even really have a place in scientific algorithms, the fact that it’s in so many places is kind of inappropriate and racist across the board.

So it’s really forced us to look internally at ourselves and kind of show the magnifying glass onto ourselves. I think about it myself when I’ve looked at papers I’ve written in the past where I’ve included covariate adjustments for race and thinking back, why did I even do that? What was I really trying to measure with that? I was probably trying to measure some measure of systemic racism, some measure of poverty, some measure of something else, but instead I included race.

And so it just kind of speaks to our need to really, really look at why we’re including things in research and in clinical algorithm development. Why are we including it? Is it scientifically valid? Are we really trying to measure something else? And just being really thoughtful about future studies that we conduct and as we move forward.

Alex: That’s very well put, Davika, thank you. And Rasheeda. This is such an important issue and it’s incredibly, I think complicated. I mean on the surface you might think, as you’ve just said, absolutely race is a social construct. So many of these decisions were based on small non-generalizable studies from a long time ago and then they sort of set the precedent going forward. Then also I think it can be complicated, the notion of simply removing race completely. Should it be, it’s a open question, should race be completely removed from all algorithms?

For example, we’ve talked about on this podcast how black Americans and Latinx Americans were at greater risk for poor outcomes from COVID. Should they reprioritized higher for scarce resources to treat COVID? I think about kidney donor lists and should race be included in a risk of future kidney disease, which would limit the number of black American donors on kidney lists.

So I just think this area is really fascinating and I just want to express appreciation for all of the great thought that is going into these complex decisions about and thoughtful decisions that need to be made about removing race and the impacts on population, right? Cause in eGFR it was causing like fewer black Americans have access to be considered for transplant and that was a huge issue. So removing it as a potential to eliminate some of those disparities, whereas in other situations removing it might actually mean that vulnerable populations get less resources directed their way.

I’ll get off my soapbox and see if you have any thoughts in response to that.

Devika: Well Rasheeda and I have talked about this a lot and she can speak much more eloquently about this, but Alex you kind of hit on one thing that I think we all agree on is that when you are making decisions about whether to include some measure, whether it’s race or what race is actually trying to measure, you need to first determine whether including it versus excluding it would cause any harm to the population you’re studying.

I don’t know that we’ve all always been that thoughtful when race was included in creating those equations et cetera. First to no harm. So certainly things should only be included if they cause no harm and even better if they can cause demonstrable benefit. So that speaks to some of what you were saying about whether reclassifying black Americans or people who identify as black in the United States as having CKD, would that give them benefit? Would that cause harm? You know, have to think of those things when you’re designing studies and deciding what to include in your equations.

Race certainly we don’t think has a place because it’s not a scientific construct, but I’m kind of speaking more generally about how we conduct studies in general. The second thing I was thinking about is just being mindful that eGFR is just that, the e means it’s an estimate. So not only do we need race free equations, but I think this national conversation has reminded us that we probably need a creatinine free equation as well. Creatinine is an imperfect marker of kidney toxin level, it’s just what we use and it’s what’s been standardized and it’s better than nothing but we ultimately just need more precise, more accurate ways to estimate glomerular filtration.

Eric: I’m going to ask about cystatin C but before I do, before we change the subject Rasheeda, anything else you want to mention on what we were just talking about?

Rasheeda: The only thing I would add is that when it comes to removing race and what that means for an older adult population is that what we described in the paper was that we would potentially see that kidney function is estimated to be lower than before. Slightly a shift in more patients diagnosed with kidney disease or now their GFR looks lower so now there’s different concerns regarding prescribing medications. Particularly like metformin that’s come up a lot this year for me with a patient who had been on metformin and all of a sudden their GFR is lower because there’s a new equation.

So these are happening, it’s affecting how we provide care to our patients. But I think while that’s on the individual level, I think on the population level we still have to acknowledge that in many ways we are dealing with because race is a social construct, a lot of the background behind that is around the social determinants of health and what can we do in general to make sure we’re accurately diagnosing our patients and in seeing as physicians how we can support improvements in society and addressing social determinants. Because those are really often the main, most important thing for our patients to really ensure that their health is maintained.

Eric: Great.

Alex: Thanks, Rasheeda.

Eric: I got a question. Should we, so the e part, how should we estimate GFR? We have the old school Cockcroft-Gault, we have MDRD, which is includes race-based. We have early CKD-EPI right? That also included race based formula. Now we have a 2021 CKD-EPI, am I saying it right or do I have to say E-P-I?

Rasheeda: CKD-EPI.

Eric: What calculator should we pull up?

Rasheeda: Yes, so maybe Devika can find a link…

Devika: Yeah, I’ll find it in and put in in the chat.

Rasheeda: The National Kidney Foundation website does now have the 2021 CKD-EPI equation. And when you look at the website, it provides an opportunity to enter both the patient’s creatine and cystatin c because this new equation comes in two forms. So if you have both measures then you can get what we think right now is perhaps one of the most accurate estimates that someone’s kidney function but you only have creatinine and you can still estimate on the GFR with that alone. That’s what we would recommend.

Eric: So 2021 CKD-EPI, which I think the VA, I’m at the VA which automatically pulls up in CPRS. Go VA.

Devika: And Eric, to your question earlier, even cystatin C has its limitations. So in general, when you have someone who…

Eric: Can I ask real quick before we talk about, what is cystatin C?

Rasheeda: Ooh….

Devika: It’s made by every nucleated cell in the body.

Eric: Oh yeah?

Devika: It’s also a protein like creatinine, but instead of being made by muscle cells, it’s just made by more cells in the body but it also fluctuates with inflammation. So it’s not that great when someone’s acutely hospitalized. It has its own limitations.

Eric: So I’m guessing like steroids and other things can affect it. Right?

Devika: It’s also another protein basically.

Eric: So Devika, when do you use cystatin c?

Devika: I like to use it when I have someone who I look at their eGFR based on their creatinine because currently I think that’s what my hospital system still kind of shows automatically. If there’s a clinical decision that would significantly affect the patient’s quality or even quantity of life, like dialysis decision making, transplant referral, all kinds of things like that and I really want the most accurate estimation of kidney function possible, I send a cystatin C to get a more accurate estimate.

So this is someone who has cirrhosis, this is someone who might be very physically frail and have low muscle mass such that their creatinine based eGFR would actually overestimate their kidney function. That’s a typical person I send cystatin C’s on. Or at the other end of the spectrum, someone who might be falsely classified as having CKD because they have high muscle mass and a creatinine that makes them seem like they have CKD because of their high muscle mass. So people at kind of those extremes where I would potentially be really changing their diagnoses.

Eric: That’s helpful. I know we have only a couple of minutes left. You also talked about SGL-2 and also NSAIDs. I was wondering if we can jump to the NSAIDs article because the geriatrics party line is avoid NSAIDs in older adults because the risk for including worsening renal disease.

Tell me about this study.

Devika: So this study was, first I’ll say, Rasheeda and I picked this because it’s pretty different than the other articles we picked. And while it is not an RCT and there really aren’t RCTs about pain management in CKD, there’s just so little known about mechanisms of pain in CKD that we’re just not there yet.

But it’s an observational study that looked at, I think this was the CRIC cohort, I’m trying to remind myself now, it’s been some time since I looked at this. But yes, this looked at the CRIC cohort and it was looking at basically people who were prescribed NSAIDs versus opioids. What they found out was that particularly among older adults, number one there was a large percentage of opioid prescriptions which was kind of concerning. Older adults with CKD and opioid use was actually associated with worse outcomes than NSAID use.

There were lots of limitations because we have no data on why each person was prescribed an opioid versus an NSAID and presumably that would really change why they experienced an outcome. So it’s not a perfect study, but if plus some other observational data has kind of opened up this new conversation, at least among nephrologists, about the fact that okay, a, we have really, really not much in our toolbox in terms of how to treat pain in people with CKD despite it being an increasing problem.

And number two, maybe we should allow gentle occasional use of NSAIDs for chronic pain management if it means keeping somebody off of opioids. There’s somebody in my clinic I can think of right now who I have done this for and it has reduced his opioid burden. I think that becomes particularly important for older adults who their goal may not be to stay off of dialysis, their goal may be to be pain free. There’s more data that supports AKI being a complication of NSAIDs rather than true CKD progression. So there’s a lot more research that needs to be done in this area to kind of, I think add to the evidence base that NSAIDs may be safe in chronic CKD.

Eric: Rasheeda, has this changed chronic practice? Has this changed your practice at all?

Rasheeda: Has it changed my practice?

I actually don’t see a lot of people with NSAIDs. I think it’s different, right? In our clinic, in the CKD clinic, we counsel patients not to use NSAIDs and as such it we have a patient who’ve been using NSAIDs, it probably contributes to their kidney disease and they’ve already stopped it, which is, I think we would have to be the ones to really hold the banner and says they’re okay for the rest of the medical community to agree with that. Because I do think instinctively that we also feel like there’s some caution.

Eric: Yeah, I mean this is a big one. This just definitely goes against the old standard party line of avoid NSAIDs at all costs in people with kidney disease. And probably the reason that you have a lot of older adults on opioids instead because we can’t give NSAIDs, the Tylenol is work not working, what should we do?

Rasheeda: But for short term use, it could be definitely that we can see NSAIDs providing some short-term pain release and can avoid any of those complications of opioids.

Eric: Now before we end, I’m going to go back to Lona.

Lona, what’s coming up in the Clin-STAR Corner?

Lona: Yeah. We have an exciting article that will be focusing on new research and innovative work in the pulmonary critical care community as well as cardiology. But you can see that the possibilities are endless. We are looking at several other specialists to contribute to this Clin-STAR Corner in future that would include emergency medicine, psychiatry, psychology, rehabilitation, and several other medical and surgical specialties that need to be represented within our JAGs Clin-STAR Corner. So I’m really looking forward again, the future is really good in terms of this articles. I’m hoping that Dr. Smith here will support them.

Alex: Terrific.

Eric: I love it. You’re like taking a wrecking ball to the silos of medicine here.

Devika: Right? I love it.

Alex: [singing]

“I put you high up in the sky and now you are not coming down.

It’s truly turned, you let me burn. And now we’re ashes on the ground.

Don’t you ever say, I just walked away. I will always want you.

I can’t live a lie, running for my life. I will always want you.

I came in like a wrecking ball. I never hit so hard in love.

All I wanted was to break your heart. All you ever did was wreck me.”

Eric: Alex, you got a Miley Cyrus. We got to just get more Miley Cyrus song going. You’re hitting that one.

Alex: Oh, don’t give the listeners ideas. [laughter]

Eric: I want to thank you all for being on this podcast and for doing the JAGS Clin-STAR Corner. I really love the articles. We’ll have links to them in our show notes and to some of the other sites like the kidney.org site for the CKD-EPI 2021.

So again, very big thank you.

Alex: Thank you so much.

Devika: Thank you so much.

Eric: And thank you to all of our listeners for your continuous support of the GeriPal podcast.