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Should partial nephrectomy be considered “elective” in patients with stage 2 chronic kidney disease? A comparative analysis of functional and survival outcomes after radical and partial nephrectomy

  • Zachary A. Hamilton 1,
  • Umberto Capitanio 2,
  • Brian R. Lane 3,
  • Alessandro Larcher 2,
  • Kendrick Yim 1,
  • Sumi Dey 3,
  • Brittney H. Cotta 1,
  • Margaret F. Meagher 1,
  • Samer Kirmiz 3,
  • Adam Bezinque 3,
  • Ahmed Eldefrawy 1,
  • Aaron Bradshaw 1,
  • Stephen Ryan 1,
  • Cristina Carenzi 2,
  • Fang Wan 1,
  • James Proudfoot 1,
  • Francesco Montorsi 2,
  • Ithaar H. Derweesh 1
1 Department of Urology, University of California San Diego School of Medicine, La Jolla, USA 2 Department of Urology and Division of Experimental Oncology, Vita-Salute San Raffaele University, Milan, Italy 3 Department of Urology, Spectrum Health, Grand Rapids, USA 4 Department of Urology, Moores UCSD Cancer Center, La Jolla, USA

Publication: World Journal of Urology, February 2019

Purpose

To compare renal function and survival outcomes in patients with baseline chronic kidney disease (CKD) stage 2 undergoing partial (PN) or radical nephrectomy (RN), as nephron-sparing surgery is considered to be elective in this group.

Methods
Retrospective analysis of patients with CKD stage 2 and T1/T2 renal mass undergoing PN or RN from 2001 to 2015. Patients were stratified into substage CKD 2a or CKD 2b and analyzed between types of surgery. Primary outcome was overall survival (OS), eGFR < 45 at last follow-up was the secondary outcome. Multivariable analysis (MVA) was conducted for predictors of eGFR < 45 and OS. Kaplan–Meier analyses were conducted for freedom from eGFR < 45 and OS.

Results
1213 patients analyzed (CKD 2a 609/CKD 2b 604) on MVA, RN (OR 3.68, p = 0.001) and CKD 2b (OR 3.3, p = 0.002) were independently associated with development of eGFR < 45 at last follow-up and RN (OR 3.76, p = 0.005) and eGFR < 45 (OR 2.51, p = 0.029) were associated with decreased OS. Kaplan–Meier analyses revealed that patients with CKD 2a/PN had the highest 5-year freedom from eGFR < 45 (94.3%) compared to CKD 2a/RN patients (91.5%), CKD2b/PN patients (87.6%) and CKD 2b/RN patients 82.0% (p < 0.001). Kaplan–Meier analyses for OS demonstrated that patients with CKD 2a/PN had significantly greater 5-year OS (97.6%) compared to CKD 2a/RN patients (95.2%), CKD 2b/PN patients (93.2%), and CKD 2b/RN patients (92.4%, p = 0.043).

Conclusions
Patients with baseline CKD stage 2, particularly CKD 2b and undergoing RN, are at increased risk of GFR < 45, which was associated with decreased OS. In patients with CKD 2b, a nephron-sparing strategy is indicated and should be prioritized when feasible.

Commented by Dr. Zachary A. Hamilton

Partial nephrectomy has imperative indication in chronic kidney disease (CKD) Stage 3 (<eGFR 60ml/min/1.73m2). In this multi-institutional analysis, patients with CKD stage 2 (eGFR 60-90 ml/min/1.73m2) were analyzed for survival and renal functional outcomes after radical or partial nephrectomy. We noted that CKD 2b substage (eGFR 60–74.9 ml/min/1.73m2) patients and those undergoing radical nephrectomy are at increased risk of developing postoperative eGFR <45 ml/min/1.73m2, which was associated with decreased overall survival (OR 2.51 and 3.76, respectively). In patients with CKD Stage 2b, nephron-sparing surgery should be considered to be a definitive indication when oncologically safe in this at-risk population.