Impact of worsening surgically induced chronic kidney disease (CKD‐S) in preoperative CKD‐naïve patients on survival in renal cell carcinoma

Abstract

Objectives To evaluate effects of worsening surgically induced chronic kidney disease (CKD‐S) on oncological and non‐oncological survival outcomes in renal cell carcinoma (RCC). Patients and Methods We performed a retrospective analysis of patients who underwent partial (PN) or radical nephrectomy (RN) and were free of preoperative CKD (estimated glomerular filtration rate [eGFR] ≥60 mL/min/1.73 m2). Patients were stratified by CKD stage at last follow‐up: no CKD‐S (eGFR ≥60 mL/min/1.73 m2), de novo CKD‐S 3a (eGFR 45–59 mL/min/1.73 m2), CKD‐S 3b (eGFR <45 and ≥30 mL/min/1.73 m2) and CKD‐S 4 (eGFR <30 and ≥15 mL/min/1.73 m2). The primary outcome was all‐cause mortality (ACM). Secondary outcomes included non‐cancer mortality (NCM), cancer‐specific mortality (CSM) and de novo CKD‐S Stage 3/4. Multivariable analysis (MVA) was utilised to identify risk factors for outcomes. Kaplan–Meier analysis (KMA) was utilised to evaluate overall (OS), non‐cancer (NCS), and cancer‐specific survival with respect to CKD‐S categories. Results We analysed 3239 patients. The mean preoperative and last‐follow‐up eGFRs were 87.4 and 69.5 mL/min/1.73 m2, respectively. On last follow‐up, 57.9% (n = 1876) had no CKD‐S, 18.7% (n = 606) had CKD‐S 3a, 15.1% (n = 489) had CKD‐S 3b and 8.3% (n = 268) had CKD‐S 4. On MVA, de novo CKD‐S 3b and 4 were independently associated with ACM (hazard ratios [HRs] 1.3–2.1, P = 0.003–0.001) and NCM (HRs 1.5–2.8, P = 0.021–0.001), but not CSM (P = 0.219–0.909); de novo CKD‐S 3a was not predictive for any mortality outcomes (P = 0.102–0.81). RN was independently associated with CKD‐S 3–4 (HRs 1.78–1.99, P < 0.001–0.035). Comparing no CKD‐S, CKD‐S 3a, CKD‐S 3b and CKD‐S 4, KMA demonstrated worsening outcomes with progressive CKD‐S stage: 5‐year OS 84% vs 78% vs 71% vs 60% (P < 0.001) and 5‐year NCS 93% vs 87% vs 83% vs 72% (P < 0.001). Conclusion Development of CKD‐S Stage 3b and 4, but not 3a, was associated with worsened ACM and NCM. The decision to proceed with nephron preservation via PN should be individualised based on oncological risk and risk of functional decline to CKD‐S 3b or 4, and not CKD‐S 3a.

Preoperative Age and Its Impact on Long-Term Renal Functional Decline after Robotic-Assisted Partial Nephrectomy: Insights from a Tertiary Referral Center

“…They also found that age (HR 1.07, p < 0.001) was associated with an increased risk of non-renal cancer mortality. Similar results were recently reported by Nguyen et al [ 25 ], which noted that a decline in eGFR below 45 mL/min/1.73 m 2 was associated with an increased risk of both all-cause and non-cancer mortality. Taken together these findings underlined an interconnection between age, renal functional decline, and mortality.…”

“…Increasing age has been advocated as a risk factor for worsened oncological and functional outcomes for RCC [ 25 ]. Nevertheless, since most of the studies amalgamate RN and PN cohorts, the impact of age on long-term renal functional outcomes after RAPN has not been well elucidated yet.…”

“…We observed a linear correlation between increasing age and a decline in estimated eGFR ( p < 0.001), as well as between age and worsening renal function. Taken together these findings suggest that renal functional recovery after surgery is an age-related phenomenon and could advocate for more comprehensive considerations regarding conservative surgery in older patients experiencing a decline in eGFR [ 25 ]. Elderly patients should be properly counseled about the risk of achieving suboptimal functional outcomes after RAPN.…”

“…Patients were sub-stratified by age [low age (<50); intermediate age (50–70); high age (≥70)] [ 25 ]. In our study, we first used the Kolmogorov –Smirnov test to check whether the data followed a normal distribution.…”

“…RCC is known to be influenced by metabolic factors [ 22 , 23 , 24 ]; therefore, exploring risk factors associated with renal functional recovery after PN is of paramount importance. While it is well-established that older age can increase mortality risks associated with renal surgery [ 25 ], the specific effects of age on the decline in kidney function following robotic-assisted partial nephrectomy (RAPN) are still debated. We sought to delve into how age affects kidney function post-RAPN, with a particular focus on the progression to moderate and severe chronic kidney disease (CKD).…”