Original StudyIncident Chronic Kidney Disease After Radical Nephrectomy for Renal Cell Carcinoma
Introduction
Globally, the incidence of kidney cancer is rising, particularly in high-income countries.1 The kidney is the 12th most common site of primary cancer, and renal cell carcinomas (RCCs) account for most of these.1
In Australia, despite increasing trends toward the use of nephron-sparing surgery, radical nephrectomy remains the most common management approach for kidney cancer.2, 3 Although radical nephrectomy has excellent oncological outcomes for localized tumors,4 concerns surrounding the risk of postoperative chronic kidney disease (CKD) after nephron mass reduction are prominent in the literature.5
Nephrectomy has traditionally been assumed to have few adverse consequences, on the basis of favorable outcomes in living kidney donors6; however, more recent studies suggest that after accounting for baseline health status, living donors actually have a higher long-term absolute risk of developing end-stage kidney disease (ESKD) and other adverse outcomes as a consequence of donation, compared with the general population.7 Because patients who develop RCC are more likely to be older and have a greater number of comorbidities compared with living kidney donors,8 a higher risk of adverse sequelae subsequent to nephrectomy in this population is likely. The incidence rate of ESKD after radical nephrectomy for kidney cancer is approximately 5.2 per 1000 person-years.9 Additionally, patients with a previously normal kidney function who develop de novo CKD after radical nephrectomy have a higher mortality rate than patients who do not develop CKD after nephrectomy.10, 11
Identifying patients who are at risk of CKD after radical nephrectomy could improve patient care, because appropriate risk stratification before surgery could be conducted to help guide management and follow-up. Accordingly, the goal of this study was to describe associations between various patient, tumor, and health service characteristics, and the development of postoperative CKD in patients who were managed with radical nephrectomy for RCC in 117 hospitals across the Australian states of Queensland and Victoria. This study expands on previous work undertaken on this cohort, in which risk of CKD was evaluated for a subgroup of patients with stage T1a RCC who were managed with partial and radical nephrectomy.12
Section snippets
Study Design and Population
Patients included in this study were from a population-based retrospective cohort study investigating the patterns of care for patients newly diagnosed with RCC in the Australian states of Queensland and Victoria between January 2012 and December 2013. Methods of data acquisition have been described elsewhere.12 Data were abstracted on all patients aged 18 years or older who were who were notified to either the Queensland or Victorian Cancer Registries with newly diagnosed RCC during this
Results
The 799 patients included in this study had a preoperative eGFR ≥60 mL per minute per 1.73 m2 and were managed with radical nephrectomy for RCC at 38 hospitals in Queensland and 79 hospitals in Victoria between January 2012 and December 2013. Postoperative serum creatinine level was recorded at a median follow-up time of 12.0 (interquartile range [IQR], 9.8-13.4) months (range, 1.6-26.0 months), with follow-up times >5.5 months for 760 (95%) patients. There were 473 patients (59%) who developed
Discussion
In this cohort of patients with RCC and without CKD, we found that 59% managed with radical nephrectomy went on to develop CKD within 12 months of surgery. This is similar to another Australian study that reported that, of 255 patients managed with radical nephrectomy across 6 Victorian tertiary referral centers, 140 (55%) developed incident CKD after surgery at a minimum of 6 postoperative months.19 The slightly higher estimate from our study might reflect that our study was conducted across a
Conclusion
Overall, we found that specific patient and health service characteristics were associated with an increased risk of incident CKD for patients managed surgically for RCC. Having a working knowledge of potential risk factors for worse kidney functional outcomes can allow for interventions to be made at the patient and health service levels. For patients, this could involve preoperative consultation with renal physicians; changes in terms of management, for example, a preference for active
Disclosure
The authors have stated that they have no conflicts of interest.
Acknowledgments
We acknowledge the work of Leah Laurenson and Christine Hill for managing and coordinating data collection, in Victoria and Queensland, respectively. We acknowledge the assistance of the hospitals and health services in both states that facilitated data access.
Data collection was funded through a translational research grant from the Victorian Cancer Agency (EOI09_E36) and a project grant from Cancer Council Queensland (APP1046732).
R.J.E. was supported by an Australian Government Research
References (31)
- et al.
Age-adjusted incidence, mortality, and survival rates of stage-specific renal cell carcinoma in North America: a trend analysis
Eur Urol
(2011) - et al.
Comparative effectiveness for survival and renal function of partial and radical nephrectomy for localized renal tumors: a systematic review and meta-analysis
J Urol
(2012) - et al.
Kidney function following nephrectomy: similitude and discrepancies between kidney cancer and living donation
Urol Oncol
(2012) - et al.
Survival and functional stability in chronic kidney disease due to surgical removal of nephrons: importance of the new baseline glomerular filtration rate
Eur Urol
(2015) - et al.
Comparison of the prevalence and mortality risk of CKD in Australia using the CKD Epidemiology Collaboration (CKD-EPI) and Modification of Diet in Renal Disease (MDRD) study GFR estimating equations: the AusDiab (Australian Diabetes, Obesity and Lifestyle) study
Am J Kidney Dis
(2010) - et al.
A new method of classifying prognostic comorbidity in longitudinal studies: development and validation
J Chronic Dis
(1987) - et al.
Renal function after nephron-sparing surgery versus radical nephrectomy: results from EORTC randomized trial 30904
Eur Urol
(2014) - et al.
Small tumour size is associated with new-onset chronic kidney disease after radical nephrectomy in patients with renal cell carcinoma
Eur J Cancer
(2014) - et al.
Screening for chronic kidney disease in Australia: a pilot study in the community and workplace
Kidney Int Suppl
(2010) - et al.
Rural inequalities in the Australian burden of ischaemic heart disease: a systematic review
Heart Lung Circ
(2017)