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Year : 2011  |  Volume : 27  |  Issue : 4  |  Page : 564-565
 

Partial nephrectomy in chronic kidney disease: Not always a win-win situation


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Date of Web Publication4-Jan-2012

Correspondence Address:
Bastab Ghosh
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How to cite this article:
Ghosh B. Partial nephrectomy in chronic kidney disease: Not always a win-win situation. Indian J Urol 2011;27:564-5

How to cite this URL:
Ghosh B. Partial nephrectomy in chronic kidney disease: Not always a win-win situation. Indian J Urol [serial online] 2011 [cited 2019 Jul 17];27:564-5. Available from: http://www.indianjurol.com/text.asp?2011/27/4/564/91460

Clark MA, Shikanov S, Raman JD, Smith B, Kaag M, Russo P, et al. Chronic kidney disease before and after partial nephrectomy. J Urol 2011;185:43-8.



   Summary Top


Chronic renal insufficiency following partial nephrectomy is an increasing health concern. A question that often confronts a practicing urologist is the long-term outcome of renal function in a patient with chronic kidney disease. Clark et al. have addressed this question in their study. [1] The authors have performed a multi-institutional retrospective cohort study in patients with chronic kidney disease (CKD) who underwent partial nephrectomy for localized tumors, to assess the progression rates to higher levels of CKD and the factors which independently predict progression. [1] All the patients over 18 years with a solitary renal tumor and normal contralateral kidney who had undergone partial nephrectomy between 1998 and 2009 were included in the study. Patients with less than 3 months follow-up, incomplete data, solitary kidney, multiple tumors, absence of renal vessel clamping or re-clamping of the renal vessels, history of previous renal surgery, or CKD stage IV and V were excluded from the study population. A total 1228 patients were analyzed. Preoperative, 3 and 18 month postoperative serum creatinine values were recorded and estimated glomerular filtration rate (eGFR) values were calculated using the MDRD (Modification of Diet in Renal Disease Study Group) formula. Patients' demographic character, body mass index, relevant comorbidities, such as diabetes, hypertension, and coronary artery disease, tumor size, histological type and pathological stage, method of vascular clamping (artery alone or artery plus vein), duration of renal ischemia, use of renal hypothermia, and estimated blood loss were analyzed. Out of 1228 patients, 228 (19%) had baseline stage I CKD, 724 (54%) had stage II disease, and 276 (22%) patients had stage III CKD. Median ischemia time was 34 min (range 7-110). Median tumor size was 2.9 cm (0.6-15.2). Renal artery alone was clamped in 883 (72%) and both artery and vein were clamped in 328 (27%) patients, whereas in 17 (1%) patients clamping status was unknown. Renal hypothermia was used in 418 (34%) patients. More than half the patients had one or more comorbidity. Of the 228 patients with baseline stage I CKD, 37% remained as stage I CKD, 53% progressed to CKD stage II and 23% developed stage III disease. Among the baseline stage II patients 5% improved to stage I, 60% remained as stage II and 35% progressed to stage III. Only less than 1% patients developed stage IV or greater in both groups. A total of 280 (29%) patients developed stage III or greater disease who had stage I or II disease to start with. On multivariate analysis, increasing age, female gender, tumor size, and clamping of both renal artery and vein were independently associated with higher risk of progression to CKD stage III or more. A higher baseline eGFR was independently related to decreased risk of progression to stage III or higher stage CKD.


   Comments Top


Partial nephrectomy has emerged as the gold standard for the surgical treatment of small renal masses. [2] Decrease in renal function is an established risk following partial nephrectomy largely due to resection of the normal kidney tissue and ischemic injury. [1] This becomes more important in patients with pre-existing renal failure. For these patients it is of primary concern to minimize the decline in renal function and to identify the factors influencing renal functional outcome following partial nephrectomy. Nearly one fourth of the patients in the present study had clinically significant renal failure (stage III or greater). Increasing age and female gender have already been shown to influence renal functional decline. [2],[3] Increasing size of the tumor is also an established risk factor for progression of CKD, as larger the size of tumor greater is the resected normal renal parenchyma volume. The clamping of both artery and vein was associated with a greater risk of deterioration of CKD status, thus clamping of renal artery alone or no clamping at all is potentially beneficial whenever feasible. [1] But there are some concerns about the study methodology that may have a bearing on this study's results. The authors have used the MDRD formula to predict eGFR which is best suited below the age of 70 years and in patients with CKD III or more. Thus the direct association between age and CKD status may not be a proper reflection of the reality. Diuretic renogram gives an accurate estimate of GFR. [3] So, instead of eGFR calculated from serum creatinine diuretic renographic measurement before partial nephrectomy and on follow-up would have shown more accurately the change in GFR.

Renal volume reduction is a major predictor of renal functional outcome. [3],[4] Although inter-related, the specific location of the tumor and accurate estimate of the resected tissue volume were not addressed in the study. Finally, 29% patients with CKD stage I or II progressed to CKD stage III or greater. This emphasizes the need for weighing the ill effects of CKD against the risk of renal mass progression, since a significant number of small renal masses are benign or with limited metastatic potential. [5] This is an important factor as many patients may not have easy access to renal replacement therapy should it become necessary. Furthermore, the median follow-up in this study was a little over only 1 year with the maximum follow-up being one and half years. A longer follow-up would very likely show up a greater proportion of worsening of renal function. Hence, the risks and benefits relevant to the individual patient should be taken into consideration before recommending partial nephrectomy for renal tumors in patients with CKD.

 
   References Top

1.Clark MA, Shikanov S, Raman JD, Smith B, Kaag M, Russo P, et al. Chronic kidney disease before and after partial nephrectomy. J Urol 2011;185:43-8.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.Lane BR, Babineau DC, Poggio ED, Weight CJ, Larson BT, Gill IS, et al. Factors predicting renal functional outcome after partial nephrectomy. none J Urol 2008;180:2363-8.  Back to cited text no. 2
    
3.Song C, Bang JK, Park HK, Ahn H. Factors influencing renal function reduction after partial nephrectomy. J Urol 2009;181:48-53.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Chan AA, Wood CG, Caicedo J, Munsell MF, Matin SF. Predictors of unilateral renal function after open and laparoscopic partial nephrectomy. Urology 2010;75:295-30.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Crispen PL, Viterbo R, Boorjian SA, Greenberg RE, Chen DY, Uzzo RG. Natural history, growth kinetics, and outcomes of untreated clinically localized renal tumors under active surveillance. Cancer 2009;115:2844-52.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  




 

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