Abstract
BackgroundNephron-sparing surgery (NSS) remains gold standard for the treatment of localised renal cell cancer (RCC), even in case of a normal contralateral kidney. Compared to radical nephrectomy, kidney failure and cardiovascular events are less frequent with NSS. However, the effects of different surgical approaches and of zero ischaemia on the postoperative reduction in renal function remain controversial.We aimed to investigate the relative short- and long-term changes in estimated glomerular filtration rate (eGFR) after ischaemic or zero-ischaemic open (ONSS) and laparoscopic NSS (LNSS) for RCC, and to analyse prognostic factors for postoperative acute kidney injury (AKI) and chronic kidney disease (CKD) stage ≥3.MethodsData of 444 patients (211 LNSS, 233 ONSS), including 57 zero-ischaemic cases, were retrospectively analysed. Multiple regression models were used to predict relative changes in renal function. Natural cubic splines were used to demonstrate the association between ischaemia time (IT) and relative changes in renal function.ResultsIT was identified as significant risk factor for short-term relative changes in eGFR (ß = − 0.27) and development of AKI (OR, 1.02), but no effect was found on long-term relative changes in eGFR. Natural cubic splines revealed that IT had a greater effect on patients with baseline eGFR categories ≥G3 concerning short-term decrease in renal function and development of AKI. Unlike LNSS, ONSS was significantly associated with short-term decrease in renal function (ß = − 13.48) and development of AKI (OR, 3.87). Tumour diameter was associated with long-term decrease in renal function (ß = − 1.76), whereas baseline eGFR was a prognostic factor for both short- (ß = − 0.20) and long-term (ß = − 0.29) relative changes in eGFR and the development of CKD stage ≥3 (OR, 0.89).ConclusionsIT is a significant risk factor for AKI. The short-term effect of IT is not always linear, and the impact also depends on baseline eGFR. Unlike LNSS, ONSS is associated with the development of AKI. Our findings are helpful for surgical planning, and suggest either the application of a clampless NSS technique or at least the shortest possible IT to reduce the risk of short-time impairment of the renal function, which might prevent AKI, particularly regarding patients with baseline eGFR category ≥G3.
Highlights
Nephron-sparing surgery (NSS) remains gold standard for the treatment of localised renal cell cancer (RCC), even in case of a normal contralateral kidney
Baseline estimated glomerular filtration rate (eGFR) was higher for the laparoscopic NSS (LNSS)-RI group compared to the open NSS (ONSS)-RI group (85.5 [interquartile range (IQR), 72.1–96.2] vs. 75.4 [IQR, 61.5–90.2] mL/ min; p = 0.03), but did not differ between the NSS group with intraoperative renal ischaemia (NSS-RI) group and NSS group without intraoperative renal ischaemia (NSS-NRI) group (79.5 [IQR, 66.3–93.9] vs. 80.4 [IQR, 59.4–91.1] mL/min; p = 0.36)
We decided to use the tumour diameter, tumour location, and ischaemia time (IT) in the regression analyses as adjusting surrogate parameters for the amount of renal parenchyma removed. This strategy is supported by a study by Meyer et al, who used a precise threea b c d. Despite these limitations, the findings of this study suggest that acute kidney injury (AKI) within 48 h postoperatively and chronic kidney disease (CKD) stage ≥3 develop in nearly 40.0 and 28.0% of patients after NSS for RCC, respectively
Summary
Nephron-sparing surgery (NSS) remains gold standard for the treatment of localised renal cell cancer (RCC), even in case of a normal contralateral kidney. Other recent retrospective data showed that in patients who had chronic kidney disease (CKD) before surgery, lower postoperative eGFR was associated with increased mortality, independently of age and comorbidities [18], and that there is an increased risk of death from any cause or cardiovascular death with decreased postoperative renal function, but the latter study was not adjusted for the baseline renal function [19] These results suggest that the surgery-related factors that influence the non-oncological outcome measures are much less important than internistic disorders such as diabetes, arterial hypertension, or medical CKD [11, 16, 18]. Several studies have shown a significantly increased risk of progression of renal failure, cardiovascular disease, and subsequent mortality in patients developing CKD [22,23,24], and approximately 16–40% of patients treated with NSS develop postoperative CKD stage ≥3 [25, 26], which is defined as an eGFR < 60 mL/min/1.73 m2 by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria of kidney disease [27]
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