Renal Function Preservation for Patients with Kidney Cancer
Renal function is a robust prognosticator of long-term outcome not only in patients with advanced renal failure such as patients who are on or close to renal replacement therapy, but also subjects who have relatively mild renal impairment. The latter is particularly relevant in subjects with renal cancer, who have the option of surgical intervention and often have been offered radical nephrectomy.
However, unlike healthy kidney transplant donors, who often fare well with a solitary kidney, subjects with renal cancer frequently have comorbidities, impaired baseline renal function, and/or the prospect of recurrence in the contralateral kidney.
Therefore, preservation of every bit of residual renal function becomes a priority. Clinicians should explore the feasibility of partial nephrectomy to minimize loss of nephron mass and optimizing peri- and intra-operative care to reduce irreversible ischemic injury.
The renal function preservation clinic for patients with kidney cancer represents a new multidisciplinary approach to an old problem, where a combined medical and surgical approach is followed to achieve the surgical goal of cancer resection with negative margins while simultaneously preserving as much kidney function as possible by optimizing pre-, intra- and post-operative care and follow-up.
Pre-operative evaluation includes detailed assessment of renal function and anatomy. Determining baseline renal function is critically important in patients who undergo nephrectomy for cause because many have some renal dysfunction preoperatively and all are at risk for chronic kidney disease (CKD) after surgery.
Residual functional nephron mass at the end of the operation, i.e., after the exclusion of the renal mass and surrounding injured nephrons, will represent the best renal function that one could attain provided all other hypoperfusion/ischemia-related injury is reversible. In addition, a thorough evaluation and management of risk factors pertinent to renal outcomes, such as management of medications, electrolyte disorders, anemia, and volume overload, is needed.
Post-operative care includes short-term in-hospital follow up for optimization of renal recovery related to reversible ischemic injury associated with surgery and long-term renal medical follow-up that includes prevention and treatment of renal complications and comorbidities associated with loss of nephron mass.
The integrated and longitudinal approach to treating patients with renal cancer, with special emphasis on preservation of renal function, is particularly important today. Repeated injuries to renal function have been shown to be a major contributor to the pool of subjects with CKD.
In addition, the population is getting older, and as people age, they acquire medical problems that chip away at their kidneys and undergo medical interventions that may led to renal complications.
Sevag Demirjian, MD, and Steven C. Campbell, MD, PhD, are associated with the Glickman Urological & Kidney Institute at Cleveland Clinic. Dr. Demirjian is a nephrologist and an associate staff member and Dr. Campbell is a urologist and Professor of Surgery.