Incidentally detected renal tumors are increasingly diagnosed in patients with chronic kidney disease.
Traditionally, localized renal cell carcinoma (RCC) has been treated surgically, but concerns that nephrectomy is associated with the sequelae of CKD, including increased cardiovascular risk and shortened overall survival, have resulted in the increased use of nephron-sparing procedures.
Unfortunately, in some patients, achieving oncologic control while maintaining meaningful function may be a difficult tradeoff. In these cases, how can a clinician (or patient) objectively balance the risks of the uncertainty of the tumor’s biology versus those of dialysis?
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The high incidence of concomitant CKD in patients with solid renal masses must first be recognized. In a recent study of more than 1,100 patients undergoing elective surgery for RCC, more than than 20% presented with baseline CKD stage III or higher, including more than 40% of patients older than 70 years.1
Next, the malignant potential of the renal mass must be weighed against life expectancy (competing co-morbid risks), taking into consideration recent data suggesting a prolonged natural history in carefully selected stage I tumors2. Finally, for patients in which treatment is imperative and renal function is marginal, quantitative estimates of the risks of chronic dialysis must be determined.
Physicians often quote that the five-year mortality risk associated with chronic dialysis approaches 100%. However, while the reported annual mortality rate in patients on maintenance dialysis ranges from 20%-25% and long-term estimates are poor, these data are drawn from heterogenous patient populations with substantial variation in co-morbidity.3 In fact, a significant proportion of patients survive on dialysis for extended periods with an acceptable quality of life, and further efforts are required to identify which patient factors are associated with improved survival outcomes.
In today’s evolving health care environment, physicians are increasingly challenged to manage risk on a per patient basis. This requires complex tradeoff analysis such as estimating the risks of kidney cancer versus hemodialysis. Such decisions require physicians and patients to review and accept all calculated risks. While standardized instruments and metrics are currently lacking, physicians must seek to objectify tradeoff risks lest decisions be based primarily on educated guesswork.
Robert G. Uzzo, MD, FACS, and Marc C. Smaldone, MD, Fox Chase Cancer Center, Philadelphia
Dr. Uzzo holds the G. Willing “Wing” Pepper Chair in Cancer Research at Fox Chase, where he is Chairman of the Department of Surgery. He also is Professor of Surgery at Temple University School of Medicine in Philadelphia. Dr. Smaldon is a Fellow in Urologic Oncology.
References
- Canter D, Kutikov A, Sirohi M, et al. Prevalence of baseline chronic kidney disease in patients presenting with solid renal tumors. Urology. 2011;77:781-785.
- Smaldone MC, Kutikov A, Egleston BL, et al. Small renal masses progressing to metastases under active surveillance: A systematic review and pooled analysis. Cancer 2011; in press.
- US Renal Data System, USRDS 2010 Annual Data Report: Atlas of chronic kidney disease and end-stage renal disease in the United States, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda 2010.
