Long-term kidney function appears similar among patients with and without stage 3a chronic kidney disease (CKD) who undergo radical cystectomy (RC) with orthotopic neobladder formation for urinary diversion, a new study suggests.
The concern has been that patients with poor renal function will be less capable of handling the additional acid load and metabolic abnormalities from a neobladder created from intestine.
“[Orthotopic neobladder] reconstruction can be safely performed in patients with CKD Stage IIIa who desire continent diversion,” Siamak Daneshmand, MD, of the University of Southern California Norris Comprehensive Cancer Center in Los Angeles, and colleagues concluded in BJU International.
Using a cohort of 1237 patients who underwent RC and orthotopic neobladder formation, the investigators matched 254 patients with stage 3a CKD (estimated glomerular filtration rate [eGFR] 45-59 mL/min/1.73 m2 based on the Modification of Diet in Renal Disease study equation) and 254 patients with higher baseline eGFR (control group). The groups were matched by age, gender, race, baseline hypertension and diabetes, perioperative chemotherapy, and preoperative hydronephrosis. The mean preoperative eGFR was 53.3 and 78.8 mL/min/1.73 m2 in the study and control arms, respectively.
Over a median 3.7 years of follow-up, eGFR remained relatively stable compared with baseline in 51% of the stage 3a CKD group and 46% of the control group, a nonsignificant difference between the groups, Dr Daneshmand’s team reported.
Less than half of patients in the stage 3a CKD group experienced a significant decline in eGFR of greater than 10 mL/min/1.73 m2 from baseline. The mean time to significant decline was longer for the stage 3a CKD group than the control group: 5.6 vs 2.0 years. In line with previous research, patients with higher baseline eGFR (90 or more vs 60-89 vs 45-59 mL/min/1.73 m2) experienced greater kidney function decline.
In multivariate analysis, neoadjuvant chemotherapy was significantly associated with a 2.2- and 2.5-fold increased risk for a decline in eGFR from baseline in the stage 3a CKD and control groups, respectively. Neoadjuvant chemotherapy was also significantly associated with a 2.2-fold greater risk for a significant eGFR decline from baseline in the stage 3a CKD group.
“Similar to previous literature, our study showed that the most significant percentage in decline of renal function happens in the first few months after [orthotopic neobladder reconstruction],” Dr Daneshmand and colleagues wrote. “An emphasis should be made on adequate hydration, avoidance of nephrotoxic insults, and close maintenance of acid/base status using sodium bicarbonate especially in the first few months after surgery, to prevent both metabolic complications and precipitous initial decline in GFR.”
Ahmadi H, Reddy S, Nguyen C, et al. Long-term renal function in patients with chronic kidney disease following radical cystectomy and orthotopic neobladder. BJU Int. doi:10.1111/bju.15685