The risks of partial nephrectomy (PN) may outweigh the benefits in some patients with preexisting stage 4 chronic kidney disease (CKD), according to investigators.
Steven C. Campbell, MD, PhD, of Glickman Urologic and Kidney Institute in Cleveland, Ohio, and colleagues studied all 62 patients (mean age 67 years; 71% male; 84% White) with an estimated glomerular filtration rate (eGFR) of 15 to less than 30 mL/min/1.73 m2 undergoing PN for renal cell carcinoma (RCC) at their institution from 1999 to 2015. Overall, 23 (37%) and 7 (11%) patients had tumor grade 3/4 and pT3a disease, respectively, but benign pathology was found in 10 (16%) patients.
The primary endpoint was time to end-stage kidney disease (ESKD). Patients with a preoperative eGFR less than 20 mL/min/1.73 m2 had a significantly shorter median time to progression to ESKD compared with those who had a preoperative eGFR greater than 25 mL/min/1.73 m2 (14 vs 58 months), Dr Campbell’s team reported in the Journal of Urology. On multivariable analysis, patients with a preoperative eGFR of 20 to 25 or less than 20 mL/min/1.73 m2 had a significant 2.6- and 5.0-fold higher risk for ESKD, respectively (P =.02 and P <.01, respectively), compared with those who had a preoeperative eGFR greater than 25 mL/min/1.73 m2. In addition, Black patients had a significant 2.6-fold higher risk for ESKD than White patients (P =.03).
Unfavorable outcomes occurred in 15 patients (24%), including 90-day mortality in 3%, postoperative complication of Clavien 3b or greater in 14%, and positive surgical margins in 12%.
Of the cohort, 94% of patients had pre-existing hypertension, 53% cardiovascular disease, and 32% diabetes.
“Our data suggest that patients with stage IV CKD undergoing PN tend to have substantial comorbidities and nonaggressive pathology, and are at risk for unfavorable perioperative outcomes and rapid progression to [ESKD],” Dr Campbell’s team stated. “Renal mass biopsy should be strongly considered to improve oncologic risk stratification and patient selection.”
Alternate strategies such as active surveillance or radical nephrectomy, either up-front or after progression to ESKD, may be more appropriate, particularly if PN is high complexity, patients are African American, or preoperative eGFR is less than 25 mL/min/1.73 m2 , the authors wrote.
The study did not compare patients managed with active surveillance or radical nephrectomy vs PN, which is a limitation.
In an accompanying editorial, Paul Russo, MD, of Memorial Sloan Kettering Cancer Center, New York, New York, commented:
“Now, use of preoperative nomograms to stratify risk, integration of selective renal mass biopsy to rule out indolent or benign pathology, and the liberal application of surveillance-only approaches when risk supersedes benefit provides the kidney surgeon with essential tools to avoid an ineffective operation.”
Aguilar Palacios D, Li J, Mahmood F, Demirjian S, Abouassaly R, Campbell SC. Partial nephrectomy for patients with severe chronic kidney disease—Is it worthwhile? J Urol. 204:434-441. doi:10.1097/JU.0000000000001021
Russo P. Editorial comment. J Urol. 204:441. doi:10.1097/JU.0000000000001021.01