Partial Nephrectomy for Patients with Severe Chronic Kidney Disease—Is It Worthwhile?

Abstract

No AccessJournal of UrologyAdult Urology1 Sep 2020Partial Nephrectomy for Patients with Severe Chronic Kidney Disease—Is It Worthwhile?This article is commented on by the following:Editorial Comment Diego Aguilar Palacios, Jianbo Li, Furman Mahmood, Sevag Demirjian, Robert Abouassaly, and Steven C. Campbell Diego Aguilar PalaciosDiego Aguilar Palacios Glickman Urological and Kidney Institute—Cleveland Clinic Foundation, Cleveland, Ohio , Jianbo LiJianbo Li Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio , Furman MahmoodFurman Mahmood Glickman Urological and Kidney Institute—Cleveland Clinic Foundation, Cleveland, Ohio , Sevag DemirjianSevag Demirjian Glickman Urological and Kidney Institute—Cleveland Clinic Foundation, Cleveland, Ohio , Robert AbouassalyRobert Abouassaly Glickman Urological and Kidney Institute—Cleveland Clinic Foundation, Cleveland, Ohio , and Steven C. CampbellSteven C. Campbell *Correspondence: Center for Urologic Oncology, Glickman Urologic and Kidney Institute, Cleveland Clinic, Room Q10-120, 9500 Euclid Ave., Cleveland, Ohio 44195 telephone: 216-444-5595; FAX: 216-636-0770; E-mail Address: [email protected] Glickman Urological and Kidney Institute—Cleveland Clinic Foundation, Cleveland, Ohio View All Author Informationhttps://doi.org/10.1097/JU.0000000000001021AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract Purpose: Partial nephrectomy is prioritized over radical nephrectomy in patients with chronic kidney disease whenever feasible. However, we hypothesized that some patients with severe chronic kidney disease might rapidly progress to end stage renal disease, in which case the morbidity that can be associated with partial nephrectomy would not be justified. Materials and Methods: A retrospective review of all 62 patients with stage IV chronic kidney disease undergoing partial nephrectomy at our institution (1999-2015) was performed. We analyzed preoperative/intraoperative factors and postoperative outcomes. Survival-analyses evaluated factors associated with time-to-progression to end stage renal disease the primary end point. Results: Median age was 67 years, 71% of patients were male, and 84% Caucasian. Comorbidities included hypertension (94%), cardiovascular disease (53%) and diabetes (32%). Median preoperative estimated glomerular filtration rate was 23 ml/minute/1.73 m2 and 73% had an open approach. Benign pathology was found in 10 (16%) patients; only 23 (37%) and 7 (11%) patients had tumor grade 3/4 or pT3a disease, respectively. Unfavorable outcomes occurred in 15 patients (24%) defined as either 90-day mortality (3%), postoperative complication Clavien IIIb or greater (14%), or positive surgical margin (12%). Median time to progression to end stage renal disease was only 27 months (58 months for preoperative glomerular filtration rate greater than 25 ml/minute/1.73 m2 versus only 14 months when preoperative glomerular filtration rate was less than 20 ml/minute/1.73 m2). On multivariable analysis African American race (HR 2.55 [1.10-5.95]), preoperative estimated glomerular filtration rate 20 to 25 ml/minute/1.73 m2 or less than 20 ml/minute/1.73 m2 (HR 2.59 [1.16-5.84] and 5.03 [2.03-12.4], respectively) and minimally invasive approach (HR 2.05 [1.01-4.19]) were independently associated with progression to end stage renal disease. Conclusions: Our data suggest that some patients with stage IV chronic kidney disease undergoing partial nephrectomy have substantial comorbidities and nonaggressive pathology, and are at risk for unfavorable perioperative outcomes and rapid-progression to end stage renal disease. Renal mass biopsy should be strongly considered to improve patient-selection. Alternate strategies (active surveillance or radical nephrectomy) may be more appropriate, particularly when partial neph