AUA 2020: Partial Nephrectomy for Patients with Severe CKD: Is It Worthwhile?

( Patients with renal tumors and pre-existing chronic kidney disease (CKD) experience an average decline of their glomerular filtration rate (GFR) of ~5% per year. Because of this, partial nephrectomy is often prioritized over radical nephrectomy in patients with CKD, when feasible. For this study at the virtual American Urological Association 2020 Virtual Annual Meeting, Diego Palacios, MD, and colleagues hypothesized that some patients with severe CKD might rapidly progress to end-stage renal disease (ESRD), in which case the morbidity that can be associated with partial nephrectomy may not be justified. Thus, the objective of this study was to analyze the relative benefits and risks of partial nephrectomy in a subgroup of patients with pre-existing stage IV CKD and to provide a comprehensive analysis of outcomes, with a focus on progression to ESRD, in order to better inform patient selection and management. 

This study utilized a retrospective review of all 62 patients with stage IV CKD undergoing partial nephrectomy (1999-2015) at the Cleveland Clinic to evaluate preoperative/intraoperative factors and postoperative outcomes. Stage IV CKD was defined as preoperative eGFR ≥ 15 and <30 ml/min/1.73m2. ESRD was defined as postoperative initiation of permanent dialysis or eGFR < 15ml/min/1.73m2. The CKD-EPI formula was used to estimate GFR values based on serum creatinine levels preoperatively and up to the last available postoperative value before initiation of dialysis or last follow-up. The primary endpoint was time to progression to end-stage renal disease (ESRD), and secondary endpoints were short and long-term perioperative outcomes.  Survival analyses were used to evaluate factors associated with time to progression to ESRD. 

Among the 62 patients included, the median age was 67 years, 71% of patients were male and 84% were Caucasian. Comorbidities included hypertension (94%), cardiovascular disease (53%), diabetes (32%), and tobacco use (58%), and median preoperative eGFR was 23 ml/min/1.73m2.  Open partial nephrectomy was performed in 45 patients (73%). Benign pathology was found in 10 patients (16%) and seven had locally-advanced disease (11%). Unfavorable perioperative outcomes occurred in 15 patients (24%) defined as 90 day-mortality (3%), postoperative grade IIIb Clavien complication (14%), or positive surgical margin (12%).  The median time to progression to ESRD was 27 months, and only 14 months in patients with preoperative GFR <20 ml/min/1.73m.2  

In contrast, the median time to progression to ESRD was 58 months in patients with preoperative GFR >25 ml/min/1.73m2.  The median time to unfavorable outcome-free survival was 23 months. On multivariable analysis African-American race (HR 2.55 95% CI 1.10-5.95), preoperative eGFR 20-25 (HR 2.59 95% CI 1.16-5.84) or eGFR <20 (HR 5.03 95% CI 2.03-12.44), and a minimally invasive approach (HR 2.05 95% CI 1.01-4.19) were independently associated with progression to ESRD. 

Dr. Palacios concluded this presentation discussing the management of renal masses in patients with stage IV CKD with the following concluding statements:

  • Patients with stage IV CKD undergoing partial nephrectomy tend to have substantial comorbidities and are at risk for unfavorable perioperative outcomes and rapid progression to ESRD
  • Alternate strategies such as renal mass biopsy for oncologic risk stratification, active surveillance, or radical nephrectomy (either upfront or after progression to ESRD) may be more appropriate, particularly if partial nephrectomy is high complexity and African-American or when preoperative GFR is < 25 ml/min/1.73m2
  • Patients with stage IV CKD are still likely to benefit from partial nephrectomy, especially if preoperative eGFR is >25 ml/min/1.73m2
Presented by: Diego Aguilar Palacios, MD, Urology Research Fellow, Cleveland Clinic, Cleveland, OH

Written by: Zachary Klaassen, MD, MSc – Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia Twitter: @zklaassen_md, at the 2020 American Urological Association (AUA) Annual Meeting, Virtual Experience #AUA20, June 27- 28, 2020
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