SIU 2017: Optimizing Renal Function Following Surgery for Localized Kidney Cancer - Post-Operative Renal Recovery

Lisbon, Portugal ( Dr. Finelli discussed postoperative methods to preserve renal function. This was a very informative final section to this master class. 

Compensatory Hypertrophy
Historically, compensatory hypertrophy was thought to play a larger role in GFR recovery than currently. He made it clear that this is likely less of an effect that we would like, and we should not depend on compensatory hypertrophy. It may account for approximately 10% GFR recovery.

Acute renal failure (AFR) predicts chronic renal failure (CRF)
Patients who develop acute renal failure are more likely to have long-term GFR loss. In patients with CKD 3, there was a 6.2% ARF rate and a 3.7% chronic renal failure rate. The incidence of CRF paralleled ARF in all groups.

NSAIDs and Ketorolac
Patients who receive ketorolac have significantly better recovery – less opiod use, earlier return to solid diet. However, importantly, there has never been any association with increased risk of ARF. He as well as the other panelists use it regularly postoperatively – rarely is there a concern to not give it. However, dose adjustment is sometimes necessary – done in conjunction with anesthesia colleagues

ACE Inhibitors
When it comes to perioperative ACE inhibitors, he emphasized that there are a lot of nuances to its use and potential benefit. This is one case where nephrology input is important. While current guidelines recommend ACE-I use in patients with CKD, the risk of ACE-I in CKD patients is a hemodynamically mediated, reversible drop in GFR after initiation and anytime during use. The degree of GFR loss after ACE-I may help guide its continued use. But, nephrology input is often recommended.

As Dr. Uzzo mentioned, there is no strong evidence for its benefit in the perioperative use, as it directly relates to GFR preservation. However, patients with CKD are at higher cardiovascular risk, and statins are recommended for patients with CKD3 (moderate for CKD 4, and not recommended for CKD 5). They reduced major cardiac events and all-cause mortality in CKD3 patients in a large meta-analysis. So, from an overall health standpoint, statins are likely beneficial for patients with CKD. 

With that, Dr. Uzzo concluded the session with brief summaries of all the talks and completed discussion of the clinical case.