Nephron-sparing surgery (NSS) remains gold standard for the treatment of localised renal cell cancer (RCC), even in case of a normal contralateral kidney. Compared to radical nephrectomy, kidney failure and cardiovascular events are less frequent with NSS. However, the effects of different surgical approaches and of zero ischaemia on the postoperative reduction in renal function remain controversial. We aimed to investigate the relative short- and long-term changes in estimated glomerular filtration rate (eGFR) after ischaemic or zero-ischaemic open (ONSS) and laparoscopic NSS (LNSS) for RCC, and to analyse prognostic factors for postoperative acute kidney injury (AKI) and chronic kidney disease (CKD) stage ≥3.
Data of 444 patients (211 LNSS, 233 ONSS), including 57 zero-ischaemic cases, were retrospectively analysed. Multiple regression models were used to predict relative changes in renal function. Natural cubic splines were used to demonstrate the association between ischaemia time (IT) and relative changes in renal function.
IT was identified as significant risk factor for short-term relative changes in eGFR (ß = - 0.27) and development of AKI (OR, 1.02), but no effect was found on long-term relative changes in eGFR. Natural cubic splines revealed that IT had a greater effect on patients with baseline eGFR categories ≥G3 concerning short-term decrease in renal function and development of AKI. Unlike LNSS, ONSS was significantly associated with short-term decrease in renal function (ß = - 13.48) and development of AKI (OR, 3.87). Tumour diameter was associated with long-term decrease in renal function (ß = - 1.76), whereas baseline eGFR was a prognostic factor for both short- (ß = - 0.20) and long-term (ß = - 0.29) relative changes in eGFR and the development of CKD stage ≥3 (OR, 0.89).
IT is a significant risk factor for AKI. The short-term effect of IT is not always linear, and the impact also depends on baseline eGFR. Unlike LNSS, ONSS is associated with the development of AKI. Our findings are helpful for surgical planning, and suggest either the application of a clampless NSS technique or at least the shortest possible IT to reduce the risk of short-time impairment of the renal function, which might prevent AKI, particularly regarding patients with baseline eGFR category ≥G3.
BMC nephrology. 2019 Feb 04*** epublish ***
Jan Ebbing, Felix Menzel, Paolo Frumento, Kurt Miller, Bernhard Ralla, Tom Florian Fuller, Jonas Busch, Justin William Collins, Christofer Adding, Hans Helge Seifert, Peter Ardelt, Christian Wetterauer, Timm Westhoff, Carsten Kempkensteffen
University Hospital Basel, Urological University Clinic Basel-Liestal, Spitalstrasse 21, 4051, Basel, Switzerland. ., Department of Urology, Charité - University Hospital, Berlin, Germany., Karolinska Institutet, Unit of Biostatistics, Institute of Environmental Medicine (IMM), Stockholm, Sweden., Department of Molecular Medicine and Surgery (MMK), Karolinska Institutet, Stockholm, Sweden., University Hospital Basel, Urological University Clinic Basel-Liestal, Spitalstrasse 21, 4051, Basel, Switzerland., Marien Hospital Herne - University Clinic of the Ruhr-University Bochum, Medical Clinic I, Herne, Germany.